We need to learn from our mistakes

It is my fourth nightshift in a row. I have slept well during the day and am not feeling particularly tired. At 4 am an old man is brought in by the EMS with abdominal pain as his chief complaint. They are laughing about how he received them with an opiate lollypop in his mouth and walked down to the ambulance seeming rather unaffected by this pain that had caused him to call for their assistance in the middle of the night. After hearing this story I go to see the man. He looks just fine, but gets really annoyed when I try to get a history, unwilling to let me know much more than that he has unbearable abdominal pain. His abdomen is rigid, but since he refuses to lay back and relax I can’t  examine him properly. He wants more analgesics and I do give him a shot of morphine, rather reluctantly since he seems to have a lot of stuff at home, including the fentanyl lollypops the EMS staff reported about. I go to check his prior records and see that he has chronic abdominal pain and was admitted a couple of months earlier for excruciating chest pain that radiated down to his abdomen. The workup then was negative. I make the assumption that the patient is constipated from all the opiates and order an enema. Afterwards he denies feeling better, but he is up and moving around his bed. His vitals and labs are all normal. I decide that he is better off at home in his own bed than in the ED on a stretcher. To arrange transport usually takes a while so I am pleased to hear that they are already on their way to pick him up. We call his home care service and they promise to go to his home and help him out as soon as he gets back. I feel pretty good about myself. This would have been the kind of admission that all the consultants always think should have been placed somewhere else, even though every doctor can treat his pain and none can cure his underlying condition. I played it cool and sent him home. The nurses think I did a good job.

– ”The family of a patient called me to complain about your behavior.” The head of the ED asks to have a word with me after the morning meeting. I am surprised by his comment; I get along well with most patients. – ”There was a man you sent home the other night. He returned the day after in shock and died in the OR, but the family is not so upset about that. They are, however, really upset about your being arrogant and they are thinking about reporting you.” My head is spinning and I am all confused. The patient died? How? I am not so worried about being reported. There are no malpractice suits in Sweden. At that time you could get reported to a national committee which could issue a warning, but that wouldn’t have any serious consequences. This committee has since been abolished. I tell the head of the ED that I want to call the family and apologize. He agrees with that and we are done. I go to review the patient’s chart. He had come back a day later in shock and was taken to the OR where he was diagnosed with perforated diverticulitis. Unfortunately he didn’t survive the operation. When I call his family they let me know how upset he was when he returned home, after being seen by such an arrogant doctor. I apologize without explanations. There is nothing to explain, no one deserves to be treated arrogantly. – ”We know you couldn’t have saved his life even if he hadn’t been sent home. The anesthesiologist told us it wouldn’t have made a difference.” I don’t know what surprises me most, that the other doctors covered up for me or that the patient’s family believed them. I let the head of the ED know that I have spoken to the family and that is the last I heard about this patient.

There were so many lessons to be learned from this case and I wasn’t taught any of them. Someone could have gone through my workup of the patient. How do you examine a patient who doesn’t cooperate? When the results of the exams are inconclusive, why not examine the patient again a little later? What are the indications for an enema in the ED? What risk factors should make you think twice about sending a patient with undifferentiated abdominal pain home? A more experienced doctor could have helped me reflect on how long night shifts influence my attitude. I have learned over the years that I tend to be less cautious at the end of a night shift. We could have discussed how my judgment was affected by my wish to be regarded by the nurses as a doctor who is efficient and not too soft on drug addicts; How the EMS report and the medical records made me assume that this patient was exaggerating his symptoms even before I had seen him. It could have been made clear to me that patients are to be treated with respect even if they are grumpy and sour. If you don’t, you will end up arguing with the patient and how likely are they to give you a relevant history then? Someone could have told me that sometimes patients behave badly because they are upset about telling the same story so many times without anybody taking them seriously and they think you are just another one who is going to make them feel worse.

But I am not the only one who could have used this opportunity to learn and improve. As a doctor you are part of a system and when you fail the system must ask itself how that could have been prevented. Was I the right person in the right place that night? After completing a 1,5 year internship I had worked in the ED for about a year when this happened. EM is a new specialty in Sweden and no hospitals have around the clock specialist coverage. Sometimes there are other specialists available, but as a junior doctor you only ask for advice when needed. Swedish medical students, interns and residents always complain about not getting any feedback on their performance. They are right of course. We have never learned how to give and get feedback and mistakenly take it for criticism. It is part of our culture. We kind of assume that everyone is doing their best and that they will learn eventually. Everyone makes mistakes; it is part of the job. It is acceptable to let a patient die by mistake. The question I want to raise is if it is acceptable not to learn from that mistake.