Removed, observed

"How many times you poke me?" she asked. Then, in her heavily accented English, "Dr. Better never took this long for LP. Five minutes, always."

I made empathetic noises, apologized a few times, and tried to focus on the needle I was moving in and out of her back. I'd done four lumbar punctures before, and felt I was good at them. Wasn't I in the exact space where I needed to be? I stopped and felt again for her spine.

On my first day on the adult hematology-oncology service, she'd been described to me as an anxious, passive-aggressive woman who hated our hospital. She created traps for us, looked for mistakes in our work, obsessed about details we'd overlooked. The only reason she was there at all was the clinical trial in which she was enrolled, and she reminded us of this every day.

I should have considered this before taking the needle in my hand. After all, lumbar punctures are among the few procedures I've routinely seen performed unsuccessfully by experienced practitioners. The landmarks for the target are quite broad--almost any soft spot at the midline of the low lumbar spine will do. Even worse, there is no immediate reassurance to practitioners when they are in the right space. There is no flash in a chamber, and only occasionally a slight popping sensation as the membrane encasing the spinal fluid is pierced. To check for correct placement, the needle is stopped, a barrel is removed, and a chamber at the end is observed carefully, over and over again.

With my chief resident watching, I advanced, removed, observed, replaced, and redirected, and did it all again, about 20 times. In between lamentations, the patient stopped and turned her bald head slightly to the side. "You're in the wrong place," she said. "Too far to the right." I aimed more toward the left, but the flesh below my needle felt unfamiliar there. Although I didn't doubt her, I trusted my fingertips.

We stopped after three passes--"Patient did not tolerate the procedure," I would write in my note--and removed the drapes from her back. There, jeering at me in Betadine yellow, were three needle marks about an inch to the right of her spine. The chief resident mouthed a word: "Fuck."

The patient was in hysterics. "How many more mistakes?" she shouted in between her tears. I asked myself the same question. I had no good answers for her, and wanted more than anything to leave. I wish I could say that by staying with her, owning up, apologizing to her, and explaining to her how I had made the mistake I'd made, I somehow changed the expression on her broken face, but I did not.

Everyone screws up a few LP's, said my chief. Don't beat yourself up.

It's not me I was worried about; I still have faith in the care we provide, even if we occasionally make mistakes. This patient does not, however. And she needs all the faith she can get.

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Thanks for your story. Rather sobering as a premed student. It seems like quite the double standard? Doctors being accused of "playing god" yet being expected to preform extremely dificult procedures flawlessly.

Oh my. Things like this were why I never had the nerve to consider med school. Actually I couldn't even bear to think about drawing blood. I don't know how you do any of it. I'm just grateful there are some people who do. I've spent a lot of time in hospitals and doctors' offices over the past four years and 90% of the time the care I've received has been excellent; the 10% not excellent has been due more to the doctor's hubris than to his or her skill. You don't seem to be working on developing the hubris, which is a Very Good Thing. You can't control the history your patients bring to you, and sometimes your best isn't enough - doesn't match up to their needs. It takes time to develop rapport with a troubled patient. Took my neurologist and me a year to get easy with each other. How many minutes did you have to develop any connection with this patient? I feel bad for both of you.

How brave of you to admit, and not just to yourself, that despite continued effort on your part to perform "flawlessly", mistakes still happen. I'm sure that at one point or another, that patient would realize your compassionate caring about her, and will appreciate it.

You know, I never did get the hang of LPs. Thoracentesis, paracentesis, amniocentesis, but not LPs. One more reason I'm glad to be an obstetrician... I never have to do them.

I'm wondering why you would write on her chart that she "didn't tolerate the procedure" when this is clearly inaccurate.

I mean, I do understand the dynamic here... but this is now etched in stone in this patient's chart with a subtle implication of blaming her, and it is one more piece of baggage added to her history. Maybe she isn't going to see it in her chart, but everyone who cares for her *is* going to see it, and they aren't going to know the whole story and they're going to continue to see her as "difficult."

What's gonna happen when it's time for the next LP? What's gonna happen the next time this patient tries to speak up for herself?

I'm not trying to pick on you, I guess I'm just more tuned into the semantics and what they mean. The notes could simply have said "the procedure failed" and left it at that. It's probably a far more accurate description of what really happened, and it doesn't point fingers either way.

Maybe the patient is subconsciously picking up on some of this and it is contributing to her anxiety and obsession?

By fierce lioness (not verified) on 04 Jul 2007 #permalink

Lioness, I can see where you'd get the impression that writing "didn't tolerate the procedure" implies that a patient is fussy--if you ever said it about someone in a non-medical context, it would seem to place blame on them for being, well, intolerant. However, it doesn't always mean that. In my experience, the phrase is often used to mean that a procedure was just too uncomfortable to be continued in good conscience. It might be that it carries more negative connotations than I'm aware of. Any other medical types have thoughts on this?

Even if it is "neutral" when used in medical-speak, you're probably right in that merely importing a phrase from the vernacular into a professional lexicon doesn't rid it from whatever connotations our reptilian brains associate with it.

That said, in this case, I do think the patient was unusually intolerant of the procedure. I think she had more fear, anxiety, and resentment than the average patient, and that those feelings increased her sensations of pain, which in turn cut short our efforts to redirect our needle. If she had not been so anxious, we might have been more eager to step back, reevaluate our placement, and try again. I am not blaming her for the procedure's failure, but I do think it's actually pretty important to consider the psychiatric milieu within which interventions like this occur. Knowing a patient is prone to anxiety usually helps us plan for their care better by offering sedation for frightening procedures, or using advanced imaging techniques for "blind" procedures like LP's. (Which is what we ultimately ended up doing for this patient.)

For what it's worth, I also documented in my note that I had missed the spinal column by several centimeters. So if there were fingers pointing anywhere after this fiasco, there was definitely one pointed at me, too.