Do You remember! Premium Non Nocere

The last couple of months I’ve been working with a very diverse team. Clinically speaking, the team was too diverse: only two clinicians and the rests are MBAers and bunch of engineers. Alas, one of the clinicians left to work in another office new to her home.

At first, I felt alone as the only physician the group, but later I enjoyed explaining to the team common pathologies, medical terminologies and trying to simplify them.

One evening I missed a friend of mine, and I called him to see if he is into jogging outdoor. When I called him, I found him in the office too. “Why are you still at work in this late evening,” I asked. 

“If I go home," he said "I’m gonna sleep, and I don’t want to do so. What about you; why are you still in the office?"

I didn’t want to tell him the truth (I’m a workaholic, and in my free time I do research). "I’m watching a movie," I said. "Do you want to come over to see it with me?”

I was watching a YouTube video by Brian Goldman, a Canadian ER doctor, who speaks out about medical errors in an unprecedented way. My friend came over, sat on a chair, me to play the video. 

“Sami - I call him so here - did you kill a patient before?”I asked.

“Me,” he replied in a surprised tone. No. Why are you asking?”

“Listen”, I said to him, "did you kill any patient other than the one you lacerated his liver during a routine gallbladder procedure and told me about last week?”

Sami got the metaphor! He smiled and said, “No, I don’t think so. That was the only patient I’d killed.”

“Let's watch this TED talk,“ I said. “It’s about medical errors. You’re going to residency, and you have got to know this stuff.”

Premium  is the first rule in Medicine, which says, “Do No Harm” and laid out by Hippocrates, the father of medicine. 

In the talk, Brian Goldman said the three words dreaded by many emergency physicians is “Do You Remember?”

Medical errors are failure. You mostly have them when your system has multiple breaches, just like the Swiss cheese (Swiss cheese model of safety incidents)

Dr. Goldman states most medical error will be in the 1st two to three years of practice. For me, that is very true. To exemplify, I’d reveal two stories happened to me. But first, let me explain why am I talking about Medical Errors in Social Media.

Two weeks ago, I read a post on LinkedIn posted by a prominent vascular surgeon who had mistakenly diagnosed a patient with renal colic early in his practice. The patient was found to have an Abdominal Aortic Aneurysm (AAA) with poor outcome. Yet, when he was the Chair of Surgery of a department, they instigated a policy to obligate an ultrasound within half an hour for any patient above 50 years old who presented with abdominal pain. I found the post very appealing and touching an issue many physicians wouldn’t be comfortable to talk about. 

Thus, I decided to break some silence and speak out about stories during my clinical practice years.

I do remember the first medication error I had when I was an Intern doctor in the Department of Pediatrics. Medication error in medicine probably is highest in Pediatrics, as the prescription involves addition, multiplication, and division. Because kids have smaller body size, they tend to get overdosed easily, and they do poorly.

I treated tens of patient along with the Pediatric resident my first day in the Peds ER. Thus, I felt prepared. The resident left the bathroom, and I treated and discharged another two patients in her absence.

“Excellent Work,” she said after she checked my notes and the prescription slip I jotted down for the patients. That gave me an impression that I’m all set!

She then left for lunch. I saw another four patients in forty minutes. She returned; it was 4:05 pm. We endorsed the evening shift. I zipped my backpack and was leaving the emergency room.

“Doctor, do you know this patient?” said to me one of the evening shift nurses while holding one of the patients I sent home an hour ago. 

“Yes, this is my patient,” I said to the nurse while staring at the kid. I was scared to death. The kid was four-years-old. He was carried on the nurse's hands with his eyes closed. Is he dead?, I thought for seconds.

We rushed to one of the ER resuscitation beds and started to check the kid airway. Another two nurses started IV line on him. The boy sobered up. Later, the treating team found that I gave the kid anti-histamine syrup ten times higher than his dose. I was embarrassed, ashamed and alone in that horrible experience. The resident and the nurses were so kind to me, but I felt defeated.

From that day, I used to check medication description for any drug comes to my mind. My friends called me Dr.Drug. I felt secured from medication errors as my pharmacology knowledge expanded rapidly, but that was for a couple of months.

When I finished my Internship, I joined a big academic hospital to work as academic staff. The objective of the job was to get training in Emergency Medicine abroad (Canada, US or other countries with advanced medical practice). However, we – rookie doctors – have to share the clinical load with other physicians in the department. 

Triaging patient is a simple task; usually, a nurse does it. "If this is nurse's work, me - as an MD - would indeed excel at doing it", I thought. Alas, this line of thinking was unreasoned, came back and kicked me in the butt. 

As I triaged tens of patients, under the adrenaline rush, I missed an apparent myocardial ST-elevation. It was not apparent to me. I probably overlooked a cardiac lead or two. I finished my shift and went home. 

Next day, I entered the ED. A coworker approached me, "Dr. Sultan, can I speak to you in private?" 

"Of course," I replied.

“Do you remember," said my coworker, "the patient came last night with epigastric pain? That patient was about to die because you made him wait unnecessarily for 3 hours. “ 

I was scared to death. I started sweating and I felt very unconfident. However, I immediately apologized and promised to practice with cautions in the future.

Next day I went up and shook hand with the patient. I asked him if he or his son need any further help. Before I leave his son put his hand on my shoulder and said, “thank you, doctor, for helping my father last night in the ER.” 

I could not utter a word and I left the room ashamed and bewildered. I was alone again. I didn’t know what to do. Telling the patient won’t reverse the error, and it is a good recipe for the lawsuit. But not telling him is unethical too. 

I left the Cardiac Care Unit (CCU), opened the exit door and sat on the stair, cried and tried to find a relief. Back then the hospital didn't have a protocol to follow when a medical error causes damage - probably until now the hospital still doesn't' have. In the previous hospital, when I overdosed a poor kid, the nurse reported an OVR (Occurrence/Variance Report) and in the later hospital probably the maximum thing would happen is to discuss the error in a Morbidity & Mortality session. No support to both victims (the patient/his family and the physician)

Practicing medicine needs a safe system and encouraging environment to talk about medical errors to reduce them in the future. Shaming/naming or looking for scapegoat won't build better and safer hospitals.