I saw a patient recently who described a four day history of severe RUQ abdominal pain that started shortly after consuming a slice of extra cheese meat lovers pizza. The pain was piercing, like a through and through spear wound. She had been vomiting and febrile and she looked quite a bit like absolute hell. Her CT done by the ER showed an ugly distended gallbladder. Her labs demonstrated an elevated WBC (over 20k) and mild early acute renal failure (creatinine 1.9, up from baseline). On exam, in addition to peritoneal signs in the upper abdomen, she had some sort of complex pressure dressing on her right groin.
-It's the same pain I told them on the other day, she said
-Told who? You went to an urgent care?
-No, I was here. They sent me home. I told them I was still hurting.
-What's that bandage on your groin?
-They did a heart scan, made sure I wasn't having a heart attack
-I see, I said. I'm not going to be sending you home. You don't have a heart problem. You need an operation.
I checked the medical record on the computer to confirm what I already knew. She came in three days prior with a diagnosis of "chest pain". Now, to be fair, many gallbladder attacks present with upper abdominal/lower chest pain. However, rather than a complete work up to determine the source of her discomfort, she went directly from the ER to the cath lab where angiography was performed in order to prove she had completely normal coronary arteries. She was discharged home 6 hours later. She had been seen and examined (allegedly) by an internist and cardiologist. The electronic medical record appeared pristine. Discharge summary airtight. The home medications had been reconciled. Explicit post-procedure instructions provided. Follow up care had been documented. She had been processed, on paper, perfectly.
I called the OR to book the case. It was 11pm on a weekday.