Monday, April 4, 2011

i make a big mistake

it is a great relief to me that i did not kill anyone in my residency, but that is not to say that i did not make mistakes, even big ones.  this one, although it ends as well as it could, still makes me feel pretty lousy to think about.

i have spoken before about the 3 west hallway of our training hospital, a long corridor of patient rooms tucked out of site of the not so central nursing station, the perfect setting for this unfortunate tale.  3 west was usually the 'GI' wing, home to all things gastrointestinal, but it was also the repository for any overflow from other floors.  you sort of cringed when you learned that your non-GI admission was going to 3 west, if only for the smells they would have to endure.

one afternoon, my attending and i were checking in on our liver failure patient.  she was jaundiced and ascitic, but stable.  as we were leaving her room, an elderly woman ran out of the adjacent room and grabbed us.  she had been sitting peacefully at her husband's bedside when he suddenly embarked on the deadly journey of anaphylaxis.  fifteen minutes prior, he had been given an intravenous dose of a new drug in a last attempt to quell his raging lymphoma.  despite a reported risk of serious allergic reactions being greater than 30%, there was no protocol for administration or observation of this new drug.

we rushed to his bedside.  he was sitting up in bed, leaning forward, clearly struggling to breath.  his mouth and tongue were visibly swollen and dusky against his otherwise too pale skin.  he looked at us with such a startling mix of terror and pleading, his wife saying the words his swollen airway could not, 'please help!'  but then, in almost the same sentence, telling us that he is 'DNR'.  do not resuscitate.  the dilemma could not have been more clear.  call a code and intubate this man against his prior stated wishes, or watch him die.  because he couldn't speak, and because his distress was so great that he couldn't even nod his head in consent, we had to decide for him.  his wife, equally distraught, just wanted us to do whatever we could.  there was no time to revisit the nuances of a hospital DNR order, no meeting of the ethics committee.

we quickly decided we would give him epinephrine subcutaneously.  by that time the nurse was in the room with the crash cart, but the only epinephrine she could find was the kind used intravenously in cardiac arrest, the difference being its much greater potency.  we, or rather i, because my attending was sort of hanging back and allowing me to take the lead, said give it anyway.  so this poor man was given a dose of epinephrine ten times stronger than what he should have had.  at this point he collapses, he's not breathing and his heart is pounding at what sounds like 300 beats a minute.  his wife is sobbing, my attending is silent.  i call a code.

i later learned that although he survived the code, his lymphoma had not responded to the new drug.  he was discharged home with hospice, and died soon after.  i also learned that a protocol for the giving of that drug had been made and included 30 minutes of post administration observation and epinephrine at the bedside.

i felt so guilty about that whole event, guilty about going against some one's end of life wishes, a man that i did not know at all, guilty for giving him the wrong dose of epinephrine and sending him in to ventricular tachycardia, guilty for not later finding that couple and telling them how sorry i was.  i felt angry at the team to which the patient belonged for having essentially no plan in place for the administration of that drug, angry at my attending for not stepping in and helping me (maybe she was as unsure that day as i was, who knows), angry at my residency program for always seeming to give me more responsibility than i felt prepared to handle.  but mostly i felt ashamed for panicking, for not behaving like the doctor i was supposed to be.  i took an action that i knew was wrong because i was caught up in the panic of the moment.  lesson learned.


  1. Interesting, may I read it again ?~! There’s a lot in that last paragraph, b. I struggle to wrestle my thoughts back into my current reality as we speak.

  2. Just like everything in our lives from birth, there is a learning curve. Doctors take on a weight greater than I probably ever will. Big hug to you!

  3. Sounds to me like everyone else in that room avoided making a decision, forcing you to take the lead. Your feelings are understandable, but in the end you did rescue him from a horrible death and allow the primary disease to take its course.

    Shame on your attending.

  4. Kinda makes you wonder about your own DNR. Will it be followed? Not as clear-cut as you think.

    Please forgive yourself for this. You're going to be a really good, if not great, doctor.

  5. thank you, readers. i have forgiven myself, i just haven't forgotten.

  6. I can so understand...I've been away from the bedside for so many years, but I can remember every single major "mistake" that I've made, no matter how many good things that I've done in the meantime. It doesn't matter that the mistake was in the face of incredible confusion and time constraints. I want to be perfect. When I'm not, I feel like I've failed. You will not forget--if you did, it would make you less of a quality physician!

  7. I don't know that you did anything wrong here. First of all, a DNR is simply that; it doesn't mean Do Not Help. Would you not give a neb treatment to someone having an asthma attack just because they have a DNR? Secondly, a lower dose of the higher concentration Epi IS indicated for anaphylaxis; however, not a full 1mg