I felt fine afterward, but within hours I developed neck pain with numbness and tingling radiating down my arms. I went to the emergency department (ED) of an elite medical center two days later, telling the staff that I was a neurologist with suspected cervical (neck) spine disease and possible spinal cord and root compression, a condition in my own specialty. I asked to have a cervical MRI scan performed, plus blood studies to detect a possible spine infection, as I’ve had one before.
The spinal consultant tested my reflexes with the side of his hand. When I asked about his reflex hammer he replied that he didn’t have one or need one — even though this is tantamount to evaluating the heart or lungs without a stethoscope.
He initially neglected to examine for the Babinski sign, a classic clinical test, which, if positive, would have strongly suggested spinal cord compression. When I remarked on this failure, he performed the procedure incorrectly. He checked my sensation with his index finger and did not examine other sensations, gait, coordination or hand dexterity.
The MRI showed clear-cut spinal cord compression due to arthritis, and a neck mass behind the spinal canal. It was an abscess — a pus collection — but the hospital’s radiologist read it as a blood clot. The blood studies revealed active infection: marked elevations in inflammatory markers, plus increased white blood cells of the “should be concerned” variety. These obvious and dangerous abnormalities were not pursued and I was not informed of them. I spent six hours in the ED, then was discharged and told to follow up with a spine surgeon within two weeks.
Two days later, I traveled home to Maine and reviewed my medical records online. I recognized the severity and complexity of my problem and went to my hospital, was admitted and underwent urgent spine surgery and long-term intravenous antibiotics. Left untreated, these abnormalities might well have caused a catastrophe: I could have become quadriplegic, unable to move my arms and legs or even breathe on my own. My response to the ED visit cannot be expected of the average patient, who would have been in deep trouble.
While recovering, I sent multiple letters detailing the specifics of my deficient care to the hospital’s chief executive. The hospital’s representatives responded, refusing to admit culpability or apologize for these failures. The spine service supervisor even excused the consultant, stating he “conducted the examination to the best of his ability.”
The lack of recognition of the serious infection went unmentioned in the representatives’ letters.
In view of the multiple serious medical errors committed during my ED visit, I offered to present and discuss my case to emergency and spine service staff. As a career academic neurologist, I thought a physician analyzing his own medical condition in his own specialty, intending to educate, would be an illuminating and teachable moment for medical staff and students and a healing opportunity for me.
In 1999, the Institute of Medicine