Bad role models

[fantasty]

This kinda goes along with the mistakes in the intern year thread. But, have you seen situations from your residents or attendings that you definitely wouldn't want to emulate? Here's a couple of mine (perhaps you can tell me if I'm over-reacting):

I've had an attending yell at a young patient who was taking mass amounts of tylenol for knee pain (I forget the exact amount but it was definitely excessive). The point is that an important educational opportunity became a screaming match and results in the patient leaving AMA.

Another time, a patient on our team died of sepsis two days after a totally botched attempt at a bone marrow biopsy performed by an intern. I'm not saying that it was causal, but all of the experienced docs in the room said it was the worst attempt at a biopsy they'd ever seen. My question to the MDs out there - is it possible to nick bowel or something similarly bad in this procedure?

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[doc05]

Another time, a patient on our team died of sepsis two days after a totally botched attempt at a bone marrow biopsy performed by an intern. I'm not saying that it was causal, but all of the experienced docs in the room said it was the worst attempt at a biopsy they'd ever seen. My question to the MDs out there - is it possible to nick bowel or something similarly bad in this procedure?

did you actually see them do the biopsy?? did you study anatomy? can you imagine how that needle could have reached bowel?

more importantly though, what was the patient's hospital course, how was the sepsis treated? what other things were done wrong?

 

[Crypt Abscess]

I have done about 50 bone marrow biopsies with no complications- this is a very easy procedure with few complications. It would be very difficult to perf someone's bowel doing this. Interesting.

 

[fantasty]

The patient did have leukemia (surely terminal). But, he was in the hospital for several weeks with fairly benign course, then rapid collapse. He started looking bad the night before he died, and went to the ICU. In the ICU, the same intern had a hell of a time placing a central line. They drew blood cultures that morning and that's how they knew he was septic, but I don't think he was treated for it.

Yes - I saw the biopsy. Looked f'ed up to me (he didn't get nearly enough tissue but they eventually stopped him). Keep in mind this was my first and only observed one. (I'm a mudphud student - this happened 3 years ago, and I had anatomy 4 years ago and have to admit I suck at it - which is sort of why I'm asking if I'm jumping to the wrong conclusions). When I talked about it with the senior resident later, she just kinda shrugged and said that we knew he was going to code (not in an apathetic way - more in a "hey, intern did his best" kind of way).

I've not a very procedure inclined person to begin with, but this event still bothers me. I'm not saying I would have done any better (this was also probably only intern's 3rd week on service).

 

[doc05]

it is highly unlikely that the biopsy caused a bowel perf. were there any signs or symptoms of bowel perf? of course not. more likely the patient's "rapid collapse" wasn't so rapid. one clue is that the resident expected the patient to code: he was obviously much sicker than you realized, and this is something you'll understand better when you've had some more clinical experience.

as for the intern you had trouble with the biopsy and the central line: that's not a big deal. realize that with enough practice, a monkey could do those procedures. interns, especially medicine interns, just don't do much in the way of procedures. but a perfed bowel from a BM biopsy doesn't sound right.

as for drawing blood cultures, that is standard, but you really don't need to "draw cultures" to say someone is septic. you can tell by examining them. by the way, what organisms were growing in the blood?

another thing: if the patient's course was "fairly benign," why was he in the hospital for several weeks??

 

[fantasty]

Thanks for easing my mind a bit. Of course, I don't remember all of the details and you're right that he was probably sicker than I credited him for (he was admitted before I joined the team, and he wasn't really a "teaching" case because we picked up new patients). I don't remember what organism they cultured. As for expecting him to code, that was once he was transfered to the ICU though (which is where the line fiasco took place). They knew he was terminally ill and wasn't going to leave the VA.

It still doesn't change the fact that I don't want to be that guy when I do my first BM! Even if it had nothing to do with the final outcome, he was obviously doing something wrong. And, my best role model on that team for empathy and patient communication was the Sub-I.

 

[Furrball]

Was he on steroids? Sometimes patients with leukemia and on steroids get bowel perfs as a complication of their steroids.

 

[fantasty]

OK - I'm showing a little OCD here. But, there has been at least one case of bone marrow biopsy leading to cellulitis then septicemia. (Br J Haematol. 2003 Jun;121(6):949-51). Granted, it was a neutropenic kid (with ALL). Maybe the assumption that the bowel was involved was stupid on my part, but the procedure site could have easily gotten infected and it's quite possible he was neutropenic. Although the time course may not be right either.

I just felt bad that I didn't look it up myself first. Anyway - the point in this whole thread was that I wanted to ask people to talk about how they learned by watching other people's mistakes.

 

[AJM]

The patient did have leukemia (surely terminal). But, he was in the hospital for several weeks with fairly benign course, then rapid collapse. He started looking bad the night before he died, and went to the ICU. In the ICU, the same intern had a hell of a time placing a central line. They drew blood cultures that morning and that's how they knew he was septic, but I don't think he was treated for it.

Yes - I saw the biopsy. Looked f'ed up to me (he didn't get nearly enough tissue but they eventually stopped him). Keep in mind this was my first and only observed one. (I'm a mudphud student - this happened 3 years ago, and I had anatomy 4 years ago and have to admit I suck at it - which is sort of why I'm asking if I'm jumping to the wrong conclusions). When I talked about it with the senior resident later, she just kinda shrugged and said that we knew he was going to code (not in an apathetic way - more in a "hey, intern did his best" kind of way).

I've not a very procedure inclined person to begin with, but this event still bothers me. I'm not saying I would have done any better (this was also probably only intern's 3rd week on service).

