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How We Learn
Anna Burkhead -- I am three weeks into my eight-week surgery rotation. I’ve been in the OR every day, but except for an appendectomy or two, all the surgeries I’ve seen have been scheduled (ie – not emergent, not traumatic).
All scheduled, except for one.
On my last call night, the surgery intern paged me and told me to come see consults with him in the ED. When I arrived, he was examining a man on a stretcher, and he asked me to begin the work-up on an elderly lady with a large abscess on her back. I didn’t get a good look at the man he was examining, except for the fact that he had a very bloody bandage on his arm.
About an hour later, I was in the OR watching a lap-chole when the intern arrived to tell our mid-level resident and the attending about the patients in the ED. He gave the short story of the woman with the abscess, and then said, "…and the other patient is a middle-aged man on dialysis who is having bleeding from the site of his AV fistula. I wrote orders to admit him." The attending said he’d go "eyeball" the patient as soon as they were done.
Twenty minutes later, I was in the surgeons’ lounge when I got wind that there was an emergent surgery about to begin in OR 3. My stylish hairnet and I (see picture) scurried over. Upon entering the operating room, I couldn’t see much of the patient, who was already prepped and draped, but I did see a large clot hanging out of a ragged opening in the arm strapped to the armboard. It was the patient with the AV fistula.
After the attending and the chief resident speedily repaired the man’s leaking fistula, the chief approached the intern. "You know he would have died, right? He would have been admitted to the floor, the nurses would have thought he was getting sleepy, and he would have died." I watched from a respectful distance as the intern nodded at the chief’s words.
It wasn’t much of a scolding, more like a passing of wisdom and lessons learned from a senior to a newbie. I realized I was witnessing a moment and a lesson that this surgery intern would never forget. It might be the scene that he’d relate to his own young intern, four years in the future, when he is finally a surgery chief.
The fields of medicine and surgery have checks and balances because scenes like the one described above happen occasionally. This is how we learn.
April 2, 2008 in Anna Burkhead | Permalink
Comments
Or maybe an observant nurse would have caught it and saved his life, like we do every day.
Posted by: Kate | Apr 7, 2008 8:06:50 AM
If that were the case, then that nurse should be commended.
This is a forum for medical students to learn, not for you to unabashedly display the enormous chip on your shoulder.
Posted by: Jennifer | Apr 8, 2008 3:36:21 PM
lesson learned
Posted by: Cherie | Apr 8, 2008 3:51:00 PM
i probably shouldn't put my foot in my mouth, (especially considering I am a student who just completed her surgery rotation)... I completely didn't follow that story. What does the bloody arm bandage have to do with the surgery? I'm not quite sure what the intern "missed". Anyone care to explain without making me feel stupider than I do at this precise moment? thanks
Posted by: | Apr 8, 2008 3:53:18 PM
Kudos to the Nurse. Once more attitude from the other side of the spectrum (i.e. Dr.'s) I have been in nursing for many years and many times it is a thankless job. Could it be that perhaps that is why there is such a shortage of nurses? And you with the comments; don't until you've worn nurse's shoes.
P.S.
I am now going pre-med.
Posted by: rosemarie | Apr 8, 2008 3:53:25 PM
To Kate: you're right, a nurse could've (and hopefully would've) recognized the situation! Thanks for your input!
To Student who just completed surgery rotation: don't worry, no foot in your mouth:) I definitely didn't make it very clear, upon re-reading it. What had happened was that the man's fistula had basically "blown", and he was slowly bleeding out. There was several enormous (golf-ball sized) clots just sitting in his arm. The attending surgeon repaired the fistula. I think what the intern missed was the active bleed, which was covered by giant clot.
Thanks for the comments!
Posted by: Anna | Apr 8, 2008 4:02:09 PM
cool stories like this get me fired up for my surgery rotation in Sept.. hope I don't get yelled at very often, or fall asleep in surgeries!
