0:00

So, okay, now this is a, this is a case

0:03

that I was involved in.

0:04

Patient had headaches and seizures.

0:08

Patient had a nasogastric tube placement

0:11

for some abdominal, uh, pathology that was totally unrelated

0:16

to the headaches in and, and seizures.

0:19

And, uh, uh,

0:21

physician assistant puts in an NG tube, has

0:26

to struggle placing that NG tube.

0:28

The NG tube is curled multiple times in the nasopharynx,

0:32

and the, the NG tube is pushed in.

0:35

The patient bleeds from the nose, bleeds from the mouth.

0:38

So basically, uh, a lot

0:39

of struggle while putting this nasogastric tube in.

0:44

So what happens next is that, of course,

0:47

the patient is having seizures also.

0:49

So they get an MRI of the brain, and MRI brain shows this.

0:53

So there is, there is, uh,

0:57

T two signal within the sphenoid sinus,

0:59

but there is this soft tissue density within the sphenoid

1:02

sinus also, and there does appear

1:04

to be focal encephalomalacia

1:06

of the frontal lobe, uh, at that level.

1:09

And then on this axial T two image, you can again see

1:12

that there is some soft tissue density within

1:14

the sphenoid science.

1:17

So the case was brought that, Hey, this is all related

1:21

to the nasogastric tube,

1:22

because this was very a traumatic, uh,

1:25

episode for the patient.

1:27

It was patient bled from the nose,

1:29

led from the mouth, and blah, blah, blah.

1:31

Uh, but we all know it's very highly unlikely

1:35

for nasogastric tube to go up into the sphenoid sinus and,

1:39

and then come out through the, uh, roof of the sphenoid, uh,

1:43

sinus so that you can have herniation

1:45

of the brain program come out with a, uh, encephalocele.

1:48

Uh, so as, as I said, the next step would be

1:53

that you would be getting records from

1:56

the prior records on the patient if any other hospital was

2:00

involved, if the patient had gotten

2:01

scanned and all that stuff.

2:03

And that was, was done.

2:05

But unfortunately, the patient was scanned at the same

2:08

hospital, uh, about two years ago.

2:12

And so this is the head CT that was, uh,

2:15

from two years ago on the patient.

2:17

And you can see that, uh, there is, again,

2:21

sphenoid sinus is not clean,

2:22

but even, even on a CT head, you can make out the density.

2:26

Soft tissue density is pretty much similar

2:28

to the brain density here.

2:30

Uh, this was the bone window

2:32

and you can see again that encephalomalacia

2:37

of the inferior frontal lobe is also there.

2:39

And then of course, you can see the breach, um,

2:42

along the floor of the anterior cranial fossa, uh, roof

2:46

of the sphenoid sinus with herniation of the brain pro.

2:49

So this was a meningo encephalocele

2:53

that was present two years

2:55

ago. So what do you do

2:58

In a case such as this, now that, you know, a colleague

3:02

of yours had read this CT about two years ago,

3:06

and you are reading obviously that MRI

3:08

that I showed you earlier.

3:10

What would you do with that, with that report?

3:13

It becomes, sometimes it becomes a very

3:15

challenging situation.

3:17

Most of the times I think that you,

3:20

you reported the patient, the, the, the, the colleague

3:24

that had missed it doesn't get sued.

3:26

But obviously there is a good chance that they,

3:28

if there is outcome, the patient knows about it.

3:31

They may, they may go after the physician.

3:33

And, uh, so really in, in, in, in, in a situation such

3:38

as this, there are things that you have to do

3:41

and things that you should not be doing.

3:44

Uh, when you are dictating, uh, a case in which, you know,

3:48

the previous, uh, the,

3:51

the finding was missed on the prior scan, just use neutral

3:55

language, fact-based language.

3:57

So like, just like, like in retrospect,

4:01

the finding was present on the date of the study,

4:03

whatever date, date was,

4:05

or like on further review,

4:07

the abnormality is visible on the prior exam.

4:11

Uh, that that's a better way of putting it, rather than,

4:16

uh, saying that the finding was missed

4:21

or there was an error made on the prior exam

4:24

or the finding was completely overlooked on the, uh, on, on,

4:28

on the prior exam.

4:29

So try not to say those words rather than stick

4:34

to these, this neutral, uh, fact-based, uh, words

4:40

document the objective finding you, you,

4:41

you see a meningo encephalocele, you see fluid within the,

4:45

within the sphenoid sinus

4:46

and just stick to that, uh, rather than

4:50

why it was not reported on the prior scan.

4:53

Don't, don't try to rationalize that.

4:56

Just stick to your findings and,

4:58

and just the objective finding on your scan.

5:01

And then of course you have to communicate this

5:04

to the patient's care team.

5:06

That is, that is your responsibility.

5:08

If you feel like, uh, a significant finding

5:12

has been missed on the prior scan, no matter

5:14

how you like the way you dictated you, you have

5:17

to call up the team and let them know.

5:19

Uh, also, and as I said,

5:21

don't use accusatory terms error, mistake,

5:25

missed overlook.

5:28

Don't, don't use those terms in your, in your report.

5:31

Uh, and, and, and, and,

5:33

and avoid speculating on why it was missed on the

5:38

prior scan and,

5:39

and don't offer personal opinions that maybe

5:42

the scan had a bit of a motion and that's why it was missed

5:46

or, or, or something like that.

5:49

So don't, don't try not to do it.

5:50

And I never, ever, ever put something in the chart

5:54

or in your report, um, in which there will be

5:56

A professional disagreement, uh, that that's,

5:59

that's really not good.

6:01

Uh, so that's probably how you should, you should deal

6:05

with a situation such as this, uh, and, and, and, and,

6:10

and not try to throw your colleague

6:12

completely under the bus.

6:14

But obviously you have to communic communicate the,

6:18

the fact-based finding, the objective finding,

6:20

and communicate with the, with the team.

6:22

Also, if you think that this miss is significant

6:27

and not an insignificant one.