it's only been a month and a half...

since I last wrote. Damn, sorry about that guys. I did get swallowed into the "abyss", but I just started my vacation for 2 weeks! Which I badly needed...

So there was this patient of mine, a middle aged female, we'll call her Ms. M. She had liver disease, caused by hepatitis and by years of alcohol use. When you get "end stage liver disease", your liver scars up and shrivels up, and doesn't do its job of filtering all the blood coming from the digestive system. In fact, because its so scarred, blood may not even flow through it anymore. Instead, it may back up and pool up in the veins of the digestive system. These veins can get engorged and dilated, and can burst open and bleed, classically in the esophagus and stomach. The bleeds can be life threatening, so when someone has had a bleed like this, we treat her, and then try to prevent any future bleeding.

One of the ways we prevent future bleeds is through a procedure called TIPS (trans-jugular intrahepatic shunt). In other words, we decompress all that blood that is backed up behind the liver. We do this by creating a tunnel through the liver, so that the blood can go through the liver and back out to the heart. Its a temporary fix, until the patient can get a liver transplant. As you can imagine, the procedure is not without risks. The liver is a blood filter, so it sees a lot of blood. If you go poking around in the liver, it can bleed.

Well, Ms. M has cirrhosis of the liver, and was scheduled to get a TIPS procedure. I was her doctor. I usually schedule 1 am "bloodwork" for my patients, so that when I arrive to the hospital, her bloodwork is done and I can proceed with whatever needs to be done that day. Well at the time I was ordering bloodwork for the next day, I was finishing up an overnight shift, and was on my 30th hour, and forgot to order bloodwork on her for the next morning. She was going for her TIPS that day.

Ms M. got her TIPS that afternoon. She was returned to her room. The next morning I arrive, and find that she is in a lot of pain, right where her liver is located. She doesn't look good. Her blood pressure is okay, but her heart rate is a little high. I'm worried about her bleeding, but because her blood pressure is okay I planned on waiting until our morning rounds to tell my resident. I don't have any bloodwork, so I can't tell how much blood is in her.

30 minutes later, I hear "code blue, 3 West" over the hospital intercom, and 3 West is where Ms. M's room is. My stomach sinks, and our team runs down there, and sure enough, Ms. M has gone into cardiac arrest. We spend an hour doing CPR, giving her electric shocks and drugs to jumpstart her heart, but it doesn't look good. We end up getting a heart beat on maximal medications and 12 shocks, and she is transferred to the intensive care unit. Surely she suffered brain damage, and her body has shut down. Her husband withdrew care after 2 days, and she passed away.

I felt very responsible for her death, and carried this guilt over my head for a number of days. Sure, I didn't perform the procedure, but I damn well forgot to order that bloodwork. Maybe if I did order it, it would have shown her blood levels were critically low, and the intern-on-call would have been alerted and something could have been done to save her life. My bosses tell me, she was sick enough to begin...anyone who needs a TIPS is a sick person, and that we were trying to help her, we can't beat ourselves over our mistakes because they are 10 other patients that I need to provide my best care for. But it was hard to deal with this.

And this is how new doctors learn. We learn from our mistakes. But unfortunately, our mistakes can hurt patients. Most of the time they don't, but sometimes they do. And every intern, and every doctor, makes mistakes. I've certainly learned never to forget to order bloodwork before I leave. But there will be plenty more to come, since its just impossible to teach an intern all that needs to be known to care for patients before they are thrown into such situations. In medicine, we all aspire to be perfect, and patients certainly hope and sometimes expect us to be perfect, but we are human. We will make mistakes.

Medicine is unique in that our mistakes can directly harm others. Its really unsettling to me. Sometimes I wish I were fixing machines or computers or cars rather than humans...those are expendable. How does one deal with this responsibility, of trying to be as perfect as one can, knowing you never can, and that the fact you can't be perfect means you will hurt people?