Posted by: McNeilly | Apr 8, 2008 4:16:53 PM
Anna: Great write-up of your experience. I wish more doctors-in-training and nurses-in-training would communicate. I learn so much from you interns/residents as you talk about your experiences on rotations. I won't take for granted an AV fistula repair admit, or if one comes into the ER (where I'm about to preceptor thru here in San Diego) because of your story.
Posted by: Nancy Chardt, RN Student, San Diego | Apr 8, 2008 4:49:53 PM
I don't think the surgeon was trying to insult nurses... The point was this patient had an arterial (and venous...) bleed, and the floor is not the place to "monitor" that. That patient needs to go to the OR, and if not there then the TLC.
So chill out.
Posted by: | Apr 8, 2008 5:14:21 PM
This is why we are a TEAM. If something slips past one then another can catch it. Nurses could have noted the amount of blood on the bandage. The size of the arm, the color and sensation of the arm/hand, blood pressure and heart rate, level of consciousness. These are in a focused exam by a nurse. Then the doctor is called. It is true that slow subtle changes can be missed in shift changes, but nurses do catch many things missed by others. We are a team.
Posted by: Sally, BSN, RN, NREMTP | Apr 8, 2008 5:46:47 PM
"I have been in nursing for many years and many times it is a thankless job. Could it be that perhaps that is why there is such a shortage of nurses? And you with the comments; don't until you've worn nurse's shoes."
Hey, guess what, being a med student, intern, and resident are all often "thankless jobs" as well. Life is hard on all sides of the medicine spectrum, not just for nurses. Perhaps a little more understanding is needed from all of us.
Posted by: | Apr 8, 2008 5:53:14 PM
Truly after working with a great team of nurses on a post-trauma floor in a top 100 hospital, I am confident that in any decent competent hospital, the gentleman in question would not have missed his care, neither from the doctors nor from the nurses. The biggest risk to a bleed like this, I would think, would be if a patient like this was stuck waiting in the ER without an evaluation for a very long time. The nursing staff I worked with was always consciencious about new admits, making sure that the patient was checked head-to-toe, backed up by the eyes of CNA's. We always attended bleeds immediately--a bleed out can happen from a bad IV as well. Yes, medical care is very much a team effort and doctors and nurses and other staff must rely on each other to get the job done. At my hospital all the hospital staff, even housekeeping, received lots of respect. The folks who clean up patient rooms can make a real difference in nosocomial infections. CNA's have more one-on-one care with patients than nurses often do and can sound an alert when a patient status changes. Many people are critical to a good healthcare team. When I left my job to get ready for medical school, I had a very favorable impression of what a healthcare team really means and I promised the nursing staff to keep it in mind down the road.
Posted by: B | Apr 8, 2008 7:48:15 PM
I am a nontraditional (older) nursing student. I enjoy reading life sories and learning from them. Thank you to everyone in the medical profession for caring and sharing your experiences. When I come home from my clinical rotation at the end of the day I feel thanked in seeing the smiles and the hand squeeze from a frightened patient that I've helped. Many times a good deed goes unrecognized,or a patient is to ill, do good anyway and feel good about yourself, the outcome, the learning experiences, and the difference we all can make in a day and in a persons well-being. Good luck to everyone
Posted by: Peg | Apr 8, 2008 7:50:02 PM
to mcneilly-when retracting, don't lean forward. if you fall asleep you may end up falling on the patient! i have caught myself nodding off while retracting. good thing i was leaning backwards.
