Sunday, April 24, 2016

Basics are THE basics. No matter how senior you are.

Once there was a patient came to a clinic complaining of abdominal discomfort for some time. Past surgical history was significant for 2 lower segment caesarean sections. She was seen by some private practitioners & since she was not improved with their treatment, she was referred to us.
Oh.. ultrasound abdomen showed a massive cyst measuring 17x 9 cm. But fortunately no ultrasound features of malignancy & CA-125 also came normal. She was given a date for laparotomy.
She admitted to a the ward for the surgery in some weeks after. Usually all the patients are admitted for surgery will be re-scanned once after the admission. Since it is difficult to go by patients in busy wards, all the patients need to be scanned are asked to come for scans after the ward rounds.
Patient was put on the bed & done a transvaginal ultrasound (TVS) by a senior doctor.
Cyst is 3x3 cm !!!! Cyst size has reduced ??
She is planned for laparotomy on next day !!! There will be a big cut on her tummy next day!!
What to do? Senior doctor who performed the scan, documented his findings & informed the consultant gynecologist .
Consultant gynecologist  went though the patient & palpated the abdomen. It was like 24 weeks size mass !!
What a puzzle. There is a mass clinically, but not ultrasonically.. !!
Well experienced consultant gynecologist who believed his clinical sense gave an explanation (which I am not mentioning now) & wanted LAPAROTOMY.
She was underwent laparotomy next day. Yes it was a large cyst of 17x9 cm !!!  In left adenexia another cyst 3x3 cm..!!
So who is correct??
Actually what happened was when she underwent a TVS, it has shown the small cyst & due to the large size the bigger cyst was missed. Had he done a trans-abdominal scan at the time of confusing scan findings he would have easily detected. Furthermore had he at least touched the patient's tummy (History > Examination > Investigations) he would not have missed this.
Fortunately nothing bad happened to the patient, The doctor who performed a TVS was a well experienced  though he made this unfortunate simple mistake. I still believe he is a good doctor & no question about it. But it is worth mentioning that "once a senior doctor makes a such mistake, will other junior doctors & ward staff follow his patient management without any hesitation?".

Lesson- Basics are THE basics. No matter how senior you are. Stick to basics.    

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