Inside Medicine Read-Through: Commentary on the New York Times article about a tragic ER case.
Two visits failed to detect a fatal illness — my perspective as an emergency physician.
Update: For those with trouble reading this due to the small print, you can visit the Fiskkit.com version of this article where I did the annotations.
Over the weekend, The New York Times published a very sad story about a young man who died after two ER visits failed to detect what became a fatal illness. As an ER doctor who trained in New York, I have a lot of feelings. To share them, I’m attempting a new format, which I learned about from my friend John Pettus, the founder of Fiskkit.com. That website lets readers annotate articles, inviting civil discussions. Below, are screenshots of my fiskkit markups of this article. The original text from the Times article is in normal color below, and my thoughts are in red ink. (Note: the “Respect” button you see in the screenshots is the “Like” button on Fiskkit.) If you want to interact directly with my comments, you can do so on Fiskkit. But I would prefer that this conversation happen here on Inside Medicine or in the chat channel on the app. Also, because these are screenshots, the links I included are not active (Note: I may zoom a bit more next time, but you should be able to zoom if the font is small on your screen). So, I’ve pasted the relevant links at the bottom of this page. Finally, if I can, I’ll do a talk-through of this all on Substack Live in the next day or two, where I can take your questions and comments.
What do you think of this format? Thanks for reading…
Links:
Other links on medical errors literature:
If you have information about any of the unfolding stories we are following, please email me or find me on Signal at InsideMedicine.88.
Oh I loved the way you did this!! Thank you so much.
Such a painful case for the family and I'm sure for all Sam's caregivers. Like Dr. Gordon, I would have liked to know an oxygen saturation; I can't believe one wasn't done at some point, assume it was just not mentioned in the article. As Dr. Faust notes, vital signs are a big red flag; the pulse rate on the second visit is disproportionate to the fever, and it would again have been useful to know what his pulse and temp were after hydration. I'd also like to know how many white cells were in the urine. Agree with Dr. Faust that the time course to deterioration after the second visit would be very unusual for sepsis. And similarly to pneumonia, I think PE would have been found on autopsy. One reference to post covid inflammatory syndrome:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2784427
I'm an ED doc whose 35 y.o. son was sent home from an ED in 2020 after presenting with severe L shoulder pain several days into an illness with GI sx (nausea, diarrhea). He was afebrile with a pulse of 126 on presentation and was discharged with a pulse of 115 after a liter of LR with a dx of viral syndrome (O2 sat nl) I brought him back to ED when he called me at 2 am with shoulder pain that was keeping him awake. Long story short, abnormal ECG, elevated troponin, fortunately relatively normal cardiac cath. Dx'd with myocarditis, and developed cough, fever, lower lobe pulmonary infiltrates on CT while admitted but did well. All cultures negative, influenza negative, Covid PCR was negative but serology was never done. I still think it might have been covid but fortunately he did well with no sequelae. Pay attention to those vital signs!
Very nice job on the discussion, enjoyed the format. And yes, that 2022 AHRQ study on ED diagnostic errors was NOT good science.