accused of killing patient

[squame]

So I just started my internal med rotation this week after having finished only psych. I had my first call last night. We are put on the floor alone -- there is a resident in the ICU we are supposed to page for anything urgent or to get orders written. Anyway around 6pm the nurse comes over and tells me there is a pt with flank pain that needs an analgesic. At signout rounds, I was told that all the patients were stable and I shouldnt' have to worry about any of them. So, I didn't see him right away becuase I was finishing a note, and wanted to grab some dinner before the caf closed. This takes maybe 1/2 an hour. When I get back to the ward the nurse is super pissed and bitching about how the med student isn't doing anything. She keeps repeating that she wants an analgesic and I can just give the order verbally and then get it signed later. I'm like F-no I have no idea what is causing this. So I call the resident without seeing the patient and tell her what I know (btw this is not my patient so I don't know him in depth). She is like, I'm not in the hospital right now, i'm in a clinic next door, why don't you go see the patient and try to figure out what he needs. I go see the patient, the patient tells me that he has had the pain all day, the vitals are normal (BP maybe a little low). I try to look up some stuff on uptodate on what might cause this post-dialysis but still have no clue. After like 15mins I call the resident and she comes to the floor. As she arrives the pt falls out of his bed, and decompensates, vitals go through the floor. He gets a bolus and is transferred to ICU where he gets a code and then expires.

So the next day the dr. asks me about call and I go, well it was very stressful and one patient died. Then I stupidly added, I'm worried maybe I should have gotten the resident earlier. Then he's like how long did it take to get the resident and I'm like maybe an hour from when the nurse told me about the pain to when the resident arrived. A few hours later the Dr. calls me in saying he's concerned I waited too long and why didn't I realize the vitals were off etc. Then he tells me I'm a sucky med student as I'm unable to synthesize H&P into a good impression, i'm behind other students (asks me what my previous grades were), and maybe with a lot of work I can do OK.

I am so depressed and unhappy I don't know what to do. I really did my best, I had no idea this would happen. I am not the best med student but I'm not the worst either and I feel the only reason he said that is because I made a bad judgement call. I am seriously contemplating just not going back, and making up the rotation in 4th year or later. I dont' know how I can face this ignominious start for the next 7 weeks.

---

Members don't see this ad.

 

[squame]

Thank you all for your support -- I really appreciate knowing this is not a normal situation and that the system is seriously messed up if it can breakdown simply because the med student did not gather enough information to report to the resident. The more I think about it the more I realize the resident is probably behind the attending's comments, as the next morning she came to the ward and repeated to me again that I need to report the vitals first thing whenever there is an issue. Also the attending seemed surprised when I mentioned she was not in the ICU when I went to look for her, so she conveniently left this out of her story.

An email has been sent to the dean and associate dean, and I will try to speak with someone on monday. I am going to request to be transferred to another hospital site or team. I am so scared of going back there.

(PS I made a new username to post this because my usual one has too much identifying information asssociated with it)

 

[tr]

I agree with the fact that this is a outrage that a med student was left alone to make decisions the intern should be making. But I think everyone is missing a critical part of the story:

Not sure what "a little low" BP is to the OP, but if the vitals were ok before the patient fell out of bed, the lead point in this whole fiasco seems to be the patient falling out of bed. That easily could have triggered him to start hemorrhaging internally from his site, decompensate, and subsequently code. Unrelated to the pain which should have been treated, but was not particularly alarming or unexpected. Is it supposed to be your fault the patient fell out of bed, too? The nurse should have assessed whether he was safe to ambulate and controlled that situation...

a) Probably the crucial piece of information here was not the blood pressure (agreed that relative hypotension is hard to judge if you don't already know the patient's baseline - although when I give signout I usually write relevant baselines on the card) but the heart rate. You can support your pressure pretty well for a long time by compensating for volume loss with tachycardia. I'd suspect this patient had been tachycardic for a long time - something that definitely should have been picked up and reported by the nurse.

b) The patient might have fallen out of bed *because* he was hypotensive and orthostatic - tried to get up, felt dizzy, and fell. It would be unlikely for him to decompensate ten minutes after the onset of the bleeding event. I saw a guy with an internal *arterial* bleed in the ED last year who supported his pressure for hours and hours before anybody figured out what was wrong with him. (Only symptom was sudden-onset abdominal pain, CT found a big fluid collection in his abdomen.)

c) The pain could very well have been related to the bleed. I missed this info before, but it sounds like the pt had had a renal biopsy and was having flank pain (so it was a retroperitoneal bleed, not an intra as I predicted - whatever). I bet the pain was from the accumulating hematoma stretching the surrounding tissues.

