Missing: A death forces a physician to ponder the way she communicates with her patients and their families. Rochester Review • University of Rochester

I stared down at my name typed next to the word "Defendant." Below my name, small print said, "You are hereby required to appear and defend the complaint filed against you . . . "

What complaint? More neat typing filled another line with "the Estate of Helen F. Simmons, Deceased." Helen? I knew her. Deceased? Oh, no. She was in her 40s, but she'd already had at least one heart attack. I realized I hadn't seen her for a while. My god, what had happened?

That was a subpoena. That's how I heard about my first malpractice suit.

On the next page was, "estate of helen f. simmons, deceased, plaintiff, vs. merilee d. karr, m.d., defendant." And there was the answer I was looking for, "Complaint: Wrongful Death Based on Medical Negligence."

Oh, my god. Deceased. It was me. I killed her. My knees swam, and I couldn't breathe.

Finally. It was like I'd been waiting for this. With every decision and every patient since medical school began, I've grilled myself: What if this is wrong? What else might this person have? What if I'm wrong? We all do, on this end of the stethoscope. Now a woman was dead, and I was no longer the only one accusing me of negligence and malpractice. All the doubt that came with my diploma slammed home. Finally I knew. I just wasn't good enough.

As I stared at the subpoena on my desk, the bustle and chatter of the clinic swirled around me, and I realized that the whole clinic knew. No one had spoken to me since the subpoena had arrived. When I looked up, Cheryl, our office manager, stood next to me. She asked me how I was doing, and I told her I wasn't sure. She made phone calls: Our malpractice insurer would assign a lawyer to defend me. Our office would copy the patient's chart for the lawyer. I wanted a copy, too. I read it until late that night, and over the following months, looking for one thing—what had I done wrong?

The subpoena arrived in March. My last note in Helen's chart was from the previous August—nine months after we had first met. She had gone to our community hospital with chest pain, and was admitted for overnight tests. The next day, December 24, I was responsible for our hospital patients. Helen had not had a heart attack, according to her tests, and her pain was gone. But she was, I realized, a time bomb. She had heart disease up and down her family tree, she smoked, and her blood pressure was high. There was a heart attack out there with her name on it.

She was friendly, telling jokes in her hospital bed. I told her she hadn't had a heart attack, but that I was worried she would sooner or later.

She wasn't worried. She wanted to go home and have Christmas.

So I decided to get her attention. Her EKG that morning was essentially normal. But not entirely. One of the EKG squiggles is called a Q wave, a dip before the spike with each heartbeat. Dead heart muscle shows deep Q waves, as low as the spike is high. The normal EKG also has Q waves, but little ones, less than a third the size of the spike.

Helen's EKG had normal Q waves. But that's not what the EKG computer said. The interpretation programs that come with the machines are hypersensitive. I suppose the reasoning is that oversensitivity is better than undersensitivity. Right on her EKG, the machine had printed "Probable inferior infarct, old." I had a teaching aid.

I told Helen she could go home. Then I showed her the EKG, and told her that, though her chest pain the night before had not been a heart attack, it looked like she could have had a small heart attack already, sometime in the past.

Her eyes got big. I waited. She said she'd tried to quit smoking before, gotten crabby, and started again. I said quitting was hard, but worth it.

I didn't see her again for a month. One day in January she came in with bad chest pain. She looked terrible, frightened and crying. I ran a quick EKG—very abnormal—and sent her right up to the hospital. That was her only official heart attack. When I saw her later in the hospital she was calmer, and very serious. She had actually quit smoking a few days before. She'd tried to exercise, probably not a good idea at the time.

A few days later the cardiologists reopened a cholesterol-plugged artery in her heart. After that, she exercised regularly without chest pain. She lost weight and stayed off nicotine. I saw her every month or two through the winter, spring, and summer, congratulating her on her progress and adjusting her meds. She had another bout of chest pain that spring, and stayed in the hospital overnight. That time her morning labs showed no heart attack. She was 44 years old.

That brought me, time-travelling through the chart, up to our last visit, in August. So far I hadn't found a lethal error, so it must have been in that last visit. In detail after detail, her chest pain that day fit the pattern of heartburn, not heart pain. The pain was almost constant—angina lasts for a few minutes at a time. She did not have the left arm heaviness or nausea that she had had with her previous heart attack. Most convincingly, she said she could work out for hours in the gym without pain. I ran an EKG on her, and it was normal.

It sure sounded like heartburn. I gave her an acid blocker, and scheduled a phone call for the next day. In that phone call, she said the medication helped. So I gave her a stronger acid blocker. And never saw her again.

I didn't talk to my partners about all this. In medicine we don't talk about our mistakes. I sent a lot more people to the hospital for chest pain. I no longer trusted my teachers or my books to tell me the difference between heartburn and a bad heart.

I knew Helen had died sometime after seeing me that August. I didn't know how she died, or when, until the pre-trial deposition of Helen's adult daughter, months after my subpoena arrived. Helen's daughter found her in bed one morning, ten days after that last appointment. Helen had died in her sleep.

Oh.

That meant that what had probably killed Helen was her heart suddenly jumping into a bad rhythm. Heart muscle damaged by a previous heart attack can fall into a strange rhythm at any time. We didn't then, and still don't, have any good way of predicting which damaged hearts are likely to do that, or when.

What killed Helen is called sudden cardiac death. There's one good drug that keeps a heart in its proper rhythm, but it can only be given intravenously, with careful monitoring. The story of heart rhythm drug development is a search for a safe, effective pill that patients can take at home—there's still a long way to go.

Helen had died of something that I couldn't have predicted or prevented.

Maybe I hadn't screwed up. Maybe I was good enough to do this. Not perfect. But good enough to care for people and help them, as much as nature and technology would let me.

I wasn't prepared for that. Learning from my subpoena that I wasn't good enough to be a doctor hurt. But it was no surprise. It was like the other shoe dropping, a constant theme of medical training. Learning I hadn't done anything wrong—at least not this time—I didn't know what to make of that.

I did know that, whatever the facts, whatever the legal outcome, I would always be responsible for Helen's death in her family's eyes. And if the jury agreed, others would consider me responsible. My name would be on national lists of doctors who had lost malpractice suits—the bad-doctor lists.

The trial took 10 days, at the red brick county courthouse a few blocks from the clinic.

In her testimony, Helen's daughter gave me another side of her mother's story—the part about working out in the gym for hours without chest pain. She testified that Helen could only stay on the exercise machines a few minutes before she had to stop—and rest until the chest pain went away.

Helen had lied to me. Perhaps that was fair—I had lied to her. Patients and doctors lie to each other for all sorts of reasons. I lied to her to save her life. Helen lied, I think, because she was playing a role, the good patient. She told me what she thought I wanted to hear. Maybe she wanted to hear me congratulate her again on how well she was doing.

But I didn't see through her. That's where I failed. I don't know if I could have helped, but missing that will always be with me. How many other cheerful lies and half-truths have slipped past me?

I "won" the case and went back to work. I call it my first malpractice suit. There hasn't been a second—yet—but I don't want to get overconfident.

Merilee Karr '75 is a family physician practicing in Portland, Ore. This essay is adapted from one she wrote for Silence Kills, a 2007 collection of personal essays about medical errors and communication published by Southern Methodist University Press. © 2007 by Merilee Karr.

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