Fieldset
World Malaria Day, Medical Errors and Humility

Every doctor has at least one in his or her closet. Call them medical errors, therapeutic misadventures, preventable adverse events, whatever. But we all have them. Any doctor who doesn’t, hasn’t practiced long enough. I added one to my closet on Malaria Day.

Every doctor has at least one in his or her closet. Call them medical errors, therapeutic misadventures, preventable adverse events, whatever. But we all have them. Any doctor who doesn’t, hasn’t practiced long enough. I added one to my closet on Malaria Day. Thankfully the patient survived, despite me.

He was just a little boy, around 4. Maybe it was because I saw him late at night and I was tired, maybe it was because the examining room was dark and my eyes are getting weak, maybe it was the more than 300 cases of pneumonia already seen in the month of April. I am grasping for excuses. The paramedic made his initial assessment; the chart said “severe pneumonia, refer to doctor”. Just another pneumonia I thought, cough, rapid breathing, nasal flaring, but I can’t really hear any crackles in his chest; not listening in the right place I rationalized. Admit, antibiotics, paracetamol, oral rehydration. Back to my tukul.

The following day the little boy is getting worse. I take a good long look at him this time, the thing I should have done the night before. I pull down his lower lid; the conjunctiva is pure white. Our nurse asks, “Was the parachek (the rapid test for malaria) negative?”

The child has malaria! Start the self-flagellation.

His hemoglobin is reported as 2, the lowest hemoglobin I have ever encountered. The malaria parasite has invaded and consumed most of his red blood cells. He gets worse before he gets better. We give him IM Artemether and a blood transfusion. I feel terrible. By Day 2 he looks a little better, by Day 3 I am starting to feel hopeful, by Day 4 he looks like a rose.

I will always remember this child and I will never, ever, (never say never) make this mistake again.