Shahar Madjar, MD

His name was Gunapala and he was 23 years old. One day, around 11 o’clock in the morning, he arrived, accompanied by his mother, at the medical ward of Colombo Medical School in Sri Lanka. He was built like a boxer; his mother was a plump, working class woman in her 40s. She told Dr. Carlo Fonseka, “My boy was discharged from this same hospital yesterday. The doctor told me there was nothing wrong with my boy, but I am his mother, and I can tell that something is wrong with my boy.”

Dr. Fonseka knew the doctor that saw the boy the previous night and considered him an excellent diagnostician.

“My boy has tight feeling in his upper abdomen, and he can’t breathe well,” she said.

“Look,” Dr. Fonseka told the mother, “your son was discharged from this hospital yesterday; today you bring him walking to this already overcrowded ward. All the patients on beds in this ward are too ill even to walk. Are you asking me to transfer one of them to the floor and give his bed to your son?”

Dr. Fonseka’s mind was already made up. He sided with the previous doctor. He examined the boy hastily, decided that this was a minor case of pleurisy, and prescribed some antibiotics and aspirin.

Later that night, when Fonseka came back to round on his patients, the nurse told him that she had given Gunapala a hospital trolley to sleep on. “He looked too sick,” she said, “you should see him again.” Dr. Fonseka told the nurse that he knew better who needs closer observation and who doesn’t. He ignored her advice.

Four hours later, the nurse called Dr. Fonseka. “Gunapala is having fits,” she said. At that time, Gunapala had painful muscle contractions, his neck and abdominal muscles stiffened and his jaw spasmed, then locked. And finally he stopped breathing. Gunapala died.

Looking back, the diagnosis was obvious. These were the symptoms of tetanus–a serious disease caused by a bacterial toxin that affects the nervous system. The toxin is produced by the spores of the bacteria Clostridium tetani. These spores are found in the soil, dust, and in the feces of wild and domestic animals. Any injury can result in these spores entering the body. These spores then produce a toxin that leads to a fulminant, sometimes deadly, episode of tetanus. The typical story is that of a person stepping on a nail, or a splinter. But any injury resulting in a penetrating wound–from body piercings and tattoos to gunshot wounds–can have a similar effect. The resulting muscle spasms can be so severe that they may cause the spine and other bones to break.

Tetanus can be prevented by vaccination. In patients who hadn’t been vaccinated in the 10 years prior to their injury, a booster of tetanus vaccine should be administered without delay.

After carefully examining Gunapala’s body, the coroner asked Dr. Fonseka whether the patient had given him a history of stepping on a rusty nail. “No,” said Dr. Fonseka; but the truth was that he had never asked.

Dr. Fonseka could never come to terms with the death of Gunapala, nor could he ever erase from his mind the image of the grieving mother. Gunapala’s mother looked straight into Dr. Fonseka eyes. She said, “… I thought doctors knew everything about all the diseases in the world!” The doctor later admitted that this death was what drove him out of clinical medicine and into a research position in the Department of Physiology “where in those days you killed only frogs.”

In 1996, 36 years after the event took place, in an article “To err was fatal,” published in the British Medical Journal, Dr. Fonseka, then a 63 year old professor of physiology, admitted to four other fatal errors. ” He wrote that his admission “may embody nothing more or less than the confession of a fool.” He added, “If, however, by confessing to the world, a fool could help to promote, ever so slightly, the ideal of error free patient care, I believe that the fool has a scientific and ethical duty to confess.”

How often do doctors make medical errors? How can these mistakes be prevented? What lessons can doctors learn from their errors? What is the optimal way to recognize errors, and to allow for the growth of medical wisdom? So many questions, so little time. I will tell you more.

Editor’s note: Dr. Shahar Madjar is a urologist at Aspirus and the author of “Is Life Too Long? Essays about Life, Death and Other Trivial Matters.” Contact him at smadjar@yahoo.com.