Wednesday, March 22, 2006

When patients are negligent

I just saw a memorable patient. The couple had been trying to conceive for over 7 years, and she was now 35. She had missed her period and had had a positive home urine pregnancy test. She wanted to confirm her pregnancy was healthy, which is why she came to me. Her blood test for beta HCG showed a level of 2000 mIU/ml, confirming she was pregnant, but I could not see a pregnancy sac inside the uterine cavity on vaginal ultrasound scanning. This meant she had an ectopic pregnancy, a condition in which the pregnancy lodges in the fallopian tube, instead of the uterus. This can be a life-threatening problem if the pregnancy is allowed to grow inside the tube, as it can rupture, and cause massive internal bleeding. I congratulated myself on making the diagnosis so early, and told her that we needed to kill the pregnancy; and that we could do it safely and easily with an injection of methotrexate, an anti-cancer drug which kills the rapidly dividing cells of the embryo, so that it gets reabsorbed by the body, without having to do any surgery. I thought they would be pleased that I had such an effective and simple solution to what could become a major problem - and which used to be one of the biggest killers of young women in the past. Much to my surprise, her husband flatly refused to believe me ! " But her home urine pregnancy test is positive, and I am sure she will have a baby !" was his refrain. He wanted a baby so badly that he was in denial mode - the last thing she wanted to hear was bad news. I suggested that they get a second opinion, and that she seek urgent medical attention before things got out of hand.
She left the clinic, and never followed up. I was very worried about her, since she was a "walking time bomb", and called her up 2 days later to find out what she had decided to do, but her husband was unwilling to take my call !
I learnt later from a colleague that her husband adamantly refused to take her to another doctor. 3 weeks later she had severe abdominal pain because of a ruptured ectopic pregnancy , and finally ended up having emergency surgery to save her life.
Everyone makes such a hue and cry when doctors are negligent. What happens when patients are negligent ? Who is responsible then ?


  1. Anonymous1:56 AM

    Dr. Malpani ... that's a really tough scene. I think that there is "negligence," and then again, there's a different kind of "negligence."

    This particular situation - if they'd been trying for 7 years, and she was nearing the end of her "safe" child bearing years, although I can see the foolishness in what they did, I can also understand the psychology behind the extreme denial.

    They perhaps saw the pregnancy as some sort of "last chance" ... and although it was unreasonable, saw you as the fellow who wanted to take that chance away from them. Perhaps if they had been given some time to absorb and understand the news - even a few days - before laying solutions before them ...

    I'm not a physician, so it's hard for me to see it from your perspective, but I do know many childless couples, and I can imagine how they would react under the same circumstances.

    Before I end - thank you for your blog. I'm a daily reader, and enjoy it very much.

  2. Anonymous5:55 AM

    Dr. M - You did all you could. You gave them the information, you gave them your educated opinion and advice. From there it's up to them. If a patient chooses to ignore your advice, they accept the consequences. If this couple's need to believe their pregnancy would work is stronger than their need to listen to professional advice, what can you do? Nothing. You can't FORCE her into the hospital.

    If she had listened to you, she would have had an easier time of it. As it was, of course, when the ectopic progressed to rupture, she was in so much pain and danger she could no longer deny the obvious, and she got taken care of in the end.

    But she chose not to take your advice. The responsibility is hers.

  3. Anonymous2:45 PM

    I see myself in this patients place 3 yrs back, but my doc wasnt as intelligent to guide me and let me know the possibilities of an ectopic, even though the BHCG count was up. They convinced me that i had a miscarriage! After 14 weeks(Yes, that long) i ended up in the emergency surgery trying to save my life, after i lost abt 3 liters of blood due to the ruptured ectopic. Only if they had told me... Doctor Malpani, you are doing an excelletn job by writing this blog. I wonder how you get the time, though. God bless!


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