Medical professionals of Reddit, what mistake have you made in your medical career that, because of the outcome, you've never forgotten? [SERIOUS]

I'm a surgery resident, and I made one mistake as an intern I'll never forget.

This post is from my blog, its really long but I apologize but it fits perfectly...

Everyone makes mistakes. Hell the internet is littered with quotes from famous people about mistakes.

"A person who never made a mistake never tried anything new." - Some guy named Einstein

"A mistake is always forgivable, rarely excusable and always unacceptable." - Robert Fripp

And it goes on.

Mistakes are different in the medical community. I alluded to it an earlier post. An athlete makes a mistake, his team might lose. An accountant makes a number, he has to make an embarrassing phone call to a client to fix his wrong.

A surgeon makes a mistake, and it can cost someone their life.

I'm by no means the first, nor will I be even close to the last to being a doctor - honestly barely a doctor a fresh graduate out of medical school - to make a mistake that has led to irreversible harm. In the surgical community, we even acknowledge that such mistakes exist and discuss them in a setting that is theoretically safe from judgement - the weekly M&M (morbidity and mortality) conference. The idea is that mistakes, as in any profession, happen and our goal should be to learn from them. This concept in itself is troubling, in essence it leads to a dichotomy between what physicians should strive to be, perfect, and the reality that like any other profession we will make mistakes.

This has been discussed previously. When I was a fourth year medical student a friend of mine introduced me to Atul Gawande, a surgeon who has written numerous books of his experiences in training. He actually has dedicated books to the topic, with a book called Complications, and another called The Checklist Manifesto that delve into the topics of mistakes and how to prevent them. Definitely great reading if you have time.

But reading about mistakes is one thing. I had read his books before starting my intern year. I knew residents who had made mistakes as medical students. It wasn't a big deal at the time. I think thats human nature. Despite our best intentions to empathize with other people, to put ourselves in their shoes and understand what they are going to we just can't. Very few people have that ability. Instead we recognize they are going through something, try and understand and be supportive, and forget about it 5 minutes later.

So enough rambling. I started intern year off on night float, made some very small mistakes that really were inconsequential, and overall had a great start to the year. I next went to colorectal, a notoriously busy service. I knew it was going to be long hours (and it was), but I loved it. I was always tired and overworked, but if you worked hard and could get to the OR in the afternoon the fellow was great about letting interns do alot. Great experience.

We rounded early on colorectal, 6am. This means I would be coming in around 4:30 to get numbers, and see 6-12 patients before rounds. Sometimes notes would need to be done too before rounds. Grueling, but I got used to it.

Every Wednesday we have conference from 7-8 AM. We did our AM rounds in the morning as normal. Nothing exciting, and we headed to conference. Right after conference I sit down with the fellow and the senior resident to run the list when I get a page that one of our patients, lets call her AT, is short of breath. Ok no big deal, I head over to the floor to see whats going on. She's a very pleasant 70 something year old lady who had part of her colon removed for recurrent diverticulitis. The case was straightforward, and she was post-op day #2. We had probably planned to send her home the following day. When I saw her I was shocked at how short of breath she actually was. That morning at 5am when I had seen her she was so comfortably. One of the immediate post operative causes of shortness of breath that you always worry about is a clot in the leg that formed from not walking enough after surgery and that clot breaking off and traveling to the lungs, something called a pulmonary embolus. The quick and easy way to get an idea of whats going on non-invasively is do something called a duplex scan, which I order. Her vital signs were completely stable so I wasn't really concerned about something catastrophic.

I leave her room, call my senior resident to run the plan by him, and start walking to our resident room. As I'm walking there I think in my head "She's on heparin, right"?

Heparin is a blood thinner that we commonly use after surgery because it can help prevent blood clots in the legs. It does come with a risk of bleeding, but generally you can fix that whereas the clots/emboli can be significantly more devastating. During rounds the morning before (Tue), my attending had asked me if she was on heparin. I honestly had no idea, but told him I'd check and if she wasn't I'd start it.

