to err medically…

Prompted by Dr Val’s guest post at other things amanzi, i’m reminded of a story my surgical professor recently told us, during his tutorial on fluids and electrolytes management in surgical patients.

Quite some time ago, a patient was in the hospital had a percutaneous endoscopic gastrostomy (PEG) tube in for some reason or other. (Inside Surgery has an excellent write-up on the entire procedure)

Then comes along a nurse, who apparently still works at the hospital i am placed at now. What she wanted to do was to supplement the patient with some potassium. She took 6mg of K+ tablets, crushed them, put in solution, and instead of giving that through the PEG tube, she injected the solution into the patient’s IV cannula. The patient obviously died from this lethal dose. Fluid replacements go in the order of 25 mEq/L. On that note, the last step in a lethal injection consists of potassium chloride at a lethal dose (source).

The professor cursed a string of curse words. He mentioned if it had been a doctor, it would have been all over the news, the doctor would have his medical practising license revoked, a big law suit will ensue,etc. But this nurse got away with “some counselling”.

im not trying to make the nurse look bad. i’m sure she felt extremely bad for her mistake. the counselling might full well be necessary. Iin fact, my sympathy goes out to her for having to live with such a mistake. It will be very brave of her to continue nursing despite this mistake and continue in her care for patients.

This then dawned on me when we consider the responsibilities placed on on doctors versus that on nurses. Doctors and nurses carry different but important roles in a multi-disciplinary team in the aim to provide optimal care for patients. That is the ideal scenario. But is it happening? Let’s consider something simple, like setting IV cannulas.

My interns are telling me the nurses page them throughout the day to ask them to set IVs. Are these nurses trained to set IVs? Some aren’t. But some RN DIV 1 are graduates!  Surely they can set IVs.. i used to think that the nurses are the ones who are so much more experienced with practical procedures like these. When i heard this was happening on the wards, i was startled. Also, apparently there is a protocol against nurses setting IVs on legs. The intern was like “You’re not shitting me, are you? There is an ACTUAL protocol saying that?!”

All in all, i think if i were an intern, i don’t think i’ll mind getting paged to do a difficult IV that the nurses could not get in after 2 tries. Obviously there is a paradox in that the nurses should be the more experienced ones yet they are asking the intern who is less experienced. 

This doctor-nurse responsibility difference reminds me of the time when i was still in the military. They had officers and specialists. I am an officer, and there are some sergeants under me. They are generally very dedicated individuals who know their stuff. But when something adverse happens (e.g. a soldier faints due to heat/physical exhaustion), the one who bears the responsibility and answers to superiors are not the sergeants, but the officers. How so? For example, the reason the soldier fainted was that water stations were not set up for the 5km run. Because the soldier did not have adequate hydration, and the weather was hot (34degC, not uncommon) and humid (~86%), he collapsed. Now the officer has tasked the sergeant to set up the water station, but he did not. In the medico-legal sense, the sergeant’s failure to act is DIRECTLY attributed to the soldier’s mishap. But in the military (at least in the one i was in), the Conducting/Safety Officer is in the wrong, because he should ENSURED that the water station was set up.

~ ~

The other day, my intern’s car was blocked by an unknown car, as a result, he couldn’t drive off for his half day off. He asked the reception to make an announcement but they wouldn’t allow it. The nurses in the ward he worked at were furious. One of them called down to reception and gave whoever that was an earful. Obviously he was well liked enough for the nurses in the surgical ward to do that. It was a nice gesture, even though he got out only an hour and half later.

A strong social support in friends is absolutely vital. Thankfully, our PBL group at the hospital recently has been getting closer. I’m enjoying it. We are cracking jokes during the PBL, we get along fine, we are sharing opinions about life, love and other stuff. I hope we get the same placements next year. I re-echo J.D.’s challenge in Scrubs Season 1 Episode 3. “Besides, I challenge anyone to survive as an intern without a close group of friends to lean on.” 

(fast forward to 3:05)

Can we then reduce medical errors? I don’t know, but i think it sure beats being an overworked, socially isolated, stressed doctor.