OwnershipBy Matthew Hitron, MD
During my third year of medical school one of my patients died. It was a medical error that killed her, and I have been told to feel that the responsibility for it is shared, as a system and as a team. I didn’t feel that way then, and I don’t feel that way now. She died not only because of a screw up, but because no one really cared. I live with the fact that I could have stopped it. She needed someone to care, and I failed her in that. She was an elderly woman with many problems and a dementia that made her difficult to interview and examine. She was uncooperative and at times combative. She had no family, with a court appointed legal guardian and HCP. She arrived from her nursing home with mucus stains on her face and two necrotic toes. She swore at you, and even spat at you when you tried to speak with her. There are ways to break down the story into its components, and analyze the systems that failed; the cracks that she fell through. But it is smoke clouding the picture of a patient who was going to challenge all her care givers by requiring of them a true and exhausting commitment to her humanity; a humanity that was easily forgotten after a few seconds in the room. She was passed off from person to person, service to service, consult to consult; and I was complicit in this.
It was two weeks into my third year medicine clerkship. At times it felt like a show and I was painfully aware of the need to impress. I was not about to back down from any task, and was constantly negotiating the third year paradox of needing to learn everything while hiding the fact that you know nothing. My resident warned me she would be tough, but I had to prove I was good. She was admitted that night uneventfully, numerous consults were called, and the day was over.
The next day she was the last patient on rounds, kept NPO and on maintenance fluids while she sat in her room like that was the curative measure. Nothing happened. The team would wait for the consults to do something and the consults would wait for the team to tell them what to do. The removal of her dead toes was at least some sort of plan, but her strangely elevated INR, her ominous acidosis, and her altered mental status were just glossed over before lunch, with vitamin K, bicarb, and olanzapine given to make everybody feel better.
I came in the next morning, and as I flubbed my way through the note jotting down a K+ value of 2.0, it never occurred to me to be sure someone else knew about it. I remember thinking “wow; that sure is low…†if it were a test question I would have gotten it right. With all the nurses, consultants, and residents milling around her, someone must have seen it too and acted with purpose. No one did that morning. Instead of taking ownership, I was just another in a long line who passed the responsibility off, with no one left after me to pick it up.
Late that afternoon potassium was finally hung on her IV. The patient was alive, and I had dodged a bullet. I walked to the stairwell, stopped on a landing and leaned against the wall, “Take ownership†I said to myself, “you may be the only one left.†I remember feeling like I learned a huge lesson without a patient having to pay with her life.
I also remember moments later, and will never forget; the panic, the disbelief, and the grim realization that a patient had fallen through the cracks to her death, while I ran up the stairs to the sounds of the code alarm.
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