Who’s To Blame?


Over the years I’ve gotten many calls like this one. “Will you look at this case? Something very bad happened and I think someone screwed up.” They seldom say it quite that bluntly, but that’s what they mean.

Over the years I’ve gotten many calls like this one. “Will you look at this case? Something very bad happened and I think someone screwed up.” They seldom say it quite that bluntly, but that’s what they mean. Sometimes its a lawyer, though I don’t take those calls anymore. But often times it’s a family member of a friend of an acquaintance of someone who met me once.


I hate getting those calls. But I feel obligated to do what I can to set the record straight before it starts getting twisted by attorneys and paid experts. And just in case someone is still wondering, though I once practiced law along with medicine, that’s history now. I don’t represent myself as an attorney, I don’t give legal advice, and I don’t refer cases where I conclude that there has been negligent care. I just try to give them some honest information.

The case that comes to mind was one as heartbreaking as it was frightening. A seemingly healthy young man, not yet 21, the pride and joy of his family, went to a local hospital ED with the complaint of abdominal pain. After an evaluation that revealed nothing of substance, the EP decided to admit the patient, taking a ‘wait and see’ attitude. While treating his pain, he admitted to the parents that he wasn’t sure what was going on. After waiting in the ED for approximately 15 hours, all the while complaining of severe, unrelenting pain, he suddenly and inexplicably died.

That’s right. A ‘healthy’ young man died in the ED of no apparent cause.


The young man’s father was Asian and I could tell in his manner that he was not given to public displays of his emotion. But as he asked me to investigate this case, he went back and forth between the frustration of the tragedy and the loving memories of his first son. I vacillated between the fear of being unable to give a satisfying response or worse, having to face and reveal the failure of a colleague. I finally agreed to meet with the father and examine the records. He seemed relieved, presumably believing that I would have a final answer. I, on the other hand, was filled with dread.

Upon entering the home, I noticed that the family had prepared a sumptuous meal. They acted as if the evening was just an expression of gracious hospitality. The facade was broken, however, when my wife, who had insisted on accompanying me, saw and embraced the deceased young man’s aunt, our connecting friend. She held her and wept with her as only women seem to be able to do. All I wanted was to get down to business. The thought of the record examination hanging over my head while eating gave me nausea. So after the briefest introductions and small talk I asked to see the papers.

The father did not have any records of his son’s previous medical care. He said that he had been relatively healthy all his life. He’d had not broken bones, no severe illness. He was an active young man who enjoyed breakdancing with his friends so much that they had scarred up the wood floor of the family’s dining room spinning on their helmeted heads. His only medical problem was that he had suffered a spontaneous pneumothorax about a year prior to this incident that would not heal with treatment by a simple thoracostomy tube. Instead he had required a segmental pneumonectomy.

He had no significant family history of anything. The family had immigrated from Asia one generation before, but there appeared to be no indication of anything suspicious.


After avoiding it as long as I dared, I finally launched into an examination of the ED record. Severe abdominal pain, mostly right lower quadrant, with some radiation to the back. Vague, but sharp at times. Associated with some nausea and dry heaves. No fevers. The pain had started a hour or two after a vigorous workout. Without knowing what eventually happened, it looked like many other kidney stones I had seen. Odd, and confusing, was the fact that the patient had a leukocytosis on the initial draw. I could see the EP asking himself whether this was possibly an appendicitis. The unenhanced CT of the abdomen didn’t help much. No stone was seen. Nor was the appendix. The mesentery was noted to be thickened.

And a lymph node was enlarged. But that could mean a lot of things, I thought. I searched the record for any clue that would suggest that the patient was in any kind of distress. Nothing. My mind jumped from what the EP knew from his perspective to what I knew now. It was at once confusing and crushing.

“So what happened then?” I asked the young man’s father.

