Recognizing Premature Closure – Day #1

This morning, our group had the opportunity to watch a film about Lewis Blackman and the medical errors he endured as a 15-year-old following a procedure for pectus excavatum. Afterwards, we were able to speak with Lewis’s mom, Helen Haskell. As Helen walked to the front to field our questions, I felt the mood of the room shift. I had never met anyone who knew a victim of medical error before, let alone a parent of a victim. This was such a profound experience in that I can now picture Helen’s face when I think about medical errors and the lives they affect – something that is so important, because it will always remind me of the humanity behind these mistakes and the reason we want to face them head on. I truly felt as though Lewis was standing beside his mother today.

The biggest takeaway from this morning’s film and discussion was the term “premature closure.” I had never heard this term before, but it is a perfect explanation of a personal habit I have been trying to combat. Premature closure was a major reason that Lewis’s diagnosis of shock went undetected, because the team assumed he was experiencing post-operative constipation and ileus. This was the simpler answer, one for which the team sought objective data (such as his sudden decrease in pain) to validate it.

A few months ago, I had a patient who was undergoing a trial of labor after cesarean section. This kind of patient is high-risk due to her history of a uterine scar (thus posing an increased risk of uterine rupture). When the patient reached about 8-9 centimeters of dilation, she began to experience a sharp increase in her pain. I notified the physicians and the anesthesia team, and the patient reported relief from the pain after anesthesia administered a bolus of her epidural medication. As a result, we assumed it was labor pain. About an hour later, the patient called out again with an increase in pain, and this time she began to gesture towards her abdomen where her previous uterine scar had been. I expressed my concern to the first-year and third-year residents who shared those same concerns. At that time, the patient was not bleeding and the fetal heart rate was stable, so we decided to monitor closely in hopes that she would reach 10 centimeters soon and be able to deliver vaginally (she had a successful VBAC a year earlier, so we knew it was a possibility). The next vaginal exam, however, revealed a number of fresh blood clots. We knew we couldn’t wait any longer, so we proceeded with an emergency c-section that revealed a partial uterine rupture as well as a placental abruption. The patient and her baby did well, but this was certainly a near-miss. Reflecting on that case, I am able to recognize that I was reasoning under the pretense of premature closure. I (plus the two residents with whom I worked) so desperately wanted the pain to be related to labor because a vaginal delivery is much simpler than a c-section. At the end of the day, though, our patient’s condition warranted a c-section, and we’re so very lucky that the outcome was not worse. I’m ashamed that I tried to explain away something that could be as dangerous and life-threatening as a uterine rupture, but I am hoping to learn from this case so that I can recognize premature closure and reverse it in the future. It is my goal to welcome differential diagnoses and effectively rule them out (or in) in order to keep my patient and her baby safe in my care. I do not want to be motivated by what is simple; I want to be motivated by what is safe. In order to accomplish this goal, I plan on re-framing my mindset (easier said than done!) by approaching all patient situations expecting the worse. This idea was a central tenet to Why Hospitals Should Fly, and I’m looking forward to our talk with John Nance to learn more about it!