Posted by: | Apr 8, 2008 9:10:35 PM
I have been an RN for 6 years and will be applying for med school next summer. I have been to many other countries on medical volunteer excursions. I LOVE these trips cuz rn's can do SO much more in various foreign countries - viva mexico!! and the learning experience is invaluable. I have seen both sides to the whole dr vs rn battle - that will forever exist unfortunately - in many aspects. As I read the dr's & rn's comments about thankless job and dr vs rn, I feel obliged to comment that hopefully, we got into medicine to help our patients - not for special recognition. I'm NOT saying that it doesn't get old when someone else gets thanked (ie by the patient) or gets credit for something you did, etc - but, I think seeing the results of enhancing a patient's health and wellbeing and therefore enhancing the lives of their loved ones AND our own IS thanks - even if its unspoken & unrecognized. Hopefully, we got into the medical field for the "right" reasons. It is obvious that dr's n rn's each contribute certain things and that what 1 lacks, the other picks up/makes up for - which is the basis of a team. No one can offend you if YOU don't let em!! Medicine is an ETERNAL learning experience - whether you have 1 yr or 20 yrs experience and we have to be able to take certain things w/a "grain of salt" and not be intimidated or offended - these things WILL affect patient care. I found in nursing school and since then, that I LOVE surgery so I'm going on. But, whether you are a dr, rn, cna, social worker, resp therapist, etc, our main focus is doing everything we can (within our scope of practice) and/or helping others do everything THEY can, so we know that we did EVERYTHING we possibly could to help our patient(s) - especially if unfortunate results occur and we have to explain these things to the family. Rise above people!! I think some of my greatest assets medically is that I have learned which battles to fight and that people have a right to an opinion. That opinion is JUST THAT!! It can't bother ya if YOU don't let it. I'll get off my ridiculously large soapbox now. Thanks to everyone who shares their stories because, as it was said before, they contribute to how & what we learn.
Posted by: Mel | Apr 8, 2008 10:44:06 PM
im planning on studing cardio pulmonary perfusion and i normally check all areas that i will work with and that i wont work with. i felt as though the intern was more focused with helping the patient get cleaned up. there are certain patients who suffer from severe gout that i have seen that just look as though their pores are literally bleeding to death but upon clean up it really just shows the patient themselves were scratching till they broke skin. its a lesson learned on the basis of checkin all possibilities before taking action but being human is learning from the mistakes made
Posted by: Jean | Apr 9, 2008 1:51:34 AM
Although I was initially peeved by the dr vs rn comment I'm glad I made time to read all of the contributions.Interesting that it was a rn that reminded us all of the "team" aspect of who we are in our roles as health professionals.I have gained a sense of renewed hope for mutual respect in the health profession by reading the entire length of this thread.
Posted by: Lynn | Apr 9, 2008 5:54:23 AM
This story particularly hit home for me. My father was a kidney patient and made medical books for a variety of reasons. I remember clearly, sitting at the dining room table when I was 14 and he showing my brother and sister and I his fistula. He explained that it was a new artery that he had to build up and that he would have needles put into it for dialysis. I placed my fingers over it and was shocked to feel the rush of blood over it. He also explained that if it was every injured, he could bleed to death.
Mistakes happen everyday and once it nearly happened with him when someone tried to take his blood pressure in that arm, even with a note overhead that reminded them not to.
As doctors, nurses..any caregiver, we have to remember that even though you may be tired, worn down, and every patient seems like a shadowy blur of the one before..each case demands a cleansing breath, a shake of the head and a solid focus.
And I'm sure, like the author noted, it will be a moment that the intern will never forget.
Posted by: lisa | Apr 9, 2008 8:16:28 AM
sorry to pull the scab from the wound, but that chief resident should have known better than to promulgate that kind of attitude. the disdain was quite overt. lets hope he's one of a dying breed. note; to call attention to an injustice is not to have a 'chip on one's shoulder'. if that were the case, the allies would have been ashamed to object to hitler's antics in ww2.
lets start respecting some of our unsung hero nurses who labour at the coalface
Posted by: restiform_bod | Apr 9, 2008 10:20:15 AM
the article is commendable as it makes that each patient is separate entity and requires us to be vigilant enough to note it
well lisa what u have said is very true as we feel tired out each patient feels shadowy image of the previous so it requires us to be really efficient
well in India the patient rush is huge and going from my surgery rotation experience it requires a lot to be good surgeon
Posted by: sandeep s sarpal | Apr 9, 2008 10:57:20 AM
Hey Anna, you make me shiver! It's a pretty good anecdote of how we do learn, but also how we shouldn't learn, it's the thin middle line between the patient's life or death. Actually is good for all of us to have a good staff member steping behind our feet when we are in trouble with a patient, let us not forget the doctor is not a superman, but it is only a man, and also can commit mistakes, let us work as a team!