You didn't know that a declining blood pressure is an ominous sign? You don't know what constitutes a normal blood pressure? What the hell did you do the first two years of med school?

Note that the nurse did not REPORT the blood pressure or the heart rate in this fiasco. She should have known on her own to report the vitals; and if she had called an intern or resident without this information that person would have known to request it. But a new MSIII who is suddenly faced with a nurse demanding "pain meds" for an unknown x-cover pt who was billed as 'stable' can't necessarily be expected to have it together enough in that instance to suspect a more serious issue and request vitals.

Actually I would like to point out that it actually constituted excellent judgement on squame's part to have gone and called the resident, rather than acceding to the nurse's demands. "Okay, sure - give him some morphine and the resident will sign the order later" might not have been an unexpected response from a stressed-out M3. Yikes.

I agree, this was not the student's fault. But for the love of God, even a first year nursing student knows the difference between normotensive and hypotensive. To suggest that an MSIII shouldn't be expected to know what constitutes normal blood pressure is just dumb.

Again, the question is what constitutes hypotensive FOR THIS PATIENT. If he is 100/60 that could either be his baseline or he could live at 180/120 and now be seriously hypotensive. The nurse knows his baseline; the covering MD (or MS-III in this case - shudder) doesn't.

 

[Hard24Get]

a) Probably the crucial piece of information here was not the blood pressure (agreed that relative hypotension is hard to judge if you don't already know the patient's baseline - although when I give signout I usually write relevant baselines on the card) but the heart rate. You can support your pressure pretty well for a long time by compensating for volume loss with tachycardia. I'd suspect this patient had been tachycardic for a long time - something that definitely should have been picked up and reported by the nurse.

b) The patient might have fallen out of bed *because* he was hypotensive and orthostatic - tried to get up, felt dizzy, and fell. It would be unlikely for him to decompensate ten minutes after the onset of the bleeding event. I saw a guy with an internal *arterial* bleed in the ED last year who supported his pressure for hours and hours before anybody figured out what was wrong with him. (Only symptom was sudden-onset abdominal pain, CT found a big fluid collection in his abdomen.)

c) The pain could very well have been related to the bleed. I missed this info before, but it sounds like the pt had had a renal biopsy and was having flank pain (so it was a retroperitoneal bleed, not an intra as I predicted - whatever). I bet the pain was from the accumulating hematoma stretching the surrounding tissues.

Yes, there are a number of possibilities, and there are a number of conjectures in yours (like that he decompensated in 10 mins). I was just raising another - that the vitals could have been WNL and the complaint of pain could be true true and unrelated to the death. The point is we don't know and it is inappropriate to assign blame since no one knows the facts, including the true cause of death.

 

[squame]

a) Probably the crucial piece of information here was not the blood pressure (agreed that relative hypotension is hard to judge if you don't already know the patient's baseline - although when I give signout I usually write relevant baselines on the card) but the heart rate. You can support your pressure pretty well for a long time by compensating for volume loss with tachycardia. I'd suspect this patient had been tachycardic for a long time - something that definitely should have been picked up and reported by the nurse.

b) The patient might have fallen out of bed *because* he was hypotensive and orthostatic - tried to get up, felt dizzy, and fell. It would be unlikely for him to decompensate ten minutes after the onset of the bleeding event. I saw a guy with an internal *arterial* bleed in the ED last year who supported his pressure for hours and hours before anybody figured out what was wrong with him. (Only symptom was sudden-onset abdominal pain, CT found a big fluid collection in his abdomen.)

c) The pain could very well have been related to the bleed. I missed this info before, but it sounds like the pt had had a renal biopsy and was having flank pain (so it was a retroperitoneal bleed, not an intra as I predicted - whatever). I bet the pain was from the accumulating hematoma stretching the surrounding tissues.

This is probably what happened. Also he had had heparinized dialysis in the afternoon.

 

[Ypo.]

Note that the nurse did not REPORT the blood pressure or the heart rate in this fiasco. She should have known on her own to report the vitals; and if she had called an intern or resident without this information that person would have known to request it. But a new MSIII who is suddenly faced with a nurse demanding "pain meds" for an unknown x-cover pt who was billed as 'stable' can't necessarily be expected to have it together enough in that instance to suspect a more serious issue and request vitals.

