In the middle of a routine upper endoscopy, a highly experienced gastroenterologist kept insisting that polyps in a patient’s stomach were colon polyps. He tried to take photographs by pressing the scope’s steering dials instead of the camera button.
The endoscopy nurse recognized the behavior as bizarre and alerted her supervisor. The physician was sent to the emergency room, where doctors found the cause: a kidney stone blocking his urinary tract, a urinary infection that had spread into his bloodstream, and dehydration.
He was one of two veteran endoscopists whose sudden confusion during procedures was described in a 2020 report in the World Journal of Gastroenterology by Mitchell Cappell, former chief of gastroenterology at William Beaumont Hospital in Royal Oak, Michigan. The cases came from 181,767 endoscopies performed over 13 years.
Polyps in the Wrong Organ
The first physician was described as elderly, highly experienced, and normally highly competent. Over the previous 24 hours, he had progressive pain in the lower left abdomen, had barely eaten or drunk, and felt dizzy when standing.
In the emergency room, his temperature was 37.9 degrees Celsius, about 100 degrees Fahrenheit. He had high blood pressure and dry mucous membranes. He knew where he was and the year but not the month or day. His white blood cell count was elevated, and his kidney function was impaired.
A CT scan showed a 5.5-millimeter stone blocking his left ureter, the tube connecting the kidney to the bladder, along with swelling of the kidney and an enlarged prostate. Head imaging, heart tests, and a drug and alcohol screen were normal. Doctors diagnosed toxic encephalopathy, brain dysfunction caused by a body-wide problem, in this case urosepsis and dehydration.
He received fluids and antibiotics, and a stent was placed to relieve the blockage. He was then switched to oral antibiotics, and the stone was removed about 10 days later. He went back to seeing patients and performing endoscopies about 10 days later, with no lasting neurological problems.
Pills From a Stranger
The second physician was middle-aged and also described as highly experienced. The night before, he had taken a 5-milligram dose of diazepam and drunk about 24 ounces of beer for back pain. He had then fasted for 16 hours.
After completing one uneventful procedure, he took two pills, described as Motrin, that a stranger handed him, a moment that was witnessed. During his next upper endoscopy, he insisted he had reached the small intestine when he was still in the stomach, turned the steering dials wildly, and forcefully bumped the scope’s tip against the stomach wall.
He was dizzy and confused about the time. By the time he reached the emergency room 30 minutes later, he was fully oriented. Brain imaging, heart tests, and bloodwork were normal, and a drug screen was negative. Doctors attributed the episode to brief toxic encephalopathy, possibly from the pills, worsened by dehydration. He was observed overnight and resumed work three days after discharge.
Nurses Were the First Line of Defense
In both cases, the endoscopy nurses recognized the problem and alerted the nurse administrator, who called the chief of gastroenterology. The physicians were told to stop the procedure, cancel the rest of their day, and go to the emergency room. Both complied.
Cappell called the problem a medical emergency because a confused endoscopist could injure a patient, for example by perforating the digestive tract. He proposed a protocol: recognize the incident as urgent, notify the department chief, and immediately abort the procedure. The paper’s title ends bluntly: “Endoscopists, first do no harm!”
Cappell served as chief of gastroenterology at the hospital from November 2006 to September 2019, intervened administratively in both incidents and then investigated them for quality assurance.
The episodes were extremely rare, occurring in about 0.0011% of endoscopies, and a computer search of the hospital’s records found no other procedures aborted for this reason. The review excluded surgeons who perform endoscopy, because their procedures went through a separate quality-review pathway. Cappell’s literature search found reports of impaired surgeons and anesthesiologists, mostly involving alcohol or drug dependence, but no prior reports involving endoscopists.
Doctors Get Sick Too
The cases highlight that sudden confusion can come from common medical problems. Confusion or disorientation is one of the warning signs of sepsis listed by the CDC, along with fever, a high heart rate, and extreme pain or discomfort. MedlinePlus lists infections, including urinary tract infections, among causes of delirium, along with alcohol and certain medicines. Fever and chills alongside kidney stone symptoms are a reason to see a health care professional right away, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
Professional ethics already call for colleagues to step in. The American Medical Association’s Code of Medical Ethics says physicians should intervene with respect and compassion when a colleague cannot practice safely.
The report has limits. It is based on two cases reviewed by one author, who acknowledged that two incidents cannot reliably define a syndrome. Neither patient undergoing endoscopy was reported to have been harmed.
For patients, the cases are a reminder that endoscopy teams include more than the physician. Nurses and staff who feel empowered to speak up can stop a procedure before anyone is hurt.
Key Questions Answered
What happened during the endoscopies?
Two experienced gastroenterologists became confused mid-procedure. One called stomach polyps colon polyps, and the other misjudged where the scope was.
What caused the confusion?
One had urosepsis from a blocked kidney stone plus dehydration. The other likely reacted to pills from a stranger, worsened by dehydration.
Were patients harmed?
No harm was reported. Nurses recognized the problem, and both procedures were stopped.
How common is this?
Very rare. The two cases occurred among 181,767 endoscopies over 13 years.
What should happen if a doctor seems impaired during a procedure?
The report recommends treating it as an emergency, alerting the department chief, and stopping the procedure immediately.
Published by Medicaldaily.com
