"How did you miss that?"

I stared at her with incredulity as she related what had transpired since your transfer a few days prior. The etiology of your recent stroke was discovered to be a vegetation perched on your heart valve. It was sending out a shower of infectious emboli which passed through your circulation wreaking havoc. One of these splinters took your speech; another robbed you of the movement of your right side; en masse, they ended up taking your life. Indeed, how did we miss that?

I didn't understand how that could happen - what went wrong that such a grave diagnosis could have been missed? I pored over your chart looking for answers. A single fever. There were no repeat blood cultures as it didn't quite meet that arbitrary temperature cutoff. The infectious disease team had already signed off following the adequate treatment of your prior bacteremia. The stroke happened over the weekend and whomever was covering initiated the basic workup. I flipped through the bowels of the chart and found it. An echo which drew attention to the ticking time bomb on your valve. This hadn't been acknowledged until your transfer where fresh eyes were laid upon your case. Was it the cardiologist's fault for not calling in the report over a weekend? Was it the nurse's fault for not seeing the result when he returned from the test? Was it our fault? Was it mine?

They told me your family was taking it well; they were singing hymns at your bedside at the end. I remembered the crinkling of your eyes and your deep laugh as you joked with me at your bedside. I knew you for a few short weeks but I could tell that there was a real kindness about you. You were a very matter-of-fact man. After all, you had told me you were not afraid to die.

In retrospect, I realize I was looking for someone to pin the blame on as a way to exonerate myself. But there was no specific responsibility - it was on everyone and no one at the same time. The stroke may have accelerated your end, but your preexisting comorbidities were always there. Initiation of antibiotics sooner after discovery would not have changed the outcome. If not the stroke, the cancer would have done it. There was no negligence. Your clinical course fundamentally did not make a difference in what happened. But it did humble me by demonstrating that errors and omissions are inevitable - it's not an 'if', it's a 'when'. And we aren't defined by our mistakes but more how we deal with them.

Since then, I always look for the echo report.