Actually I would like to point out that it actually constituted excellent judgement on squame's part to have gone and called the resident, rather than acceding to the nurse's demands. "Okay, sure - give him some morphine and the resident will sign the order later" might not have been an unexpected response from a stressed-out M3. Yikes.


Again, the question is what constitutes hypotensive FOR THIS PATIENT. If he is 100/60 that could either be his baseline or he could live at 180/120 and now be seriously hypotensive. The nurse knows his baseline; the covering MD (or MS-III in this case - shudder) doesn't.

Exactly. Thank you for saying it so I didn't have to.

 

[Tired]

Again, the question is what constitutes hypotensive FOR THIS PATIENT. If he is 100/60 that could either be his baseline or he could live at 180/120 and now be seriously hypotensive. The nurse knows his baseline; the covering MD (or MS-III in this case - shudder) doesn't.

Agreed. I was more responding to the comments about "MSIIIs can't be expected to know that a falling blood pressure is a bad sign" or some variation thereof. Of course they can, and at least in my hospital, are expected to.

 

[squame]

Note that the nurse did not REPORT the blood pressure or the heart rate in this fiasco. She should have known on her own to report the vitals; and if she had called an intern or resident without this information that person would have known to request it.

These kind of reports were coming at me the whole night. After this guy went to the ICU, a nurse came over and told me a patient was spiking a fever. I went to see the patient but he didn't speak any english or french (monolingual italian) and was somnolent as I had woken him up. All I found on physical exam was right lower abdo pain and the nurse informed me he had a loose BM, however he had received some stool softener. I thought he might have c.diff but I had no clue what to do! When I called the resident about it, she was running the code on the other guy, and rattled off some lab tests really fast that I should order, which I did. The resident shows up eventually, the guy goes septic from C.diff, I had to call in the patient's family -- luckily this one survived. This was a very complicated patient, he had myelodysplastic syndrome with already messed-up CBC. Later the resident bitched at me for telling her over the phone that the old labs showed normal WBC instead of elevated (these latests results were in the computer, not printed in the chart which is where I was reading from -- then,"you should always get labs from the computer"), and didn't I know how to write a proper note (my HPI was very short, left out pertinent positives and negatives as I had trouble talking to the patient -- then, "you can always find a way to communicate if you have to"). Turns out the resident spoke italian.

Meanwhile, all night I had minor reports from nurses 1) nurse unable to insert foley because the patient is refusing it as it won't go in easily, what should she do? does the pt really need it anyway? 2) New admit around midnight I was supposed to see and write a holding note for 3) patient is anxious and can't sleep, is requesting more risperdal but her second dose was at 5pm and the order is bid 4) patient is complaining of calf pain, but she is a hypochondriac and always has complaints like this (around 5am).

For (1), I told the nurse to put the damn foley in because the doctor ordered it. I did (2) while the resident was writing the note on the c.diff patient around 3am. I ignored (3), told the nurse I can't sleep a lot of nights too. (4) I assessed the patient and after my evaluation was pretty sure it was muskuloskeletal and/or psychogenic, wrote my note -- by that time the morning team was starting to arrive. Nobody ended up seeing this patient again.

I know this must all sound ridiculous but that's how the night went. I am afraid the dean is going to tell me it's impossible to switch locations at this point and I have to go back to that hospital. I don't understand how all the other med students in all the past years were able to deal with this stuff without feeling over their heads or anything bad happening. I mean, I ignored some of the complaints, but what if they had started going downhill too?? I am impressed that my classmates are able to deal so confidently (the girl on the day before me told me she had no major issues, she even slept 5 hours), but it is too much for me. I can't stop thinking about all this.

 

[Tired]

These kind of reports were coming at me the whole night. After this guy went to the ICU, a nurse came over and told me a patient was spiking a fever. I went to see the patient but he didn't speak any english or french (monolingual italian) and was somnolent as I had woken him up. All I found on physical exam was right lower abdo pain and the nurse informed me he had a loose BM, however he had received some stool softener. I thought he might have c.diff but I had no clue what to do! When I called the resident about it, she was running the code on the other guy, and rattled off some lab tests really fast that I should order, which I did. The resident shows up eventually, the guy goes septic from C.diff, I had to call in the patient's family -- luckily this one survived. This was a very complicated patient, he had myelodysplastic syndrome with already messed-up CBC. Later the resident bitched at me for telling her over the phone that the old labs showed normal WBC instead of elevated (these latests results were in the computer, not printed in the chart which is where I was reading from -- then,"you should always get labs from the computer"), and didn't I know how to write a proper note (my HPI was very short, left out pertinent positives and negatives as I had trouble talking to the patient -- then, "you can always find a way to communicate if you have to"). Turns out the resident spoke italian.

