Missed
The woman is young, from one of the lower social demographics, and comes in with painless PV bleeding. I think it seems fair to call it 'torrential' loss, seeing the towels she has soaked by the time that she comes into the department, but it is all without any discomfort at all, and abating even as I conduct my workup. I've met this one before and she has been impeccably polite, so I treat her as gently as I can.
Given that we can't for logistical reasons get a urine BHCG from her, I take blood and send it off for the serum values, quietly hoping that the number comes back zero, so that she, and I, can get on with our lives. I talk her through my deductive process, go and work up another patient, and keep a watchful eye on her from the desk.
The value returns as about 18000. I inform her quietly of her unexpected pregnancy, likely already dying, and call up the gynae RMO.
I am a little surprised by how things turn out after this, but even writing with the cold clarity of hindsight, I can rationalise nearly everything that happens subsequently.
Rather than admit the woman, the RMO organises an outpatient ultrasound for the next day. I suppose at this point, we are both looking at a haemodynamically intact individual with the question 'where is this going?' on our minds. The case looks like an inevitable abortion rather than an ectopic, although we have not conclusively ruled out the possibility, but the woman looks stable, her bleeding is settling and she has no pain. There is an exit plan; she doesn't need a bed overnight for a simple scan.
She goes home with her partner given careful advice about what to look out for. I inform my consultant of the slightly unusual outcome, and find myself shrivelling inside under his quizzical expression. You should have scanned this yourself, he points out. Under the tide of withering self doubt, I had not thought to do so, as ever obeisant to the opinion of our 'specialty' colleagues. Always the servile, still.
I sleep restlessly that night. It only occurs to me two days later why that should be, the scars from my personal life as ever bleeding into the professional domain. I go in anyway, with a dark pall settling quietly over the world.
The consultant from the night before finds me in resusc and shakes his head at me. My heart sinks just a little lower into my tightened chest. He turns away momentarily to find the ultrasound report from our lady and I have enough time to choke back the doubt with as neutral an expression as I can muster.
There is a live pregnancy in the uterus. It is embedded within the caesarean section scar she has received from previous parturition. Which, to my horror, makes this an ectopic pregnancy, of sorts. It has to be removed. The consultant replaces his expression of concerned disapproval with one of concerned and sincere disappointment, and I feel something small inside me die as well.
"What are you thinking?" he asks.
"I need to mull." I reply, wondering how I ever managed to make it this far. I need to leave. There is not enough air in the room. Charlatan. Charlatan. Charlatan.
He wanders with me to the other side of the department, advising about the serum values and LMP dates where scanning this myself would become a useful exercise. I'm listening half heartedly as the vortex opens up. She's sitting watching me from an open curtain as I walk into the lower acuity side of the ED. The consultant leaves me to it.
"I've heard what happened. I'm sorry." I tell her.
To my intense dismay, she brushes off the comment. Not your fault, she says. You treated me really well. You're the best doctor I've ever met.
She points to a poster on the wall and suggests that I should be nominated for employee of the year, focussing on the few kind words and the time I spent, rather than the fact that in this instance, I got it glaringly, painfully wrong. Such kindness in the face of failure.
Thank you, she says, again. Thank you.
I walk back to to TC, with my head low, and the same word going through my head over and over and over, like mantra.
Charlatan.
Given that we can't for logistical reasons get a urine BHCG from her, I take blood and send it off for the serum values, quietly hoping that the number comes back zero, so that she, and I, can get on with our lives. I talk her through my deductive process, go and work up another patient, and keep a watchful eye on her from the desk.
The value returns as about 18000. I inform her quietly of her unexpected pregnancy, likely already dying, and call up the gynae RMO.
I am a little surprised by how things turn out after this, but even writing with the cold clarity of hindsight, I can rationalise nearly everything that happens subsequently.
Rather than admit the woman, the RMO organises an outpatient ultrasound for the next day. I suppose at this point, we are both looking at a haemodynamically intact individual with the question 'where is this going?' on our minds. The case looks like an inevitable abortion rather than an ectopic, although we have not conclusively ruled out the possibility, but the woman looks stable, her bleeding is settling and she has no pain. There is an exit plan; she doesn't need a bed overnight for a simple scan.
She goes home with her partner given careful advice about what to look out for. I inform my consultant of the slightly unusual outcome, and find myself shrivelling inside under his quizzical expression. You should have scanned this yourself, he points out. Under the tide of withering self doubt, I had not thought to do so, as ever obeisant to the opinion of our 'specialty' colleagues. Always the servile, still.
I sleep restlessly that night. It only occurs to me two days later why that should be, the scars from my personal life as ever bleeding into the professional domain. I go in anyway, with a dark pall settling quietly over the world.
The consultant from the night before finds me in resusc and shakes his head at me. My heart sinks just a little lower into my tightened chest. He turns away momentarily to find the ultrasound report from our lady and I have enough time to choke back the doubt with as neutral an expression as I can muster.
There is a live pregnancy in the uterus. It is embedded within the caesarean section scar she has received from previous parturition. Which, to my horror, makes this an ectopic pregnancy, of sorts. It has to be removed. The consultant replaces his expression of concerned disapproval with one of concerned and sincere disappointment, and I feel something small inside me die as well.
"What are you thinking?" he asks.
"I need to mull." I reply, wondering how I ever managed to make it this far. I need to leave. There is not enough air in the room. Charlatan. Charlatan. Charlatan.
He wanders with me to the other side of the department, advising about the serum values and LMP dates where scanning this myself would become a useful exercise. I'm listening half heartedly as the vortex opens up. She's sitting watching me from an open curtain as I walk into the lower acuity side of the ED. The consultant leaves me to it.
"I've heard what happened. I'm sorry." I tell her.
To my intense dismay, she brushes off the comment. Not your fault, she says. You treated me really well. You're the best doctor I've ever met.
She points to a poster on the wall and suggests that I should be nominated for employee of the year, focussing on the few kind words and the time I spent, rather than the fact that in this instance, I got it glaringly, painfully wrong. Such kindness in the face of failure.
Thank you, she says, again. Thank you.
I walk back to to TC, with my head low, and the same word going through my head over and over and over, like mantra.
Charlatan.
posted by Bas at 3:59 AM
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