“His eyes just rolled back and he fainted. Everyone rushed in a began working on him.” They said his heart stopped. In my minds eye I could see the bewilderment of this sudden code. “They put a needle into his heart, but they didn’t get anything.” I presumed that a pericardiocentesis had been performed. Then they put a tube into his chest and got a lot of blood.” I felt a certain identity with the clinicians as it appeared that they were finally getting to a cause. But why would this young man have blood in his chest?

Restraining my curiosity no longer I turned to the autopsy results. “Aortic dissection” was the final diagnosis. I sat stunned. I had seen pictures of this young man. He didn’t have Marfan’s syndrome.

Could he have had a coarctation that led to dissection? Then I got into the details of the description of the vasculature. A dissection that started at an avulsed testicular artery and extended over the aortic arch all the way down into the spermatic cord before it ruptured into the pleural space. ‘Friable vascular walls raising the possibility of Ehlers-Danlos Syndrome’ was the comment of the pathologist. I questioned the father about elastic tissue. No?

I sat quietly processing the awful scene, a whole team of physicians and nurses trying to resuscitate a young man who had quietly exsanguinated right in from of them. “There is no possible way they doctors could have known what was happening with your son,” I said to the father with finality. “I know that you want to find someone responsible for this awful tragedy. But they did the best anyone – -and I mean anyone – could have done under this circumstance.”

“But 15 hours? Couldn’t they have done something?” he asked plaintively.

“I am so, so sorry for your loss,” I said, wishing I could reach across the room to comfort the soul of the grieving man. “But the doctors acted reasonably, by anyone’s standard.” I began scanning the ED chart one last time to see if anything at all would give a clue, some insight into the final outcome. Then I saw it. It wasn’t a clue to the diagnosis. But it was a clue to the depth of the family’s pain. The ED record clearly recorded that the patient and his mother were offered the opportunity to have an elective exploratory laparoscopy. There were no details of the discussion. But it appeared that they were given the one opportunity to possibly discover the cause of his illness…but declined. While I felt that no surgeon could have found and adequately repaired this occult injury, I feared that the mother was blaming herself for what she perceived as her failure.

“You need to tell your wife that it was not the doctor’s fault. But you need to tell her it wasn’t her fault either. Sometimes bad things happen. And it’s no one’s responsibility.”


  1. I’m glad you saw it through to the end… and discovered the underlying self-blame of the parents. Sometimes it really isn’t anyone’s fault.

  2. I enjoyed reading this very much and can imagine, like you did, what the experience must have been for both the family and the team involved. Tough stuff.

  3. Thomas Richardson on

    Thank you for this article. It is something that, if you practice long enough, will happen to any of us, and also is one of the hardest things to teach young doctors coming out of residency—sometimes you can do your best and badness happens anyway. Whether a strange diagnosis like this, or you treated someone appropriately i.e. tPA for MI and they bled in their head, it just happens. If only that lesson could be an entire class in law school as well.

  4. Adan Atriham on

    There no doubt that aorta pathology is heard to diagnosed and also deadly.
    I had one case in a young man (30’s) who’s only complain was severe rectal pain, after a negative basic evaluation, a CT abdomen was done with contrast showing a Ao dissection into the iliacs. The explanation for his rectal pain was a possible embolus occluding a small branch to the rectal artery.

  5. Anytime someone dies, it is a loss. Grief and sorrow are certain to follow. No matter how old or how young, how sick or how healthy, a loss is a loss. The title “Who’s To Blame” is very telling. The answer to this question varies as the vast and diverse believes of Mankind do. There are several combinations to the problem and the reaction. Sometimes, there is someone to blame. The reaction may be that the person to blame gets the deserved consequence; i.e., a law suit and a verdict or a settlement. Sometimes, the person to blame gets nothing. However, when there is no one who can be blamed and nothing happens, that is a relief. The biggest problem that faces Physicians in general and Emergency Physicians in particular, when there is no one who can be blamed, but someone wants somebody to be blamed, or in another words, pay a price.

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