Meanwhile, all night I had minor reports from nurses 1) nurse unable to insert foley because the patient is refusing it as it won't go in easily, what should she do? does the pt really need it anyway? 2) New admit around midnight I was supposed to see and write a holding note for 3) patient is anxious and can't sleep, is requesting more risperdal but her second dose was at 5pm and the order is bid 4) patient is complaining of calf pain, but she is a hypochondriac and always has complaints like this (around 5am).

For (1), I told the nurse to put the damn foley in because the doctor ordered it. I did (2) while the resident was writing the note on the c.diff patient around 3am. I ignored (3), told the nurse I can't sleep a lot of nights too. (4) I assessed the patient and after my evaluation was pretty sure it was muskuloskeletal and/or psychogenic, wrote my note -- by that time the morning team was starting to arrive. Nobody ended up seeing this patient again.

I know this must all sound ridiculous but that's how the night went. I am afraid the dean is going to tell me it's impossible to switch locations at this point and I have to go back to that hospital. I don't understand how all the other med students in all the past years were able to deal with this stuff without feeling over their heads or anything bad happening. I mean, I ignored some of the complaints, but what if they had started going downhill too?? I am impressed that my classmates are able to deal so confidently (the girl on the day before me told me she had no major issues, she even slept 5 hours), but it is too much for me. I can't stop thinking about all this.

At first I was inclined to think that you were being overly-dramatic about your situation. Then I thought that you might just be a verbose troll. But honestly, I'm kind of coming around, because quite frankly, what you describe is every call night I have had this year. And I'm an intern, not a student.

If you're telling the truth, this is pretty grotesque. I can't imagine what your school or this hospital is thinking, having nurses page an MSIII for these kinds of issues. These are all ostensibly small issues, but each presents the small but real possibility of disaster, if you don't know what to look for (ie - the things your residents is getting on you about).

I'm pretty worried about you.

 

[Kimmer]

NEVER going to Canada again.

 

[Pinkertinkle]

Pft, its canada, not like you can get sued.

 

[AMmd]

Suddenly everything becomes much clearer.

hahahah you're such an idiot!

 

[ericdamiansean]

the other hospital sites don't do this, i just got oh so lucky. plus this is in canada so i guess it wouldn't happen in the US?

This can happen anywhere, and recently, there was a case where the attending did not see a neonate personally when an intern had a problem inserting an IV and accidentally inserted it into a muscle, gave the abx and the kid ended up with an infection and lost the arm. In this case, the instructions were given over the phone and by the time they realized what was going on, it was too late. And it also happened in a major hospital.

To the OP, as a medical student, your responsibilites are limited, and there are a few people ahead of you whom the blame would go to before it gets to you, unless of course you did something really wrong or irresponsible.

Ask around and you're more likely to find a resident who's worried about the possiblity of killing someone, rather than a medical student. The higher you go up, the more responsilities you take on, the more you lose.

So, don't worry, hopefully you'll ride this one out and don't be too hard on yourself. If you would be facing anything ie. inquiry, document everything you remember including the sequence of events, that'll help, and also talk to your tutor.

 

[sga814]

Take Home Message- Socialized Medicine SUCKS!!

Sorry Canada.. ey?

 

[ChickFingaz]

Why is it your business who is doing what on the floor? Seriously, if the entire FLOOR died at the same time and I was just a medical student and the nurses were telling ME about it? I'd just let the motherf**er burn. Then, when the attending grilled me about it, I'd be like, "call was uneventful" and hold up my hand for a high-five.

Fineline, you are quite funny. You dropped a few lines that had me laughing when I read this last night.

Squame, your situation is an interesting one, that I am sorry you had to experience. I think there are some solid comments in this thread, particularly from Tr and OBP. I would be scared out of my mind to be left alone on a floor. I'm an MSI so this is even more petrifying. I hope everything works out for you. As AmoryBlaine poignantly stated, "to suggest that a September MSIII killed a patient is beyond pale..."

