Monday, October 8, 2012

Sometimes The Truth Is Scarier Than Fiction: A First-Hand Account Of A Medical Mistake

“To err is human; to forgive, divine.”
-         Alexander Pope

 It’s the time of year when people start thinking about immunizations, especially for the flu, and if you’re elderly or chronically ill, potentially a pneumonia vaccine.

I can see in my medical record that it is saying I am due for a pneumonia vaccine, which is typically administered every five years.

But when it comes time, I’m going to refuse it.  Don’t get me wrong, as someone with a crappy immune system, I don’t want to die of something like pneumonia.  But on the other hand, the vaccine almost killed me the first time, so maybe you’ll understand my reluctance. 

It’s also coming on Halloween, and Selena of Oh My Aches And Pains! has asked us to reflect on medical mistakes in the October edition of Patients For A Moment.

I’m transported back to my first hospitalization.  I remember the details like they were yesterday.

My rheumatologist told me to get a pneumonia vaccine.  I’m not sure why I didn’t get at his office, but I got it at the student health center.  When the nurse swabbed my arm, she did it lower than normal, and I commented that I thought it was a weird place for an injection.

She passed off my question like it was no big deal, and gave me the shot.

I went home.  That was Friday afternoon.  On Saturday, I woke up feeling awful, and noticed a red, painful welt the size of a quarter at the injection site.  I slept most of Saturday.  When I got up on Sunday, the quarter size welt had turned into a welt the size of a fist (see picture below). 

I called the doctor on call at the student health center.  First he quizzed me on the fact that I had a flu shot rather than pneumonia shot, and then proceeded to question me about why I had gotten a pneumonia vaccine.  In the end, he told me that what I was experiencing was “normal,” and that if it wasn’t better by Monday, I should come in to the student health clinic to get it checked out.

I happened to be talking to one of my blogger friends who also has lupus, and sent her a picture of my arm from my web cam (see picture below).  She was very concerned, and suggested that I call the rheumatologist on call at the hospital.

I did.  I received a call back from a doctor with a heavy accent.  The only thing I understood was her telling me to get myself to the ER.  And that’s what I did.  By myself, because I thought they’d give me a prescription and I’d be on my way.

But no.  Instead, I ended up in the hospital for three days.  At first, the doctors could not stop the infection from spreading.  By the time I got to the hospital, my entire body hurt, and I had a fever.

When all was said and done, at one point, the infection went from my shoulder to my elbow.  My entire arm was inflamed and felt like it was going to explode at any moment.   

The diagnosis was Cellulitis, an infection in the tissue of my arm, because in reality, the vaccine had been injected into my tissue rather than the muscle.  I was glad that no one had suggested to me at the time that Cellulitis and Necrotizing Fasciitis (Flesh eating disease) have very similar symptoms.  In reality, things could have been a lot worse. 

I was taking CellCept at the time, so I was put into reverse isolation.  (That was the only saving grace of the situation.  I scored a private room.  You have to focus on the positive, right?)

I was at a major research hospital, and they were telling me that they had never seen a vaccine reaction like mine before.

In the back of my mind, I wonder what would have happened if I would have waited until Monday, like the student health clinic suggested.  Chances are, I may not be alive today.

And that’s profoundly scary.

The student health center refused to take responsibility for what happened.  One nurse even accused me, telling me that I should never have been told to get the vaccine in the first place.  And the hospital never directly came out and said that the injection was administered incorrectly.  They agreed that the injection site was in a strange place, but they also thought that I was experiencing some sort of allergic reaction, as well. 

Mistakes happen.  All.  The.  Time.  We are human.  But medical mistakes can be deadly, even if what caused it seemed so innocuous to begin with.

Like getting an immunization at the urging of your physician to protect you from an infection that could be deadly to someone with a compromised immune system. 

According to an article put out by the Institute Of Medicine (1999), “At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented…Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.”

They define four main types of error categories: Diagnostic, Treatment, Preventive, and Other (IOM 1999).  In a study of family practices (outside the hospital setting), five types of errors were identified: Prescription errors, Laboratory errors, Filing system errors, Dispensing errors, and errors in responding to abnormal lab results (Dovey, et al. 2003).

Patients are not the only ones impacted by medical errors.  Medical professionals are also impacted.  Trust in the medical system goes down.  And so does morale.

The IOM estimates that these errors cost hospitals nationwide between $17 and $29 billion a year.

And medical errors, specifically preventable ones, go directly against the Hippocratic Oath, “First do no harm.” 

Sometimes the truth is scarier than fiction.

I never imagined that something like this could happen to me.  But it did.

I’m also lucky that I made it through going to the emergency room by myself.  But I truly thought that I’d be in and out relatively quickly.  I’m lucky, because as the infection spread and I got sicker, the clarity of the details of my story deteriorated.  Thankfully, there had been enough documentation in the process that this didn’t affect my care or treatment.

If you have any type of negative reaction from a vaccine, regardless of how minor, you should visit, and file a report with the Vaccine Adverse Event Reporting System (VAERS).  You should also make sure that you read the vaccine information sheet that is provided when receiving any vaccination. 

VAERS receives 30,000 reports annually, of which 13% are classified as serious, meaning they have lead to disability, hospitalization, life-threatening illness, or death.

I think the best piece of advice I can give is to follow your intuition as a patient.  Ultimately, I was right that the vaccine was being given in a weird place.  Yes, medical professionals are supposed to know what they are doing, and what is best for the patient, but in reality, this doesn’t always translate.

And if you haven’t been on the receiving end of a medical mistake, be grateful.  You’re one of the lucky ones.


Dovey, S., Phillips R., Green L., and Fryer G.  2003.  “Types of Medical Errors Commonly Reported by Family Physicians.  Graham Center One-Pager #16.

Institute of Medicine.  1999.  “To Err is Human: Building a Safer Health System.” 


  1. I too,reacted badly to the pneumovax and I will not get it again. Of course I worry about getting pneumonia, but as you and I k ow, there are worse things out there. I have been on the end of many medical mistakes and prevented even more by advocating for myself. It is so scary to have to be constantly on the defensive and it puts off the medical professionals who don't like educated and assertive patients. Thanks for bringing up an important topic.

  2. I'm so glad I have found your blog, I think it is going to really help me and become one of my go to blogs. I've recently started blogging myself after having a chronic (so far undiagnosed) illness for the past year and its so nice to find blogs like yours out there. Keep doing what you are doing!

  3. Blogger won't let me comment using my WP blog ID, so I'll try using a Blogger ID.

    I tried posting to this and it didn't work. But the short version is that a friend of mine got MCS and CFIDS from a flu vaccine (she'd been on the edge of illness and it pushed her system into collapse) and a year later, I got MCS and CFIDS, too, and I have always said "NO thank you!" to any vax suggestions since then. I'm glad you're still with us! Scary!

  4. I had a similar reaction to my first pneumonia vaccine, which was administered in my then PCP's office (except my bad experience ended after the ER without being admitted). It was before I was sick, and the PCP insisted I needed the vax because I have asthma, even though my asthma was mild and under control.

    I ended up with red swelling from my shoulder to my elbow, but when I started having trouble breathing, my now husband took me to the ER. The doc, who had ignored my calls to his office, later insisted that the ER and I had over-reacted and I didn't need the prednisone that got it all under control. It was a bizarre experience that I'd almost forgotten until I read your post.

    I remember that the redness and some slight raised texture lasted on my arm for over a year because it still showed on my wedding day over 1.5 years later. Weird.