Vaginal Bleeding


Topic: Pain in the Hip


A description of the scenario
A 32 year old woman presents with vaginal bleeding. She is booked for D&C, but this is canceled twice (doctor sick, hospital full). When being admitted 11 months after booking as you put on your gloves, she tells you that you are the first person to attempt an examination in 3 years.


Here are the tasks assigned to students
1. The "Ideal Oncology Curriculum" says that you should have a general idea about the health system. Reflect.
2. List the diseases causing vaginal bleeding, and then group them for impact of delayed diagnosis.


Here is a copy of the oncologist's thoughts about this case - what was said and the presentation

When I read this scenario, I have a premonition. Why am I being asked to comment on this case in a Cancer forum? Because it is obviously a cancer! Reflecting on the performance of our system and people can be downright depressing, or can fine tune our own performance.

Firstly I take it as a given that I am not going to make the same kinds of mistake. A well known book by E. E. Gordon has a pertinent quote for this scenario. He was talking about collapsing building, but the sentiments are applicable.
"… much more often the 'real' reason for an accident is preventable human error.
It is rather fashionable at present to assume that error is one of those things for which it is not really fair to blame people, who, after all were 'doing their best' or are the victims of their upbringing and environment, or the social systems - and so on and so on. But error shades off into what it is now very unpopular to call "sin". …I have been forced to the conclusion that very few accidents just 'happen' in a morally neutral way. Nine out of ten accidents are caused, not by more or less abstruse technical effects, but by old-fashioned human sin - often verging on plain wickedness.
Of course I don't mean the more gilded and juicy sins like deliberate murder, large-scale fraud or Sex. It is squalid sins like carelessness, idleness, won't-learn-and-don't-need-to-ask, you-can't-tell-me-anything-about-my-job, pride, jealousy and greed that kill people."
J.E.Gordon Structures or Why Things Don't Fall Down; Da Capo 2003

So let's make some predictions - at the D&C, when the patient goes to sleep, the O&G does a vaginal examination, blanches and realizes the mistake. We say in medicine - " if you don't put your finger in it, you put foot in it".
But perhaps we should look back first to discover the antecedents of this disaster. Why no PV in three visits? Tired, distracted by a phone call, confusing patients and thinking you had done it, too many patients on the day, had a migraine, patient did want me to, no nurse available. Could that be you or I? I have no doubt it could be me.

What about the system? Health is very expensive. And we produce nothing. A big black hole for money. If you thought ocean racing yachts were a drain on finances, run a public hospital! But how does that affect me, and later you? Well, anything that a manager can do to make us see more patients reduces their employment bill. How do they achieve this? Pressure? Expectation? Do we help do it to ourselves? When clerking 40 patients today, does one intern feel superior to another who sees only 25? Do we have to be comfortable as we work? Do we work better and faster under pressure? Do we work better and faster under too much pressure?

Finally what does the doctor do? We enjoy the respect and trust of patients in the good times, what do we do when we make a mistake? What do humans do? What do managers tell us to do? What do lawyers tell us to do? What's the difference between a lawyer and … NO! Sorry

It's not too pleasant. Its not too enjoyable. It takes too much time. But occasionally its necessary because 11 months later it is too late.

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