BMJ  2003;327:1084 (8 November), doi:10.1136/bmj.327.7423.1084

Filler

A memorable patient

Don't place all your trust in machines

While attending a post-take x ray meeting as an orthopaedic senior house officer, I presented my sixth femoral neck fracture of the night. "Mrs X is a an elderly lady from a residential home, with left ventricular failure and advanced dementia. She was found on the floor in her room in the early hours of this morning, unable to weight bear. Plain radiographs show she has sustained an undisplaced subcapital fractured neck of femur on the right," I said as I flashed the radiograph up onto the screens.

My audience was quick to point out that the radiograph clearly showed a left sided injury, with the right side being normal. My consultant asked the on-call registrar, who couldn't remember the side, but the radiographer present in the meeting was eager to assert that, with the advent of digital imaging, "the laterality marker is placed on the radiograph by the computer so it must be correct, it must be the SHO who has made the mistake." As I expect any other tired senior house officer would have done, I apologised and made a mental note to change the operating list.

When we arrived at my patient on the post-take ward round the team launched into another discussion of how important it was to identify the correct side of injury, since one would be a long way into a hemi-arthroplasty before finding that a mistake had been made. Because of her dementia, the patient was unable to contribute to the discussion. The registrar then drew back the sheets to show the large black arrow she had drawn the night before, and the grimace on the patient's face when the leg was rolled in the bed. As expected from an undisplaced fracture, there was no deformity. Suggestions about how one should avoid making such mistakes were volunteered. Thoroughly disheartened, I kept quiet.

Fortunately, the consultant took the time to examine the "good side." On drawing back the other side of the sheets, he found the large black arrow that I had drawn the night before. On his moving the right leg, the patient displayed a great deal more discomfort, and it was obvious the fracture was on the right!

Needless to say, I am now careful to be a little more trusting of my memory and little less trusting of machines.

John Radcliffe Hospital, Oxford

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