Sunday, November 4, 2018
Intern Year: Errors
“I did this,” I thought to myself over and over again as I helped to roll my patient down to the ICU.
“This is my fault.”
My mind was racing with the myriad of things that I could have mistakenly done – or not done – in the week prior to inadvertently cause my patient to suddenly decompensate out of nowhere on a Sunday morning.
Was it the bed rest? Did I keep him on it too long? Oh God. The senior helping me just told me he should have been on a higher dose of clot prevention medication. Did he throw a clot in his lungs? Oh God. His heart. His kidneys. He just had surgery on his intestines. But what about his wound that’s basically been falling apart? Oh God. It’s a blood clot in his lungs, I just know it.
I don’t know what I don’t know, I don’t know what I don’t know, I don’t know what I don’t know.
It’s an intern mantra we repeat to ourselves, but it only goes so far when serious repercussions can happen as a result of knowledge gaps. And at the end of the day the phrase ends up sounding hollow and empty – laughable even - when those lapses in experience can be equated to us inadvertently rolling the dice with other people’s well being.
I had been alone during my last week on the Colorectal Surgery service, playing a myriad of roles on a fairly busy service, but with only a portion of the knowledge to carry out even just one of those roles. I had been dreading the week for the entire month, but I somehow managed to make it through the week unscathed. I was grateful that the service had fewer OR cases than normal and I also lucked out with only one new patient consult the entire week. What had at first seemed like a terrifying week ended up being one of valuable use as an intern – one where I was able to step up, do a bunch of cool senior level OR cases (mine, all mine!), and make decisions with my big girl pants fully hiked up.
I went into the weekend with a 24-hour call on Saturday into Sunday, feeling like everything was winding down. I was ready to get it over with and be done with the stress of the week, the promise of starting on my pediatric surgery rotation just a few blessed days away. I made it through rounds and performing most of my tasks on Sunday morning with no issues and was about to leave within an hour or so, my excitement and relief swelling as the time continued to pass and I moved into hour 29 of working.
The irony of my patient crashing within that last hour doesn’t escape me.
He had been a complex patient, one who had underlying, serious disease in a lot of his organ systems. I had been involved in this patient’s care since the early days of the month, and it had been a struggle from the beginning to gain control of the system-of-the-week that was having issues. By that last Sunday, everything had mostly resolved and he was on the upswing. My attending and I had even talked about discharge plans that morning.
Another irony that doesn’t escape me.
After I rolled my patient down to the ICU, the pressure of the week – and of the day – hit me. I’m grateful for the senior resident that took me aside to offer support, and for my co-intern that gave me a hug once I walked back upstairs.
I went home soon after, and was somehow able to go to bed and fall asleep despite the knowledge that once I woke up, I’d probably be able to find out what had gone wrong.
The relieved sigh that escaped my lips upon finding out that it hadn’t been a pulmonary embolus – the thing I thought I had caused – echoed the internal alleviation of tension that also occurred with the discovery, though I still felt awful and was still worried about what would happen to him.
Regardless, I did my best to unwind for the remainder of the evening, knowing that I had to reset and get ready to start a new rotation in a new location (the worst combination) the following day.
I checked my phone right before going to bed to look through the patient list one more time, seeing if there was anything else I could tidy up before the new residents took over the service, and also wanting to chart stalk one last time to see how my patient was doing.
I blinked once.
My heartbeat picked up. I refreshed the screen.
I blinked again.
Another patient of mine had not only gone to the ICU, but was also in the process of being emergently taken to the OR.
I did nothing but sit on the couch in the silence of my apartment and stare off into space for a few moments, the gears in my brain frozen, unable to think, let alone feel, any emotions, having already devastated the majority of my reservoir earlier in the day (and the week).
Click. Click. Click. The gears began thawing. And it started coming to me in pieces.
His labs. The nurse off-handedly making the remark that his room smelled a bit worse than usual in the morning. The fact that he had been clinically stagnant the past couple of days – not doing worse but also not really improving either. He had been another medically complex patient, but still…oh God.