Posted by: Juan R | Apr 9, 2008 3:04:58 PM
About the chief's comment.
First, it is the resident's responsibility to make sure a patient doesn't get to the floor in the first place if an emergent OR visit is what they need.
Second, to all the defensive people on this board, there ARE hospital floors out there that do NOT have nurses that would recognize such a failure in a timely fashion (eg maybe the patient was admitted to a medical floor with nurses not used to caring for surgical patients), and the patient would indeed bleed to death. Be that a systems problem or a staffing problem, it's nonetheless a very real, potentially deadly problem.
I took the comment to be not a dig on nurses in general, but perhaps a recognition of the shortcomings of the given facility. Even with a competent staff, the level of care on the floor may not allow for a quick bleed out to be caught in time.
Posted by: NYCChiquita | Apr 9, 2008 7:12:14 PM
All of us are fallible - medical students, doctors, nurses. None of us will get it right the whole time, and when we fail we need to be able to trust in our colleagues from other disciplines. That doesn't remove our own responsibility to learn from mistakes, but it makes the healthcare system a more human place - and therefore maybe a better place for our patients?
Thanks, Anna, for a thought-provoking story, and to all who made me think afresh about teamwork.
Posted by: Anna J | Apr 10, 2008 12:42:33 AM
thanks anna I'll consider that in the future.
Posted by: dr.zee | Apr 10, 2008 4:39:13 AM
Thanks Anna... really good one!!!
also we should learn that medicine is not BOOKS... its the people and patients who need our help !!!
Posted by: Omar | Apr 10, 2008 6:29:38 AM
that was a good story :) thanks for sharing!
Posted by: ditzydoctor | Apr 10, 2008 7:57:50 AM
beautiful word Sally! we are a team. This makes our heart sure that we are not alone.we can learn from each other which is not in any book!
Posted by: Mandana | Apr 10, 2008 8:19:58 AM
Your checks don't balance if you think nurses do not prioritize ABC's.
Paula Wolfe EMT/BSN student
Posted by: Paula Wolfe | Apr 10, 2008 8:16:14 PM
that was a cool story to share.That is truly how we learn, at least sometimes
Posted by: akenji | Apr 11, 2008 8:31:52 AM
This is a great story to share about learning from all aspects (both attendings, interns, and nurses). This story was not to insult or bash nurses (who I agree can be unappreciated), or insult or bash interns, residents or attendings, but to show how quickly things can go wrong to an untrained eye. It sometimes takes witnessing a potentially drastic situation for us to learn or pass on a bit of knowledge to those who are less experienced. I know that as an intern, I will know about 2% of what the seasoned nurses know, and I respect them for that, but on the same token, inexperience leads to lots of mistakes (from nurses and doctors), so we should take time to learn from the ones who came before us. I am a 4th year medical student who recently matched into surgery, and I realize that the interdisciplinary nature of medicine is not at the level it should be, specifically regarding communication between doctors and nurses; however, for the nurses on this board there is nothing to take offense at - because you are VERY appreciated (even if you don't hear it). But always remember that without nurses and doctors working together, very little would be accomplished and patients would suffer. We are each other's support system, and this medical student's experience documents that quite eloquently. We all (nurses, interns, residents, and attendings) should have each other's back, and that of the patients.
Let's keep this in mind everyday.
Posted by: Kimberly | Apr 11, 2008 1:59:50 PM
nothing beats a good history and physical examination
Posted by: yojie | Apr 11, 2008 4:11:20 PM
There are places in Africa where all the doctors do is show up, read charts and perform operations. Every other thing is done by the Nurses. I such places, a wise med student, intern or doctor knows better than to antagonise a nurse by making remarks like "the nursing staff could have missed the signs and the patient would have bled to death". Antagonising nurses like like that could mean your future in that hospital is very bleak. In my own part of the world though.