"Did I remember to do that"?

I start to panic a little, and kind of half run to the resident room. I have to check the computer and see if its ordered. I log in, look at her orders.

Its not there.

I forgot...

My heart sinks. I start hyperventilating. And honestly - I'm pretty laid back most of the time. I didn't know what was happening. I all the vascular lab and beg them to do the duplex right away. I plant myself in the nurses station in front of AT's room and wait for them.

As I wait, I tell myself I'm overreacting. Its not a big deal. She's probably just a little fluid overloaded. Its not going to a clot in her legs. The vascular tech arrives, goes in the room. I start to calm down. Its all going to be ok.

I pace around the nursing station, waiting for him to finish. I'm convinced its going to be nothing.

The tech walks out of the room, and I chase him down.

"Did you find anything" I ask.

"Yup, acute clot in the left femoral vein" he says, and hands me a schematic of where her clot is.

That crushing overwhelming feeling comes back. I don't know what to think. I call my senior resident, update him. He tells me to text the attending, Dr. P. I get ahold of him, and let him know that she's short of breath, and has a DVT (the leg clot) - making it likely (but not 100%) that she has a pulmonary embolus (PE). He agrees that she probably has a PE, and wants to get a special kind of CT scan to diagnose it. He also wants to start her on a heparin drip to presumptively treat her, all reasonable things to do. I tell him I'll take care of it and we hang up.

He then texts me "Hey bladder whisperer, she was on heparin right?"

My heart sinks. "No actually she wasn't..."

"Wait, I thought I asked you to check yesterday?"

I didn't know what to say. All I said was "Honestly I forgot". I was ready for the worst. I thought it was over. His response?

"Oh BW, that was a mistake".

Then silence

I felt terrible. He wasn't mad, he was disappointed. It all hit me like a ton of bricks. This was his patient, his license, his name on the line. This complication, regardless of who caused it, is his responsibility. And it was my fault. Already I felt like nothing because I felt responsible for AT's current shortness of breath, and now I was putting my team through this.

The rest of the day was a whirlwind. I still had 10 other post operative patients to take care of, discharges, consults etc. The thing about being busy is you don't have time to think. I just worked, and got through it.

But the day had to end at some point. I walk to work, and left around 7pm. The walk home I finally had some time to think, and thats when I started to get inside my head. I made it home and just broke down. I got no sleep that night, just tossing and turning. Around 2am I finally gave up, and headed into the hospital. The rest of the team had already moved on, new patients and new things to take care of. But for me it was all about AT. I couldn't stop thinking about her, stop checking in on her. I tried rationalizing it to myself, that despite the heparin she would have gotten it anyways. I tried shifting the blame to the other people who hadn't ordered it or caught the mistake. It stayed with me every second, every decision.

But life goes on. She did great on the heparin drip, and her shortness of breath resolved. She was bridged to coumadin, and planned to be discharged home. At the time of her discharge I stopped by her room to wish her luck and make sure everything was taken care of and we said our good byes.

At that point her husband stops me and says "I just want to thank you for everything you've done for me and my family". He gives me a firm handshake and says "If you are ever up in our neck of the woods look me up, I owe you a beer".

I looked down, because I knew if I looked him or his wife in the eyes they would see right through me. The thing is in my guilt I had made sure I came to see them multiple times a day, and basically was there for them the second they needed anything. From their standpoint, AT had developed a complication and I was on the frontline, the doctor who was with them and helped them through it. Dr. P didn't throw me under the bus and tell them it was my fault, all he had told them was it should have been ordered but mistakenly hadn't.

It broke my heart. Their was nothing i could say, and I mumbled a response back and got out of the room.

It took weeks for the numbness to resolve, and the incident has change me as a person. I've made many mistakes in my life, and will make many more. But the knowledge that I caused harm to someone, that someone may have lost their life and will certainly have some morbidity from a mistake I made lies heavy in my heart, even more than one year later.

/r/AskReddit Thread