Life in the Balance
When I had been a doctor for two months I made my first significant mistake. I could claim that it was because I was sleep deprived, distracted and overworked, because I was all of those things, but none of them was the fundamental problem.
It was Saturday morning and I was 24 hours into a long weekend on call, when the microbiologist called to inform me that Petros, a patient I’d admitted overnight, had positive blood cultures – ‘gram negative rods in both bottles, grown within 8 hours.’
I understood what he was saying – that Petros had bacteria in his blood stream, and I knew that that was not normal, but what I didn’t grasp was the gravity of the situation.
There are compartments in the body that always contain bacteria, the skin, mouth and bowel being good examples and others, such as the urine, lungs, brain and bile that should be sterile. When bacteria get into the wrong place we get symptoms of infection in that area, but we usually remain well in ourselves for days, even without antibiotics. When bacteria get into the bloodstream however, we can get very sick very quickly. If only I’d appreciated this at the time.
“When bacteria get into the bloodstream however, we can get very sick very quickly. If only I’d appreciated this at the time.”
I had just completed five years of medical school so I was awash with medical facts - I just didn’t know what to do with them. I could reel off ten causes of ‘clubbed’ fingernails ranging from lung cancer to ulcerative colitis, but what I couldn’t do was use this information. Should I request a CT scan of the chest of every patient with clubbed nails to look for lung cancer? I had lots of knowledge, but no experience and that meant that I couldn’t see the wood for the trees.
I’d received plenty of abnormal test results over the preceding two months and run with them to my seniors like an eager six-year-old, only to be met with either a shrug of disinterest or withering sarcasm. As far as I was concerned the bacteria in Petros’ blood was most likely to elicit a dismissive,
‘Contaminant! Did you wash your hands before you took the sample?’
Before I’d had time to reconsider this conclusion, I’d been bleeped twice more to insert a urinary catheter and write up a new drug chart. These were solid tasks, within my skill set, that needed to be done and so off I went. Very soon Petros’ blood full of bacteria had slipped out of my tired and inexperienced medical mind completely.
When the nurse bleeped me six hours later to tell me his blood pressure was now 80/50 my stomach dropped. Petros was now critically sick, going into septic shock and those hours inactivity might be the difference between him living or dying. My SHO (one rung further up the food chain), was too tired to hide her exasperation and as I sprinted the one hundred yards back to my ailing patient, I was in no doubt about the magnitude of my mistake. When I arrived sweating at his bedside, he looked awful; grey, clammy, breathless, and barely conscious.
An hour, a failed intravenous cannulation and a desperate phone call later, Petros was on his way to the intensive care unit and that night, lying in my on-call room, I prayed to every God I could think of for him to get better. I was lucky (or perhaps my prayers were answered). By the following lunchtime Petros was sitting up smiling and drinking a cup of tea. He was unrecognisable, a large bruise on his right forearm where I’d missed my cannula, the only remaining evidence of my misdemeanour and I can still remember the sensation of relief washing through me.
For months memories of that day sent shivers down my spine as I swore that I’d never make the same mistake again, but as the months turned to years I began to think more broadly about what lessons could be learnt. I’ve concluded there are three.
To start by pointing the finger at other people, my first lesson relates to the behaviour of my senior colleagues. They were good doctors and kind people, but by being sarcastic (even jokingly) they had created an atmosphere in which I hesitated before speaking up. They weren’t bullies and I enjoyed the hospital banter, but equally, as the new boy, I didn’t want to look a fool more often than was absolutely necessary. Would I have reported this result sooner if I’d not feared humiliation? Almost certainly not, but I am conscious that what may appear to be no more than harmless fun can have more serious consequences than anyone involved realises.
The second lesson I learnt was to take notice when someone makes a specific effort to give you information. It may seem unimportant to you, but the fact that they’ve gone to the trouble to ensure the message reaches you should set off alarm bells. It is obviously important to them, so it’s worth a second thought, at the very least, before being dismissed.
Finally this incident reminded me that mishaps are never isolated mistakes.
This event might appear to be a straight forward episode of human error, but there is always context. I was tired, nervous, distracted, inexperienced and almost certainly hungry when I received the information. I made a mistake undoubtedly, but the most important question is why. When we investigate these incidents it is vital that we dig into the circumstances, focus on learning rather than punishment and fight hard to reach unbiased and compassionate conclusions. This turned out to be a near miss, but it could easily have ended tragically in which case I might well have been hung out to dry.
Want more? Find Jim on Twitter