You really should see another BM biopsy before you judge how this one went. BM biopsies tend to look f'ed up in general - they are some of the most medieval-looking procedures we do, and can be pretty horrifying for any med student to watch their first time. It doesn't necessarily mean that it was botched, it's just the nature of the procedure.

As far as the central line - it's not uncommon to have difficulty with a central line placement, especially if the patient's anatomy is different (anatomical variations happen pretty frequently). My only comment with this is that the resident would have taken over if she had thought that the extra time the line placement took would have endangered the patient in any way.

And last - you say the patient had leukemia (?type?) +/- neutropenia. In my experience, these patients can crash fast and hard. It's probable that the difficult BM bx was just a coincidence, especially if there was no significant erythema around the site afterwards. In addition, it sounds like the horse was out of the barn by the time the central line was done - I don't think that difficulties there would have made much difference.

 

[irlandesa]

I respectfully disagree with Crypt Abscess; I have seen 3rd year Heme/Onc fellows do less than a fantastic job on BM biopsies to put it mildly, and have never seen an intern permitted to even attempt the procedure... If an ugly BM biopsy on a terminally ill patient is the most reprehensible and incompetent thing you see as a med student or patient, you are one lucky mofo.. Back to the original topic, a few examples:

1)On my Peds rotation, a woman who spoke very little English and didn't know the name of the medication her daughter was receiving for her ear infection came to the ER, where my resident (a 23 y/o girl living with her incredibly rich family) and the ED attending treated her like she was the most incompetent parent ever instead of trying to help and educate. Although the ABx situation was straightened out, she ended up refusing further observation of the child and left AMA b/c my resident was such a bitch to her.

2)The intern I worked with on my Sub-I had been out of med school for 2 years, and had had to scramble into a Psych internship at a less-than-renowned community program b/c of problems he'd had obtaining a residency position in the past. In spite of this, my resident not only turned my supervision entirely over to him (which is NOT supposed to happen on a Sub-I), and he would follow me into patients' rooms to "make sure you know what you're doing", and when I tried to draw blood (with VERY poor instructions and suggestions by him) he lectured me in front of the patients about what a failure I would be on my ICU rotation and in life if I didn't learn to do it right. What a wonderful way to establish patient trust.

3)"So, how much do you weigh?" was the VERY first thing said by one of my psych attendings to a morbidly obese woman, at the top of his voice, in front of an entire team of residents and medical students. This question precluded going over how she would like the team to help her, or any questions about her hospital course or medical history.

Fortunately, I have run into many great role models during the past 2 years, but there are other people I wouldn't want to treat me if they were the only physicians on the planet..

 

[germanIMG]

I can say I easily performed 100+ BM biopsies and perforation of the bowel is anatomically pretty much impossible, that is if you biopse where you are supposed to..
The weirdest think I have seen, was a broken Jamshidi stuck in the Pt and Surgery had to be called.
Regarding the scenario: Pt with leukemia. Could very well be that he was down with his Thrombos which makes BM biopsy very bloody and messy. Subsequent hematoma are great breeding ground for bacteria, specially in neutropenic pts, which a pt with leukemia almost per definition is, as even when he is not < 500, his leukos are far from functional. Same goes for central line. Last, keep in mind, these pts usually had already placed a significant number of central lines, sometimes with subsequent thrombosis of vena subclavia and/ or scarring . So this is about the technical most challenging thing to do. Sometimes has to be done under doppler control.
wouldnt really judge the performance of anyyone, unless you have a full understanding of the big picture..and even then...
only critic: if the pt was really terminally ill and complication were forseeable, if I were the senior, I would not have let the intern deal with this, unless he is experienced enough. Not pleasant for the Pt, not pleasant for the intern as well.

 

[pretzel]

Concerning another thread on IMGs, wouldn't that be great to be a fellow intern with germanIMG? Dante, I don't know if you've worked with mice in lab, but you can jam a needle right into the abdomen to inject into the peritoneal cavity because the bowels move out of the way. If you've been to the OR, the same applies to human bowels, so even if the intern didn't biopsy where he was supposed to...

 

[Pili]

A third year resident doing a parecentesis of an-about to explode-with pressure -ascitic belly screamed at the intern that if the vacuum bottle was not perfectly connected a pneumoperitoneum would be caused on first sticking patient...Has this guy ever heard of force vectors?

 

[fantasty]

I'm not a mouse poker - I'm an epidemiologist Let's forget I said anything 'bout the colon, shall we

Thanks though - you've all answered the question about my over-reacting

Regardless of what he did and whether it had anything to do with the outcome, he did it wrong. All of the experienced doctors were even appalled and said it was the worst attempt they ever saw. (Of course, they'll probably change their opinion when I'm on my sub-i ). And, you're right - I'll probably see a lot worse in the future, and unfortunately probably do a lot worse too.

Everybody makes mistakes and everyone has to start learning somewhere. All this doesn't change the facts that there are some awesome clinical role models that I've worked with, and some that I would never want treating me in a million years.

The other story in my original post was at a free clinic that I volunteer at on a regular basis, and this same doc has made multiple patients cry because of his temper. On the other hand, I worked with a hospitalist last summer that was a clinical genius and still outstanding with patients.

 

[doc05]

A third year resident doing a parecentesis of an-about to explode-with pressure -ascitic belly screamed at the intern that if the vacuum bottle was not perfectly connected a pneumoperitoneum would be caused on first sticking patient...Has this guy ever heard of force vectors?

sounds like a ridiculous premise. more importantly, is there any real risk with a small pneumoperitoneum?? no.