That dreaded moment...
When your worst newbie fear that you may actually kill someone with your lack of expertise and/or just plain being wrong comes true… well, sort of? I keep meaning to write some nice sunshiney posts because the last couple of weeks “on my own” at work have been going pretty well. Still learning lots and feeling dumb constantly, but generally I was getting more confident and feeling better about my skills.
Until I had that patient. She was an internal medicine consult. Post-op management for an orthopedic surgery. She had some pretty serious underlying medical issues and a severe neurologic disorder that left her bedridden, but the surgery went well. She was supposed to discharge the next day. I was in her room TONS. She was on the needy side and had a semi-needy family with lots of questions, which was fine, I had the luxury of the time to spend with them as our census was down and I wasn’t very busy. I suctioned her while doing my exam and boosted her up in bed. I’m comfortable with those things since I used to be a CNA.
Anyways, I digress… The surgery went very well. Ortho wanted her discharged. They were very busy and she seemed stable. I thought she was ready to go. No fevers, stable blood pressures, white count not elevated, hemoglobin stable, no sick symptoms. I told the ortho team she was good to go from my perspective and then went to run it over with my attending.
Not so fast, she said. She was concerned about the patient’s secretions and thought maybe it wasn’t just the chronic postnasal drip the patient complained of. She ordered a chest x-ray. Honestly, it looked better than her pre-op x-ray to me. But of course I called the radiologist. Left lower lobe pneumonia, he said. Shoot. I almost sent this lady back to her nursing home AND I didn’t see the freaking pneumonia. We started antibiotics, I ordered the sputum culture and viral PCR tests, I explained to the patient that we were being cautious and treating her for probable pneumonia.
Then I enjoyed my weekend and holiday off. I didn’t think much about it. And as I was just warming up to a full patient load today (9-12 patients, which is a huge source of anxiety for me) I received a message from my attending. The patient had declined over the weekend and despite several rapid responses that temporarily stabilized her condition she had died of respiratory failure. If I had sent her back to the nursing home Friday she would have died that very night. “There would have been a call to the medical examiner and we would have been in hot water” is what the message said.
This has haunted me the entire day. I tend to be someone who over-orders tests and imaging. It freaks me out that I still managed to miss something here. My attending was not trying to wave it in my face that I had made a mistake, she wanted me to learn from it. I wish I could say that I have, but I know there will be more situations like this in the future and that none of them will look like this particular situation. That’s the scary thing about this job, every day the patients and presentations are different. Sometimes everything is a mystery and you are just wading through clues and changing story lines.
My fellow NPs/PAs tried to comfort me. “It’s happened to all of us, a thousand times,” they said. But I still feel awful.
Cheery posts to come in the future, I promise.
I look forward to your cheery posts too, of course — but it is posts like ^^THIS one which truly portray the practice of medicine in all of its stressful glory.
It’s a curiously cruel progression: the more that a PA/doctor/healthcare provider learns about the nuances and vagaries of patients and their diseases, the more that provider can find to worry and double-check about in apparently “obvious” cases.
It’s a Blessing and a Curse, this constantly-enlarging storehouse of knowledge and experience in your head.
But a GOOD provider welcomes the Curse, and does not thicken the skin against the nagging doubts and memories of missteps. A GOOD provider lets the twin terror-terriers “Shoulda” and “Coulda” nibble at the heels, ever eager to improve upon past performance. A GOOD provider shares those dropped balls and botched plays with colleagues (current and future) to help them all avoid that fumble when they themselves are on the field.
You are a GOOD provider. Don’t let anyone (including yourself, or the midnight pillow ghosts of this patient) tell you otherwise.
