Wednesday, December 30, 2009


I've thought about whether I wanted to post this or not for a few days. In the interest of representing what it is truly like to be an animal doctor, I think I would be heavily remiss in not sharing one of the the hardest parts of being a veterinarian (or any sort of doctor).

I made a mistake.

It's arguable whether or not it cost my patient her life.

On Sunday morning, a nice woman brought in her Golden Retriever. She had been hit by a car. Her respirations were rapid and shallow. I suspected a pneumothorax. Her gum color was not good, and her blood pressure wouldn't read.

We started stabilization: IV fluids, pain medication, and a chest tap. I removed over 3 liters of free air from her chest. At that point, I made the decision to put in a chest tube. She responded rapidly to this treatment. I discussed her condition with the owner, she left a hefty deposit and left her dog in my care.

Over the course of the day, we were slammed. I didn't eat, drink, or use the bathroom until 4:30 that afternoon. I was rushing around managing the patients pouring through the front door, as well as the 11 hospitalized patients in the back. See, we'd been open since Christmas Eve. I'd worked 14 hours on Friday, 14 hours on Saturday, and (as it turned out) 14 hours on Sunday. Further, I'd been sleeping terribly (Friday and Saturday night, I got a cumulative 6 hours of sleep). I was tired, emotional, and overwhelmed. I wasn't on my A game, or I can assure you, this never would have happened.

At any rate, over the course of the day, my patient's breathing became more and more shallow (despite the chest tube evacuating the air in her chest). Her gum color wasn't good (pale pink), and her blood pressure dropped repeatedly despite fluids.

ANY OTHER time - ANY OTHER day - I would have immediately suspected internal bleeding. The dog practically had a flashing neon light the size of a Mack truck above her head screaming HEMOABDOMEN HEMOABDOMEN HEMOABDOMEN!!!! It actually occurred to me that I should wheel the ultrasound over and check, but then something always intervened - another dying animal through the door, or something in the hospital needing my attention RIGHT THAT SECOND. I never did put the u/s on her.

As I transferred her over to the doctor on shift after me, my technician turned and said, "her blood pressure is 39 (normal systolic BP should be around 100!)." After I left, my colleague checked her belly, and sure enough: horrible internal hemorrhaging.

Surgery revealed a liver that was in multiple pieces and more than 3 liters of blood in the abdomen. My patient arrested under anesthesia.

My colleague has tried to make me feel better by telling me it wouldn't mattered had I caught it early or not, the liver was shattered. Somehow, that doesn't help. You see - somewhere in the back of my mind, I KNEW that my patient had internal bleeding, and I didn't look for it.

Why? Perhaps because I was exhausted and couldn't deal with the idea of an intensive surgery. Perhaps because I'd annoyed the techs enough that day and just couldn't stand seeing them roll their eyes when I asked that the ultrasound be wheeled over to the cage. Perhaps because my last hit by car hemoabdomen died on the table.

I'll never know the answer. I only know that I missed something that was blatantly obvious and now my patient is dead.


Mary said...

I am so sorry. Know that you've made such a huge difference for so many lives and you're human. That being said, fatigue must play a huge role. During my husband's residency, he's been working 30 hour straight shifts, and when he comes home, it's almost like he's drunk, he's so loopy.

I hope things settle down for you soon and you're able to get some sleep.

My caiques had to visit the emergency vet earlier this week so was thinking about you (they're fine).

Elizabeth said...

I am sorry this happened, but I am glad you posted about it, that says a lot about you and I admire that.

Did you explain what happened to the owners? I know that would be difficult but I would want to know if it had been my dog.
The outcome may not have been any different even if you had done the ultrasound but it's a lesson. Don't waste the lesson.

Hermit Thrush said...

I think what you and I most share in common is being awfully hard on ourselves.

Even excellent doctors miss things on busy shifts. Of course, it says a lot about you that you do feel terrible-- it means you hold yourself to a very high standard and make no excuses for yourself to let yourself off the hook internally, morally. That is a good thing.

However, it doesn't help to beat yourself up, though everyone does when they feel responsible for a patient dying. (You really, really ought to read that book by the human ER doctor that I wrote about on my blog-- it has a whole chapter on this subject.)

You've learned your lessons--
I'm sure that next time you will be more vigilant about checking for internal bleeding. I'm sure you will put the patient's care and life before the possibility of annoying the technicians (though working with technicians who are annoyed with you is really the pits).

In the end, that is all that you can really dwell on, the lessons learned, and then move on emotionally as best you can.

If I ever find time I'll write up some of my horrible mistakes on my blog. I think maybe it would make you feel better knowing that is just part of how it goes, as awful as it feels.

The Homeless Parrot said...

Elizabeth: I did not tell the owner. I thought about it, and I couldn't see any reason or good that could come out of it. If I make a mistake that directly results in a patient's death or poor response to therapy: eg I cut the wrong thing in surgery or overdose a dog on a medication or let a dog fall off the table while I'm doing an exam, the owner is informed because of the ramifications. In this case, telling the owner would only make them feel bad, I fear. The hemoabdomen WAS caught and it was addressed. The liver was destroyed, so - according to my colleague that did the surgery - the point was really moot. I couldn't see to what end informing the owner that it took 8 hours to catch the hemoabdomen would have. If you have thoughts that I'm not including in that logic process - please share. I'd like to hear it from an owner's perspective.

Nicki said...

We're human. Sometimes it sucks but life does go on.

Elizabeth said...

Don't get me wrong I am not critizing you for not telling nor for the mistake.

I ask because I wonder how Vets do handle this type of situation and to let you know that we do want the truth as clients. Yes there will be clients who will blame you but then there will be ones that know you are human and are doing your best for their pets.

I know my vet is human and I do not expect perfection, I know mistakes happen. But I want to know about them. My concern is that hiding mistakes can make things look bad, actually worse than it is. You know the old, if she didn't tell us about this what else is she hiding from us.

Would I hurt more because I was told about the mistake, I just don't know for sure, but I do know that having my vet tell me about it would "increase" my regard for her.

I feel some part of you is wondering whether the fact you missed it made a difference or not because you wrote "It's arguable whether or not it cost my patient her life." But you are beating yourself up because you did not give this dog your best. Remember you did the best you could at the time. As I said I admire you for telling US!

The Homeless Parrot said...

Elizabeth: I thought about this issue very carefully. If there was something to be gained - for myself OR for the owner - in the telling, I would do so. The owner was already heartbroken. Marching into the waiting room and saying, "a mistake was made, but it was caught, and the appropriate course of action instituted. Plus, your dog likely would have died anyway," just didn't seem constructive. I couldn't see how telling the owner would have been beneficial. Now, as I said, if I had administered a lethal overdose, or tied off a ureter by mistake during surgery, or done something negligent - that would be a totally different story.