The Yale Journal for Humanities in Medicine

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The Error
(continued)

“Oh!” she exclaimed, “didn’t you know?” There was a beat before she spoke again, and in that eternal second I felt myself stiffen, bracing for a blow that seemed almost imminent. “Morgan is back in the hospital!”

Blam! The words shot through me like a jolt of lightning. My head felt as if it would explode under the shock, and a sharp pain wound itself around my spine, forcing my body into a violent spasm of agony.

“Can you tell me what happened? Is he all right?” It was such a stupid question. How can you be all right when your doctor’s mistake put you in the hospital?

“He seems fine now, I think.” Ms. Jasmone’s tone returned to normal, her instincts as an aunt taking over again. “I have his telephone number if you want to call him.” She gave me the number and we said goodnight.

Suddenly the floor gave way beneath me and I was falling, tumbling down into a deep, dark chasm with no bottom. I looked up but could scarcely see the apartment before me. Clanging dishes in the kitchen, a siren wailing outside on the street, they were barely audible from inside this desolate place. I closed my eyes and in the darkness saw Morgan. He was in pain, writhing, afraid. He was smothered in a web of intravenous lines, heart monitors and face masks. He was being poked and prodded by some other intern, asked the same twenty questions fifty times.

Alone in the belly of my mistake, my time with Morgan in the clinic replayed itself in slow motion. Why didn’t I check the computer’s dosage twice? Why hadn’t ‘10’ set of alarm bells in my head? When is ‘pointing and clicking’ not just that? My patient was in the hospital and I was to blame. I glanced up at my wife in the kitchen, oblivious to Morgan’s suffering. I told myself that doing the right thing often hurts, and picked up the telephone again.

“Hello?” Morgan’s deep voice was a relief. He sounded tired, but not in pain.

“Mr. Davis, is that you? It’s Dr. Simpson calling.”

“Oh, Dr. Simpson! I got your message but it was too late!” He spoke quickly, excitedly, and I found myself staring into space, completely absorbed by his words.

“I got home and took the pill like you said, before I went to sleep, and they did make me dizzy. But the next morning when I woke up I felt real, real bad so I took another pill, and then I almost fell down the stairs! I had to crawl to my bed and lay down but I was nauseous. Then I was gettin’ these chest pains so my cousin told me to call the ambulance and now I’m back here in the hospital again. Oh, it was just terrible, doc.”

He took another pill in the morning? I was confused. Why would he do that? And was he having chest pain now, I asked.

“Oh yes, and I been short of breath too, just like the other times I been in the hospital Dr. Simpson.” Oh my God, I muttered, did I trigger a heart attack?

“Have they done any tests yet?”

“They wanted to do something on Monday, doc, but they say I’m too big for the machine so they might send me to Boston or something. But I won’t be taking that medicine again, that’s for sure!”

“I’m so sorry this happened, Morgan. The dose of Hytrin I gave you was too high. I tried to reach you at the shelter but I guess it was too late.” He told me he had left the shelter a week ago and was staying with a friend.

I remember that he didn’t sound angry. There was no malice in his voice, and in fact he seemed happy when I said I would visit him first thing in the morning. He should be furious, I thought to myself. Wouldn’t I be? Why wasn’t he mad? Had I been vague? Didn’t I use words like ‘my mistake’ and ‘wrong’? Had he not heard me? Had I fudged and emphasized how rushed we were, or did I imply that the pharmacy was somehow at fault? Had I owned up to the error?

The moral imperative to be honest with patients about an error is clear. Patients want to know the truth, and hate being lied to most of all. Still, it is hard to use the first person. “The dosage was incorrect,” is easier than “I prescribed the wrong dose.” “A mistake was made,” is easier than “I made the mistake.” The difference is subtle, but to me the emotional burden of the latter is clear, and that much harder to blurt out. “I” wrote the wrong dose. “I” made the mistake. “I” am sorry.

The next day was Saturday, my day off. I would check on his condition myself, and apologize in person.

* * * * *

The cardiology floor was quiet when I arrived. A beep or a blip here and there. A pile of rhythm strips pouring out of a heart monitor onto the polished floor. Down the hall a nurse walked a thermometer on wheels from room to room like an English terrier on a leash. I took Morgan’s chart from it’s rack and began to read. He had come to the hospital with chest pain and shortness of breath. They gave him an aspirin, a few nitroglycerin tablets and oxygen, but nothing helped, and eventually his pain subsided on its own. Morgan’s electrocardiogram was abnormal, but it had been abnormal before and there were no new changes. Old studies of his heart showed evidence of prior damage, but they were always limited by his enormous size.

The good news was that he was stable, without any signs of a heart attack. The bad news was that instead of enjoying the sunny weekend outside with his friends, he was lying in a hospital bed, waiting to be transferred to Boston for an angiogram on a table built specifically for people over three hundred pounds.

* * * * *

I knocked on the door of room 223. Morgan was sitting up in bed, chatting with a friend of his at the bedside. He introduced me to his friend, who politely stepped out, and I took a seat facing him. Reclining in the hospital bed, he looked like a giant reclining on a throne. Already feeling small, his dominating presence made me feel even smaller. Morgan was beside himself about the chest pain.

“How am I ever going to know what’s going on inside my chest if they can’t do that procedure?” He was looking directly at me, waiting for a second opinion.

“Having a look inside is the only way to know if your arteries are clogged, that’s true. There are other tests, but you’ve already had them and they are less accurate in large people.”

“For sure!” He was howling and rolling his eyes, both at me and at the medical system he was dependent on. “But I just got to know, doc! I can’t keep coming in like this. It’s horrible and it scares me half to death!”

Continued
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