Indexing Title: MPADUA’s Medical Anecdotal Report [04-5]

MAR Title: Left-Right Disorientation

Date of Medical Observation: Nov, 2000

Narration:

I was on duty as a second year resident at the Emergency Room when a Surgery Pre-resident informed me that the Internal Medicine Department referred a 35-year-old male with a pneumothorax secondary to ruptured bleb due to pulmonary tuberculosis on the left. I browsed at the chest X-ray plate and noticed a 35% pneumothorax, I concurred to his decision to do closed tube thoracostomy on the left.

He prepared the materials and later on informed me that the patient is ready for the procedure. We performed the thoracostomy with another senior resident. After inserting the chest tube we let the patient cough but we did not note any bubbling. After the procedure, a repeat chest X-ray was requested.

After a few hours, the Internal Medicine Medical Clerk referred back the chest X-ray plates and noted the chest tube to be in the right place, with the last hole inside the pleural cavity. But what was significant was the finding of pneumothorax on the contralateral side of the chest tube. I thought that patient developed pneumothorax on the right.

I compared the first chest X-ray plate with X-ray plate post-thoracostomy and noted that we committed a mortal sin – we inserted the chest tube on the wrong side! I can not believe that it happened. We explained to the patient that we have committed a mistake and we would like to insert another chest tube on the right. Patient agreed to the procedure, knowing that his condition will improve.

Insights (Discovery, Stimulus, REINFORCEMENT):

This is one of the pitfalls of physicians, we are only human beings and are bound to commit mistakes. I was lucky at that time because the patient did not file any complaints against us. But I know that I committed a grave mistake for not checking the chest X-plates carefully. Since then, I always check the laterality of X-ray plates that is being referred to me not only once but twice. I hope that will never happen to any one of us again.