Saturday, April 21, 2007


Dropping the Ball
When something doesn't go according to plan, it's usually a system failure. There are rare occasions when someone pulls off an act of sheer banditry that couldn't be anticipated or mitigated by anyone else. But mostly, everyone fucks up a bit. I'm guessing most people feel the same way I do about this - everyone makes mistakes, but we rarely like to admit / talk about it. Mistakes in medicine are always a little bit higher stakes than in other jobs.
Personally, I've made my share of errors; I've learned from all of them, but the rude fact of life is that shit still goes wrong. Generally, I've got tickets on myself. I reckon I'm good at what I do, so when it turns out I haven't done it to my best ability, I feel shit about myself for days.
I guess it's the same for us all.
It's easy to write about times when you did something that worked, or that paints you in a good light. The reverse is harder.
I could imagine it might happen something like this:
Picture a man who is involved in a car accident. He is rescued by the Paramedics after some 30 minutes. They assess him as having sustained no serious injuries, and he is shipped to the local ED. He is boarded and collared, and assessed promptly on arrival. His spine is cleared, and no serious injury noted. He is left for formal assessment.
Several other patients arrive in the Department around the same time. One is apparently critically ill, and goes straight to resus, prolonging the wait of our fictitious patient.
He is eventually seen by a doctor about an hour after he arrives. He has no complaints, except of some pain in his knees, which he has grazed in the accident. Physical exam is unremarkable at this stage, barring the fact that he is cool and clammy. His pulse feels rapid, but of good volume. He is known to be in AF. The attending physician notes that he was given 20 mg iv morphine on scene, and attribute the beads of sweat on his forehead to this.
The patient is moved to another clinical area for monitoring. His first set of obs are done, after some 90 minutes. His blood pressure is borderline low, and his pulse still fast. An ECG confirms AF with a rapid VR, and slightly ischaemic picture. He complains of no pain, and his doctor wonders if the appearance might be the effect of the digitalis he is taking. Repeat exam is still unremarkable, barring ongoing clamminess. His doctor is slightly concerned by this. It can't still be morphine after all..? A period of observation is proposed; the patient declines, stating that he feels fine.
Anxiety growing, his doctor asks him to wait a little longer, and asks for routine blood tests and a fluid bolus to be given.
Something like an hour later, the patient looks worse. His BP is lower and his pulse faster. He now has abdominal pain - although his belly is still soft.
Now: 3 hours after arrival, he is moved to resus. Repeat assessment reveals some firmness of the rectus muscles. This will rapidly develop into a peritonitic picture.
Finally he gets a CT scan, and surgical consult. CT shows intraperitoneal bleeding, and he goes straight to theatre. Operative course is uncomplicated, and he recovers on ITU.
My guess is things like this happen all the time. In retrospect, the hypothetical patient was unwell for a while, but an unclear history and paucity of physical signs allowed false reassurance. That he waited 90 minutes before first formal nursing assessment didn't help. As I said, this was a fictitious example. The Shroom might learn from such a train of events however. If mechanism sounds high risk, it is, even if the patient looks and fells well. Never trust the abdomen - trauma is a frighteningly dynamic process. And, especially, even if you think you know you're shit, you probably don't know it as well as you think you do.
Like I said, this was just hypothetical, and I'm certainly not trying to teach anyone to suck eggs


Cal said...

Didn't they do an USS of the abdomen? That might've picked up the intr-abdominal bleed.

And the sweating etc... that was because his symapthetic output was increasing as he struggled to maintain a BP.

Was the first fluid bolus given at 90 mins??

DrShroom said...

A FAST scan would almost certainly have helped. At fictitious DGH, however, they aren't done as standard. Even if they were, this patient was not worked up as trauma - the beginning of the whole system failure. And indeed, with the retrospectoscope, his clammy appearance is textbook shock. Any half decent practitioner of physick should have seen that. Shroom knows this, and is ashamed for his fictitious counterpart. Surely an experienced practitioner would never make such an elementary error..?
Beware your sins, little fungi, for they will surely find you out

deputydawg said...

Every frontline healthcare professional's nightmare -some poor patient slips through the safety net of initial assessment/obs.No excuse,but often when the dept is in overcapacity , the workload dilutes all staff to work in a ridiculously unsafe environment.

Chrysalis Angel said...

Hello, I'm new to you and hope you don't mind my commenting. Nice blog you have. When you said "mechanism of injury", I immediately thought of what we call the "walking wounded". We would get to the scene of an M.V.A. and they would be up and walking around, talking to us and denying treatment, then collapse with internal injuries they didn't know they had.

That was a great comment to Sisyphus by the way. I had to come over and visit. Best to you.

DrShroom said...

Thanks, All, esp CA.
Much appreciated