Correct Diagnosis

By Jim McVeagh 12/12/2009

It is always a tragedy when a young life is lost, but it is especially heart-wrenching when a young man dies from something you would not normally expect such a person to die from. Such is the case of Dean Carroll, the 22 year old who presented to an emergency department and left with a script for pain-killers, only to die from a spinal abscess the next day.

Unfortunately, his death was inevitable, according to the testimony of the three expert witnesses at the inquest. I agree with them. Dean not only had a rare condition, he was unusually young for an epidural abscess and had no unusual signs or symptoms at the time that might have warned his doctor. Coupled with a late night presentation to a busy ED and his demise was a forgone conclusion. Even if he had had suspicious symptoms, it is highly unlikely he would have had the MRI that would have made the diagnosis.

This is why the headline is inaccurate – “Correct diagnosis may not have altered outcome” is not precisely true. A correct diagnosis would have saved his life. The point the experts are making is that a correct diagnosis in this case is essentially impossible. Impossible for the young doctor who had the misfortune to be the one to examine Mr Carroll and impossible also for the senior doctor on that night. Literally, the only thing that would have produced a correct diagnosis and saved Mr. Carroll’s life, would be if we had a protocol to do an MRI on everyone who presents to the ED with back pain. This is simply not possible.

The dilemma of high tech medicine is that the pool of resources available to us is always finite. This is true even in the US, where they spend five times as much on health care as we do. Consequently, regardless of the system of care, doctors wind up making sub-optimal decisions, not because they are bad doctors, but because we simply can’t justify the expense. Mr Carroll might have been saved – but only at the expense of hundreds, if not thousands, of other lives elsewhere in the health system.

Consequently, and much as I respect Mike Ardagh, I cannot agree with his statement that “Dean Carroll’s care “was not good enough””. While there is always room for improvement in any situation, the reality was that Dean Carroll would certainly have died, even if the ED was quiet and the senior doctor had seen him and admitted him. As the outcome would have been unchanged, I submit that, by definition, the care must have been adequate. One can only consider care inadequate when the outcome could have been different. In the real, constrained world in which we live, Mr Carroll’s care was perfectly adequate – it was simply not enough to save him.

To suggest otherwise is to invoke the “rule of rescue”. Not a good idea in medicine.


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