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.
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Stories from the ER veterinarian world
DISCLAIMER
Any similarity between my stories and any person or animal, living or dead, is strictly a coincidence. Names, breeds, sexes, and details of the stories have been changed to protect the guilty and innocent alike.
About Me
- The Homeless Parrot
- I am an emergency veterinarian in North Carolina. Despite the crazy people I deal with, the awful cases of injured and sick animals, and the overall stress of emergency work, I absolutely love what I do. Happily married since I was 20, I have a wonderful husband who has a PhD in Mathematics, and a daughter around whom our world currently revolves. We also have a zoo living in our house that can be alternately wonderful and maddening. There are cats, parrots, and a dog who is very low on the totem pole. Our days are never dull and we are learning to balance the demands of work and family. If you'd like to contact me: homelessparrot@gmail.com
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Medical terminology
- Azotemia - elevation in kidney enzymes (BUN and creatinine) indicating dehydration, kidney failure, or urinary obstruction
- Lactate - a salt/ester of lactic acid that is produced as energy for a cell when oxygen levels are low. In critically ill animals, elevated lactate can be an indicator of inadequate blood flow to organs (perfusion), decreased delivery of oxygen, and/or decreased oxygen uptake. Values > 6-7 are usually considered to be poor prognostic indicators for survival.
- GI sloughing: when the cells lining the GI tract die (can be secondary to MANY things, including heatstroke) with resulting bloody diarrhea, bacterial translocation into the bloodstream and sepsis
- TTJ: transfer to jesus: code for when an animal needs to be euthanized or die
- DIC: disseminated intravascular coagulation: a very, very bad thing - when the hemostatic system gets out of whack, and clots start forming in the blood vessels until all clotting factors are wasted. once those are gone, internal hemorrhage ensues, followed by death, usually. also known as "death is coming"
- Pleural effusion - fluid contained in the pleural space (chest) - this is not the same as fluid in the lungs (see pulm edema) - in cats can be caused by infection in the chest, heart failure, cancer, FIP, feline leukemia, FIV, and in some cases, the cause is never found (idiopathic)
- Anisocoria - unequal pupil size (related to any number of causes including brain damage/head trauma)
- Laterally recumbent - lying on side, unable to rise
- Hyperglycemia - elevated blood glucose
- Hyperkalemia: elevated blood potassium - a life-threatening condition related to several disorders (kidney failure, antifreeze toxicity, urethral obstruction...etc)
- Sepsis - refers to a bacterial infection in the bloodstream or body tissues. This is a very broad term covering the presence of many types of microscopic disease-causing organisms.
- Nephrectomy - kidney removal
- Splenectomy - removal of spleen
- Pulmonary edema - condition in which fluid accumulates in the lungs, usually because the heart's left ventricle does not pump adequately ( can be caused by heart failure, electrocution, drowning, too many IV fluids, to name a few)
- Tick borne diseases - any of a myriad of diseases transmitted by ticks - including but not limited to Rocky Mtn Spotted fever, Lyme disease, Ehrlichia
- Fine needle aspirate - A method of sampling in which a needle is used to suck in cells or tissue bits for diagnoses (good for diagnosing masses/lumps)
- Blood glucose - The principal sugar produced by the body from food–especially carbohydrates, but also from proteins and fats; glucose is the body's major source of energy, is transported to cells via the circulation and used by cells in the presence of insulin (normal range in a dog/cat is 75-100)
- PCV - packed cell volume - the volume of packed red cells in milliliters per 100 ml of blood (normal range 35-45)
Diseases I see/treat frequently
- Dystocia - difficulty birthing. May be responsive to oxytocin administration (Pitocin, as in people) but may require c-section.
- DKA - diabetic ketoacidosis: the extreme end of the diabetic scale. A patient that is diabetic can develop DKA when other diseases make the blood glucose hard to regulate. Other diseases that are commonly associated include urinary tract infection, pancreatitis, pyometra, skin infection, and cancer. In DKA, the body starts metabolizing fat and producing acids that cause a drop in blood pH, nausea, weakness, severe dehydration, electrolyte derangments, and death.
- DCM - dilated cardiomyopathy: an idiopathic (cause unknown) cardiac disease in which the heart chambers become very thin/dilated, and cardiac output drops radically. Causes arrhythmias, tachycardia, and sudden death. Seen in large breed dogs like Dobermans, Great Danes, etc.
- Lymphoma - cancer of the white blood cells, the most common and treatable form of cancer in dogs
- Blocked cat - slang term for a male cat with a plug of mucus and crystals obstructing the urethra (fairly common in male cats) definitely a life-threatening because urine can't get out of the body! If present long enough, causes shock, acute renal failure, hyperkalemia (elevated potassium), coma, and death. Symptoms include straining in the litterbox, yowling while trying to urinate, producing small, bloody drops of urine (also symptoms of feline cystitis, a non-lethal condition)
- GDV - stands for gastric-dilatation and volvulus - a condition of large breed, deep-chested dogs (usually) in which the stomach rotates 180 degrees on its axis and thus - nothing can enter or leave, considered the "mother of all emergencies" - it warrants immediate surgery and carries a guarded prognosis
- IMHA - immune-mediated hemolytic anemia. A disease in which the immune system attacks the red blood cells and destroys them. It causes profound anemia and is life-threatening. Causes are primary (no known cause) and secondary ( tick borne disease, cancer, and heavy metal intoxication). Treatment is immunosuppression with drugs primarily. Prognosis is guarded at best.
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7 comments:
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).
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.
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.
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.
We're human. Sometimes it sucks but life does go on.
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!
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.
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