I should've kept my mouth shut!

December 16, 2005

Long before HIPAA, an embarrassing incident taught this doctor that some conversations should never take place.

My best lessons in life and medicine have come from my worst mistakes. I've been so appalled or chagrined by something I've done that I vow never to do that again. One such encounter is appropriate to remember in this age of HIPAA regulations.

I was only a few years out of residency, working energetically as the only doc at a satellite clinic in a small town. I did full-line family practice, including ED, ICU, and ob/gyn. The area physicians rotated the responsibility of admitting patients who didn't have a local doctor to our 30-bed community hospital.

The night had been busy and I'd hardly gotten started when the ED called. A young pregnant woman had come in complaining of "cramps." When I arrived, I introduced myself to a quiet, pixie-faced woman whose swollen belly ballooned the hospital gown.

In trying to piece together her medical history, I determined she'd moved a lot during the pregnancy and received only sporadic prenatal care. She didn't know the date of her last menstrual period. She was also unsure regarding prenatal testing results and didn't know if she'd had an ultrasound. When asked her estimated date of confinement, Jane couldn't remember any dates she'd been told. "But it must be now," she said helpfully, "since the baby's comin'. " I began to wonder if Jane had had any prenatal care.

There wasn't a lot of time for discussion-she was in active labor and dilated to 5 cm. Her fundal height was 33 cm. The baby's heart tones sounded fine, but I didn't have records of serial measurements, ultrasound dating, firm last menstrual period, or early uterine size estimates. Was the baby pre-term, intrauterine growth retarded, or simply smaller? The fleeting idea of transferring the patient to a facility with a neonatologist was forgotten when Jane started to vomit. Sure enough, a quick check showed she was now dilated to 9 cm. As Jane had predicted, the baby was "comin' now."

We whisked Jane up to our delivery unit where an external monitor thankfully showed nice variability and no late decelerations. I briefly wondered how this labor could be progressing so rapidly, when it seemed every other first-time mother I delivered was in labor for days, with lots of time to make decisions about care.

Jane started pushing and 15 minutes later I held a beautiful, pink baby girl in my hands. Little Susie looked great, weighed in at a little under 6 pounds and looked to be 37 weeks gestation. Jane was thrilled; I was relieved and exhausted from the all the worrying I had done that night.

I share my frustration with my colleagues

The next day I was still tired. Time seemed to drag as I saw my morning patients, but I finally finished and left to make rounds at the hospital. Mother and baby were doing very well, snuggling and learning the ropes of breastfeeding.

After checking on several other patients, I went to the hospital cafeteria to get a quick bite before returning to the clinic. I sat with other doctors from town who, on seeing my bleary eyes, asked about my night on call. I talked about what occurred the night before, as I often did when I encountered a particularly challenging, draining, or unusual case, careful not to use any names.

As a group, we voiced our frustration at seeing patients without an adequate history, with no records, and whose previous care we knew nothing about. We groused about our "unassigned" patients and the difficulties we experienced being doctors for them.