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Medical Humanities

Close Calls: Mistakes and Mentorship in the ICU

Standing at the head of the patient’s bed in the intensive care unit, I felt my patient’s carotid artery thump against my fingertips. The loudest sound in the room was the regular susurrus of a mechanical ventilator.

The supervising resident met my eyes. “Put the catheter in here,” he gestured to the internal jugular vein. “Do. Not. Put. It –” he slid his finger a half-centimeter left, to the pulsating carotid, “—there.”

I nodded, silently rehearsing the vascular anatomy I’d learned two years earlier in medical school. If I punctured the carotid artery by mistake, the patient would bleed and could have another stroke.

We donned masks and thick paper gowns and I smeared iodine disinfectant on the patient’s neck. I had relaxed a little when we unfurled a sterile drape over the unconscious patient’s face.

Earlier, I had called the patient’s daughter to ask permission to perform the procedure. I listed risks of catheter insertion: pain, bleeding, infection, and nerve damage among others. I mentioned we would take care to avoid accidental puncture of the carotid artery. All questions answered, she consented.

“No big deal, right?” she asked.

“No big deal,” I said to comfort myself as much as her: it was my first time.

With a pop, I cracked open a glass ampule of lidocaine, and injected a little mound of anesthetic under the skin. Then, while I covered the carotid artery with the fingertips of my left hand, my right hand pushed the tip of a long needle into the patient’s newly-numb skin. The needle tugged a little at the tough epidermis before sliding smoothly into the deeper tissues below.

“Farther,” said the resident. “A little farther.”

I knew that once I punctured the vein, just a little suction on the stopper would fill the syringe with blood. I pushed the needle farther in and drew back. Nothing. I redirected, pushed in and drew back again. Nothing.

I was sweating under my gown. Each breath fogged my glasses a little more.

“Let me try,” said the resident. He took the needle from me, felt the carotid pulse for himself, and adjusted the angle of the needle. “Easy street,” he said, handing me the syringe.

I pushed in, and pulled on the stopper. Nothing.

Push, pull – blood entered the syringe. Dark purple blood.

“Black gold,” said the resident.

I exhaled. Dark blood meant venous blood from the internal jugular vein. I was in the right spot. Had I punctured the carotid artery by mistake the syringe would have filled with bright red blood bound for the brain.

I stopped breathing again when the syringe filled with bubbles. The resident and I stood silently for a couple of breaths, watching the syringe fill with more pink bubbles each time the patient’s chest filled with air.

“Shit,” said the resident, taking the syringe from my hand. He withdrew the syringe from the vein, and applied pressure with a gloved hand. I watched, my own carotid pulsing at my chin.

A STAT chest x-ray confirmed our worst fears: the right hemithorax, instead of being occupied with fully-inflated lung, was a black air-filled void at the bottom of which sat a fist-sized clump of lung. Clearly, the tip of my needle had passed through the wall of the vein and punctured nearby surface of the lung. I pictured a gash in the spongy surface of the lung, its lips leaking air into the patient’s pleura. Soon, the patient’s blood pressure began to fall, a sign that the leaking air was building up at high enough pressure to prevent the heart from pumping effectively.

The cardiothoracic surgeon arrived minutes later in rumpled green scrubs and cowboy boots. A bundle of instruments was tucked under his arm, among them a long rubber tube that flopped down almost to the floor. The surgeon too called the daughter, and then, with incredible speed, he sterilized and numbed the chest wall, poked a hole between two ribs, and jammed the mouth of the rubber tube into the hole. Almost immediately, I heard air whoosh out of the patient’s chest and into the tube, and the patient’s blood pressure began to improve. The surgeon sauntered out of the intensive care unit, saying over his shoulder, “Don’t worry about it, everybody screws the pooch sometimes.”

I picked up the phone to let the daughter know her father was doing better, and to apologize. I choked up on the phone, and felt aghast when she comforted me.

On rounds the next morning, I kept seeing the syringe fill with blood, and then air. I recited the vitals signs of other patients and woodenly enumerated their lab results, but the whole while I kept seeing the black void of air filling up my patient’s chest. The finger-thick rubber tube protruding from his chest felt like an accusation.

The senior resident and I were about to discuss another patient when a nurse ran up. “There’s a code in Bed 6!” she said. We ran after her, passing en route the site of the previous night’s calamity.

“We need IV access,” called the charge nurse.

“He’s your man,” said the senior resident. He saw my hesitation, and gave me a gentle shove toward the patient. “You’ve got this,” he said.

I got ready while the resident started to run the resuscitation effort. “Resume CPR,” I heard him say as I prepped the site for line insertion and started hunting for the vein. “Is he intubated yet?” the resident asked the anesthesiologist while I laid my instruments out on the sterile drape.

I felt for landmarks with my gloved hand. Lymph nodes, artery, and vein. Nudging the tip of the needle under the skin, I pulled on the stopper and, so easily it startled me, the syringe filled with dark purple blood on the first try. No bubbles this time, just a flood of dark blood and, for me, complete relief. “There you go,” the resident said, looking over my shoulder. “That’s what I’m talkin’ about!”

Medical mistakes harm or kill hundreds of thousands of patients every year. There are thus major nationwide efforts afoot to prevent medical errors. But no matter how many quality improvement interventions we make, fallible human beings practice medicine, and mistakes will be made. We must therefore do our best to prevent mistakes, and also learn to respond healthily when mistakes do occur.

Learners make more mistakes than experienced clinicians. This makes it tempting to exclude learners from participation in delicate procedures. Yet without the chance to participate, the next generation of doctors will never learn to do their jobs.

To balance these concerns, we must provide adequate supervision and build patient notification of trainee participation into the informed consent process. We are learning how to educate learners about medical error. From effective disclosure to engagement with quality improvement efforts, this is some of the most important material our students will learn in school.

Very importantly, medical students are more likely to disclose errors appropriately when provided with supportive mentorship. I saw the gold standard up close, and suspect such mentorship also leads to resilience in the face of error. My senior resident encouraged me to be fearful of making mistakes. Yet at the same time he pushed me to keep trying after I had made one. This is a delicate balancing act: we must have high expectations while at the same time allowing for human fallibility. Otherwise our mistakes can turn toxic. Without room to be human, physicians can seek maladaptive ways to handle the stress of failure. I feel lucky I was encouraged to keep on trying, and to keep on learning.

When the code was over and the patient was stabilized, the resident came over to me.

“Want to make a different kind of phone call?” he asked. “Let’s let his wife know he’s out of the woods.”

He sat next to me as I dialed her number.

“Make sure you tell her you helped save his life,” he said.


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Author bio:

Tim Lahey, MD MMSc
Geisel School of Medicine at Dartmouth Medical School
Timothy.Lahey@Dartmouth.edu

 



 

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