Thankfully, his serious complication had been caught by the senior on call that same day just a few hours after I had left, but it still was a terrible feeling to know that I had missed something on one of my patients….that I was unable to put the pieces of the puzzle together from the trickle of clues that had been left here and there along the course of the morning. What if it hadn’t been caught that day?
Hindsight is 20/20. Hindsight is 20/20. Hindsight is 20/20.
Another phrase we tell ourselves. It’s comforting and painfully true, but it also serves as a reminder of our human limitations.
The next morning, I woke up to start my first day on pediatric surgery filled with uncharacteristic anxiety and aversion to going into work. I remember staring at the computer screen in the OR lounge that morning, unable to focus on looking up numbers and information on the list of new patients.
Thankfully, expectations were low on the first day and, since I wasn’t assigned to be the intern seeing new consults that day, I spent most of the day doing nothing but operating. While that normally would have excited me to no end – pediatric surgery is what I want to do with my life, after all – instead it felt unsatisfying, filled with brief moments where I just wanted to crawl out of my skin and hide.
Surgery residency is always go, go, go.
And I just needed it to stop, stop, stop.
Which, of course, it never really does.
I deliberately reached out to one of my closest friends that day, telling her that I needed to talk to someone (an action I rarely do), and I was thankfully able to talk with her a couple of days later. It helped, as did seeing that my two patients that went to the ICU gradually started to improve over the following days. I still felt slightly off though, and I spent my first couple of weeks in mostly solitude, not really wanting to socialize or talk to many people outside of work.
I knew that what I was feeling was partly heightened by the fatigue that had gradually built up during the months. There was also the reality that I was also still a fairly new intern that had just recently moved to a new area with no partner and no family. And no matter how blessed I feel by my new resident family, at that time they were equally – if not more – busy and stressed as I was.
The rational, logical part of me knew that it was all a perfect recipe for the way that I was feeling and possessing that knowledge helped me move through the days. If the concept of resilience was a moving object, I was trudging just behind it.
Thankfully, the familiarity and enjoyment at being back in the pediatric world started to bring me back to my baseline. I started to feel a sense of contentment that increased day by day. It wasn’t until my string of four nights straight that I felt back to normal, resilience once again back on my side.
Working nights can inevitably be chaotic, but I’ve also found that I enjoy them immensely. The solitude and limited interactions of the night were often a stark difference from the whirlwind rat race of days, and they provided a recharge to my introvert batteries that I needed. When combined with the fact that it was pediatrics, it was potent enough to snap me out of my funk.
As the weeks passed, both of my patients that went to the ICU were transferred to the floor and eventually discharged. I still intermittently check to see if they were re-admitted, something I don’t really do with other patients.
Looking back now, I sometimes feel juvenile for feeling the way that I did – for having such a lingering reaction. They hadn’t died. In fact, one could reasonably make the case that complications were to be expected given their medical histories and statistical chance.
However, it doesn’t change the fact that on that day and the week prior, I had been the resident responsible for their care, seeing them far more frequently than the attending or anyone else except for the nurses.
The experience was yet another new one in residency – learning how to grapple with the reality and concept that not only do patients not do well sometimes, but they also end up not doing well because of the things we as doctors inadvertently do or not do, despite our best intentions and the amount of hours we put into taking care of them.
We’re human, too, after all.
I know that this will happen again. And not only that, I know that there are worse things that will happen - worse events missed, worse errors, worse outcomes. I also know that in the future I will most likely look back on this entry and shake my head at my naivety. Even now, I look back at some of my entries from medical school with a wistful smile.
Regardless, getting used to the reality of complications, errors, and bad events happening to patients is yet another hurdle that we face as new doctors that unfortunately needs to be experienced. It’s not something that we can escape, no matter how hard we try. And with that comes the inevitability of learning how to cope and move on.
We owe figuring out that process not just for ourselves but also for all of the patients that will follow.