 

[SMRT]

So I am trying to figure out what school you are at in Canada. As far as I know, all schools in Canada start their year in late August or early September, and third years usually have at least a week of "intro to clerkship" stuff. So assuming you started in the last week of August, had one week of classes, then started on the wards in the first week of september, that means you had a three week long Psych rotation before starting Internal Medicine?? As well, most students do their internal medicine at a teaching hospital where you do "team medicine" and are always on call with at least a senior and a junior resident. Even in a community hospital, I find it very hard to believe that you were first call with the resident not even in house. And why was the resident responsible for both the ICU and the medical ward? Maybe you are in one of the rural programs and they work differently (but in that case, the nurses are so used to working without students and residents, that I find it unlikely that they were relying on you and didn't just call the staff if the resident wasn't available). I don't expect you to say where this happened, but something just doesn't add up.

 

[Blade28]

If that's what happened, I wouldn't beat yourself up over it - sounds like the intern/resident should have been there more quickly if the patient was deteriorating.

It should never be the med student's fault for a patient doing poorly, short of something obvious like ordering a huge dose of morphine, cutting the IVC, etc.

 

[squame]

So I am trying to figure out what school you are at in Canada. As far as I know, all schools in Canada start their year in late August or early September, and third years usually have at least a week of "intro to clerkship" stuff. So assuming you started in the last week of August, had one week of classes, then started on the wards in the first week of september, that means you had a three week long Psych rotation before starting Internal Medicine?? As well, most students do their internal medicine at a teaching hospital where you do "team medicine" and are always on call with at least a senior and a junior resident. Even in a community hospital, I find it very hard to believe that you were first call with the resident not even in house. And why was the resident responsible for both the ICU and the medical ward? Maybe you are in one of the rural programs and they work differently (but in that case, the nurses are so used to working without students and residents, that I find it unlikely that they were relying on you and didn't just call the staff if the resident wasn't available). I don't expect you to say where this happened, but something just doesn't add up.

We started school end of july. The school and affiliated hospitals are in a major canadian city. I was forewarned by upper year students that the hospital site I was assigned has tough call because there is no resident with you and you have to make some judgement calls, but I never realized it would be this bad.

 

[fakin' the funk]

Agreed. I was more responding to the comments about "MSIIIs can't be expected to know that a falling blood pressure is a bad sign" or some variation thereof. Of course they can, and at least in my hospital, are expected to.

They don't, and shouldn't, have any RESPONSIBILITY for acting on that knowledge, however.

 

[rocky316]

You wouldn't happen to be out at UBC would you? A friend of mine told me about an unfortunate circumstance involving a classmate. Never really got told the details but I guess if it's not you, you're not alone.

 

[Tired]

They don't, and shouldn't, have any RESPONSIBILITY for acting on that knowledge, however.

Agreed, though I still don't think it's unreasonable to expect the student to make a call about it.

 

[Top Gun]

The resident you paged twice, is she an intern or a more senior resident, like a PGY 2 or PGY 3? If she's a PGY 2 or PGY 3, I don't understand why a third-year med student would be left alone to cover the floors. That's the job of the intern. Surely the program you're at has interns. The pages you're getting are more appropriate for an intern to handle.

 

[achybrachy]

You are a STUDENT, and as such, your primary role is to LEARN, not to make critical decisions or orders.

Amen to that.

To add my 2 cents, I'm an MS4 and I'm not sure I would have done anything differently. I would like to think I would have put up a bigger fight with my intern for leaving me alone, but that might just be 20/20 hindsight talking.

 

[Miami_med]

This is obviously not your fault. While many med students may find themselves overstepping their bounds on some occasions when it hits the fan, but even at my insane poverty ridden county hospital, I've never been on a floor without at least an intern to turn to.

 

[no-see-um]

Students are supposed to be supervised. Sounds to me like they are looking to place blame rather than to be responsible for what happens in their hospital.

 

[xanthines]

Everyone already quoted/repeated/echoed all the good stuff, except this:

Beware. The amount of Axis II pathology in Medicine is unparalleled in other professions.
In order to survive, we all need to learn how to deal with irrational colleagues.

Ed

Of course, I would have phrased it much more colloquially...

-X

 

[squame]

just to let everyone know, i spoke with the internal med unit coordinator and he transferred me to another hospital. he already knew who I was as the hospital had contacted him about me being a "problem" student , but after he heard my story he was very sympathetic and made some calls to have me transferred. This is the main teaching hospital and it is so much more normal, the program is structured, the students are always on call with a senior resident, and the nurses don't ask students for orders. I need to be on my best behavior now, eeeek.

thanks to you all I was able to stick to my guns and remain confident that i should not be held responsible while speaking with the big-shots

 

[Doodledog]

Great. I'm very glad it worked out for you. With that I think I'll close this thread as everything has been said that needs to be said. Feel free to start a new thread here or elsewhere as the need arises!