Posted by: Brooke | Apr 11, 2008 9:37:09 PM
It's good practice never to discount any patient because of lack of symptoms. Recently I was in a wreck and had I not insisted on a dye test we would not have discovered the rupture/hematoma in the subclavian artery until too late. It's not always the patient that exhibits outward signs of pain or readily visual symptoms that is most in need. Your story is a good little anecdote to remind us to keep vigilant. We must remind nurses and ourselves to not get complacent and insist that they remember a human life may be in the balance with every person through that door.
Posted by: Shaun | Apr 12, 2008 7:56:38 AM
learning is acontonuing process never stop for adoctor or amedical student thank u 4 sharing this experince with us
Posted by: soso | Apr 12, 2008 8:15:59 AM
well anna, the intern is certainly at fault in missing an active bleed. But you are right this is how we all learn.After working with many efficient nurses throuhout my residency i think a good nurse woukd have definitely spotted the bleed and alerted the on call person. In my experiance i have seen that a good nurse may be much better than an average intern
Posted by: math | Apr 13, 2008 10:36:33 AM
nice story!!! i'll keep it in mind...
Posted by: rami | Apr 14, 2008 9:29:22 AM
Nurse vs Doctors. What if there were no doctors to operate,only nurses to prepare and palliate and care for a patient ( the other many things they do)? But what if there were no nurses only doctors who operate on unprepared patients,no post op monitoring, no care both before and after surgery? Doctors and nurses both serve distinct and sometimes overlapping functions.Both are needed. Imagine a hospital with only nurses, but also imagine a hospital with only doctors. We are all needed. Also remember lab technicians, radiographers, physiotherapist,pharmacist etc. How would a hospital function with only doctors and nurses? All are a team with various roles and functions. Just like the body with many parts and organs working together as a functional unit. No man is an island and no man stands alone.
Posted by: debbie | Apr 16, 2008 2:47:08 PM
A poignant story indeed. Arteriovenous fistulae are never something to be taken lightly, and when bleeding must be reviewed by a senior or experienced surgeon or dialysis nurse urgently.
The point of the admonishment was that one cannot make assumptions about the ability of others to cover up for a mistake or error that you have incurred. Yes, a good nurse would have noticed that the patient was bleeding uncontrollably, but if you think about it, it would not have been difficult for this patient to die on the ward.
1. Patients with an arteriovenous fistula typically have low resting blood pressures. From the point they entered the emergency department their BP would have easily been around 90 systolic. Once that had been accepted as a baseline a ward nurse might not call over a minor fall in blood pressure.
2. Patients with renal failure are always anaemic. That's why they're often on EpO.
3. On top of this, it is likely that the standard ER response to hypotension and bleeding may have been fluid resuscitation. Renal failure patients do not tolerate large fluid shifts and rapidly go into APO or have myocardial infarcts. At that stage it may be too late.
4. The standard management for a bleeding wound is application of pressure. Given how much bleeding is likely to have been present, I can easily imagine that an ED would apply a large bandage (not that large bandages control bleeding better than small bandages wiht focal pressure). If you were the nurse on the ward who saw some oozing through the bandage, would you take it down or reinforce it with another bandage? How much oozing (and it would be a small ooze, not a large spurt) would it take for you to call a doctor? Would it be too late by then?
5. Even if the bandage had held, and the patient remained stable, by the next day the fistula would be occluded. This patient would have lost their dialysis access, and require insertion of a temporary dialysis catheter and creation of a new AVF. If I had spent an hour of my life creating this fistula, I would be very upset if someone blocked it off because they couldn't be bothered or didn't know enough to organise an operation to fix it.
Just a point - large, dilated fistulae are often full of golfball sized clots. It is a sad statement about needle access techniques, but it is almost normal.
regards,
Sheepish
Posted by: Sheepish | Apr 20, 2008 4:38:20 AM
