Clinical mishaps are likely to be overlooked and buried—or concealed by sympathetic patients, relatives, or colleagues. Mine was very public, the talk of the hospital. Doctors came from far and wide to admire it, and if it wasn't photographed for a textbook it should have been. As an exchange student in the United States, I was asked to do a tuberculin test on a patient with mysterious shadows in her lungs. Tuberculin came in twin packs labelled “first strength” and “second strength.” I misunderstood the instructions and used the wrong one. The patient had an extreme response—a black carbuncle on her arm the size of a plum. Everyone was kind about it, particularly the victim. In those days patients entering teaching hospitals cost-free did not expect them to be risk-free. But they did expect their experience to be exotic. This certainly was. The reaction was construed as of great diagnostic significance, not that we ever made a diagnosis.
Nowadays, I suppose I might be sued, the incident reported, and somebody might tell the manufacturer that their labelling was inherently ambiguous. Sometimes first strength means weaker than second, sometimes stronger. Think of football teams. Thirty seven years later, I cannot remember which pack was which. Anyway, read instructions carefully. Twice. If you write them, keep them simple. Even better, keep the stronger stuff somewhere separate.
As a young doctor, I buried the usual complement of patients—through ignorance, misdiagnosis, or oversight, but not, I comfort myself, through neglect. I lost plenty of sleep, but never worrying about, or regretting, clinical decisions. Decades later, however, I still squirm when remembering what should be best controlled and least excused—things said or not said rather than what was done or not done:
As a house surgeon, I clerked an anxious patient with varicose veins. She was scheduled at the end of a long operating list and was preceded by a patient who would either be opened and shut or involved in heroic surgery. My patient was warned we might not get to her, and so it happened. Cancelling or postponing operations was rare in those days. As he began stitching up the previous patient, the registrar released me from helping and sent me up to the ward to apologise: “Guarantee her a place on the next list. Best coming from you, Hugh.” Little did he know. After that first case, however, varicose veins seemed superficial and trivial.
Tired and dishevelled, I made for the lift after checking that my theatre pyjamas weren't bloody. It was Friday evening. Outside the ward visitors waited their cue to enter. Inside there was bustle and excited anticipatory chatter. Supper had just finished and was being cleared up. Except for my patient. In accordance with custom, she was laid out like a corpse in a sepulchre—in shroud-like theatre garb, with curtains half drawn, and “Nil to eat or drink” exhibited over the bed.
“I'm very sorry we can't do your operation today,” I explained. “You are guaranteed a place on the very next list.”
She gazed at me in silent, anguished terror.
“Anyway,” I said, trying to be helpful and make conversation, “now you can eat and drink. . . .”
Her countenance failed to change.
Just as I realised the implications, I added, “. . .and be merry.”
“Yes,” she said melodramatically, “for tomorrow we die,” and burst into tears.
An unwritten role of hospital nurses is mopping them up after doctors have been. What was said could not be unsaid. I stood looking at her, tired, hungry, at a loss what to say, the situation beyond my control.
She had her operation on the next list and didn't die. Somehow that did not really make amends.
Footnotes
We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.