Morbidity and Mortality

I"m on call today. So far, it"s been a pretty good day. Taught a resident how to do forceps. Did a delivery with a medical student. A couple of c-sections, a D&C. Nothing too scary.

So.. I"ve spent most of my night up in my office working on my M&M (morbidity and mortality) conference presentations for Thursday. For our perinatal conference, it doesn"t work the same as a general M&M (which happens in a wider forum on a different day). We pick 3 cases (with the neonatology fellows) and discuss, sometimes in depth, the resolution of these cases (it"s good for us to know how the babies that we"re sending to the NICU do). We also will focus on more complex cases, or on cases which could have been managed better.

So, here"s the problem. There"s a case I decided to do and put on the list. So, I have to present her. The issue is: she was really sick. ICU, ventilator dependant, hypoxic respiratory failure sick. And her diagnosis was obvious. But missed. Probably because she came from an outside hospital with a different (but incorrect) diagnosis. It was sort of a "failure of imagination" as it were, but because she had a relatively common complication of pregnancy (although it was a very severe form), she had multiple intubations and was delivered very preterm (likely would have happened anyway) without the benefit of steroids (which she would have had if the diagnosis had been correct.)

Because of all of this, because I think it"s important to look at our mistakes so that we don"t continue to repeat them, I"m going to present this patient. I was not involved in her care, and people who are my friends and colleages were. And I think that the correct diagnosis and course of action are particularly obvious in retrospect.

The thing that I"m struggling with tonight (other than the amniocentesis I"m about to do on an 18 weeker who has basically no amniotic fluid) is, how do I talk about this in a way that"s not going to offend those who were involved in her care. Because, afterall, the answer is really obvious in retrospect. The problem is that everybody just took the diagnosis from the transferring hospital at face value.

I"m open to any suggestions, but now I think I"m going to go face the impossible amnio, and then maybe go to bed, since I"ve been here since 8am, and I"m likely to be here well into tomorrow afternoon/evening.