Mistakes in Medical School

Thomas Robey -- How many times in medical school have you thought, “Wait a minute, was that right?” Sometimes we students question statements made from classroom podiums. Other times it’s a policy made by school administration. Maybe a classmate’s behavior raises concern. The further along I get in my medical education, the more I notice myself asking that question of my own clinical decisions.

My first week in the county hospital’s emergency room has prompted a spike in moments of post facto doubt that I did the right thing for a patient. Addressing mistakes in medicine is an important skill –- and it’s one that I feel I am not yet prepared for. All I know now is that I’m painfully aware of both the potential for and reality of medical mistakes.

As far as I can gather, this sort of introspection occurs when providers take on new and increased responsibility, are in the process of learning from experiences, and find themselves in a new environment. For me, the longish transits to and from work permit additional opportunities for reflection.

Students on my emergency medicine clerkship are given responsibility unrivaled by any other rotation in our training. We are expected to carry 3-5 charts at a time and take initiative for patients’ care from the moment they are put in a bed until their discharge or admission. There are caveats, of course. This doesn’t apply to trauma patients: students participate in care, but certainly do not call the shots! Also, attending physicians chart a complete note in addition to the student’s record, must co-sign orders and expect to receive regular updates. But the basic decisions are the student’s to make. Due to the busy nature of the ER, and the throughput, a faulty action may not be realized until the patient is out the door.

Take for example the injection drug user I cared for this week. She came in with a deep deltoid abscess in her shoulder. Why so deep? She had run out of veins so was now muscling heroin. I did a thorough exam of her lesion, determined there was no subcutaneous gas and used ultrasound imaging to identify the depth and size of the abscess. I was able to get a little bit of blood for labs and found her white count was 14,000 but her sodium level was normal. (Potentially systemic infection, but probably not necrotizing fasciitis.) Knowing that muscle abscesses cannot be drained in the ER, I referred her to the general surgery service. I was caught up on the logistics of her transfer; for example, no one could get satisfactory venous access, even with ultrasound guidance. I didn’t realize until after she was admitted to the operating room that I’d not listened closely to her heart. Yes, cellulitis can kill people, but the more fatal consequence of IV drug use is endocarditis and septic emboli to the brain. I was so caught up in doing the right thing for her wound that I lost track of the big picture.

It’s a good thing that my attending listened to her heart, and the anesthesiologist, and surgeons and... but in the end I am left with the truth that I let her down. I suppose that’s why experiential learning works. You can bet on my listening to every injection drug user’s heart from this point forward.