Tuesday, July 22, 2008

Really Rough

I didn't blog about all this when it happened because I didn't know what to say. I'm also working very hard to maintain anonymity (for me) and confidentiality (for my patients) on here, so it's difficult to write about things. But here goes. (Read at your own risk--this is not happy).

Friends, I thought I had killed a patient the other day.

It was a totally bizarre situation. I was just thinking to myself that she'd been in the hospital too long, and had been working with case management to get him "placed" out of there. I get nervous when I look at the roster and see that a patient's been in the hospital longer than a week, because complications go up exponentially after a certain period of time (for example, I think the UTI rate with an indwelling Foley is nearly 100% by one week). On the neuro floor, a UTI is not the benign thing it may be in other places, like an outpatient OB/Gyn clinic. On the neuro ward, a UTI can present with altered mental status or even concurrently with stroke, and can lead to sepsis before we even know the patient has a UTI, because often they can't tell us it burns when they pee, because they've had a stroke or they have diabetes and don't feel it or they have a Foley and it hurts all the time anyway.

Anyway, I'd started working on things to get her out, and then I was off part of that weekend, so someone else rounded on her. And I picked her back up Sunday, and none of us noticed that one of her medications had disappeared after Friday. I continued to say in my notes "DVT prophylaxis with subq heparin" without noticing that my med list, which is imported from the actual med list in the computer, did not show heparin. I did not have her on TED hose and SCD's simply because I didn't know you could gain benefit from using those together with heparin (heparin as opposed to LMWH because my attending likes it.) We were working hard to get her out, and we'd found a good place for rehab...

And then one morning I came in to find out there had been errors overnight. She had a vital sign in the range of "notify house officer" that wasn't reported. Cursing that morning, I ordered lab tests and x-rays, but at least she looked okay on exam, in fact slightly better than the day before.

And then her father called us in, because "she didn't look right". I went in, and indeed she did not, breathing fast and sweaty, but still awake, still trying to talk. She was tachypneic and tachycardic, so I ran to get my chief. "She's on heparin, right?" he asked me. "Of course she is, we ordered it," was my reply. Famous last words, as we looked through the med list and caught the omission. I asked the nurses, who called the pharmacy, who finally told us that heparin orders expire automatically 7 days after admission. WTF? No one knew that this was the policy, and I hadn't received a notice in my computer system, nor did the medicine show up in my "expired orders" list. It just vanished.

We got her a dose right away and started workup for PE, but not long afterwards she coded and died. I helped with the code (although I did NOT run it--I left that to a third-year medicine resident, and I did chest compressions like a good little intern), and then left to write some orders for another patient. Sitting there, out of the melee, I burst into tears. It was all my fault! I'd killed her, I was a terrible doctor, only a few weeks into my training! It was the most bone-squeezing gut-wrenching hot burning guilt I've ever experienced. It was totally intense. My attending asked some probing questions about what happened, and I told him about the heparin error. Even though we weren't sure why the patient had coded, as we had no direct evidence of PE, it loomed large in all our minds.

All night, I was miserable. The next day, I went into the autopsy I'd had to request from the parents, and was greeted with some sweet words: "there's no saddle embolus." In fact, there was no PE at all. We are still waiting on a cause of death, but it seems that my error had nothing to do with it.

Now, I'm trying to figure out how to get past this. I check and double-check everyone's DVT prophylaxis orders, and the hospital is going to revise their DVT protocol and oversight. Still, I feel some guilt, as well as just sadness and trauma from the sudden death of a patient I'd seen for over a week, who was supposed to be on her way home.

I spoke to my psych chief resident today, and I just have to say that they are super wonderful. I'll be meeting with them a couple of times to talk about the death, and they helped me with something I need to talk to my neuro chief about--namely, that I haven't been getting proper backup when I'm on call, despite all the rules about doing so. The chief just kept saying "we want you to feel supported through this" and I was so touched I cried (I know, it's shocking, I never cry). I just reread House of God, and Chuck's line at the end has always stuck out to me: "How can we care for patients if'n nobody cares for us?" I'm not sure if it's just my program, or others, but I feel very cared for right now, and really, really glad I'll be switching to psychiatry in January and leaving this crap behind. (Not that patients don't die on psychiatry, but I'll be getting a lot more sleep, that's for sure!)


Mayhem said...

That was...horrible. As I read it, I could see where it was going but I never thought the patient would die. There are supposed to be backups to prevent these things, like nurses. How come no one told you that they weren't giving the heparin even though you kept writing the order? Most of the nurses I've met would have said something because they know the importance of DVT prophylaxis. I'm just sort of shocked. I can't even imagine how you are feeling right now. Thankfully, your programme seems to care about their residents.

Tiny Shrink said...


The medication had dropped off the nurse's list, too. Everything at this hospital is done in a computer system, and this is one case where the computer actually made a big contribution to the error. The nurses simply didn't notice that one day there was no heparin on the list (and possibly this was also over the weekend with weekend nurses as opposed to the usual week day shift). Oddly, the nurses were unaware, as I and my team were unaware, that heparin expires automatically; we all had to find out from the pharmacy. Truly, as my attending said, "a wedge-shaped infarct in the system."

The MSILF said...

God. Now I feel bad about bitching about MY first mistake on the blog...although it could have been this bad...but I'm glad you wrote this, because 1. it's not just me, and 2. mine also involved a bad piece of machinery that was set up in a way no one would expect.

And thank God there was no embolus.


Midwife with a Knife said...

That is a terrible way to feel. I'm glad you have more support through this than I did through a similar circumstance.