I learned early on that you don’t say “oops” in the OR during an operation. Even though the patient can’t hear you (supposedly), you still never give any indication that a mistake occurred. Ever. It’s like religion. Don’t mess with it.
What I’m still coming to terms with is that you really shouldn’t say “oops” anywhere in the medical field. A trial lawyer’s favorite word is “oops”. And there’s this unspoken pressure to withhold admission of mistakes from patients because – doctors worry – the patient will lose confidence in the competency of the doc if it is clear that a mistake was made.
I once gave a patient what is generally regarded as a pretty small dose of dilaudid – a narcotic pain med commonly used on hospital floors. She was about my age and of normal weight and having excruciating headaches, we think caused by herpes virus infecting the meningeal layer of her brain.
Imagine that pain for a moment: If you’ve ever had a cold sore or fever blister…think of that happening inside your skull, but scattered all over your brain. I think I’d rather just crush my head in a trash compactor. Naturally, until we could actually do something to cure this woman (there actually isn’t much that CAN be done), I wanted to do what I could to help with the pain. Still, she was young and thin, so I ordered a fairly minimal dose range of 0.5 mg – 2 mg. The actual amount could then be determined by the nurse based on how much pain the patient was having.
The next day, I returned to the hospital to find that my patient had nearly quit breathing overnight, after just one dose of the narcotic at 1 mg. The nurses had called a “rapid response” team to her room, which is one step away from calling the “code” team, which is that group of heros in primary-color spandex who come in and bashes on your dead chest screaming, “C’mon, dammit, don’t you leave me!” So, basically, she almost died. My first thought was that I contributed to the problem because I gave the order for the narcotics. I figured I shouldn’t have given a dose range and should have just written for the 0.5 mg dose until I saw how she handled that amount. And I could have spent more time with her to determine how she reacted to narcotics. I could have avoided narcotics in general and just told her to, “Quit gripin’ you baby-faced American. It’s just a headache. They don’t have IV dilaudid in Darfur and everybody does just fine.”
So, I got up to her room quickly after morning report and found that her mom was also in the room. I should mention that I regarded both of these women as friends as well as patients. This woman’s headaches waxed and waned, so in the previous days I spent as much time talking about life and joking about all kinds of common interests with she and her mom as I did talking about her condition. We got along great and I related to them – in particular I related to my patient’s wry sense of humor and I admired her courage as she dealt with what really is a “short straw” dealt to her by life. So, naturally, when I heard she almost stopped breathing, I was concerned and dismayed. It was like being told your friend almost died but don’t worry, everything’s ok now.
Really? What happend? I need to talk to her and make sure for myself. Like any friend would. Like any doctor should.
Swooping into her room that morning, I already noted that her vital signs had stabilized over the previous few hours and that things were – from a “gonna die or not” perspective – resolved. “Jeez, what a tool of a doctor you have!” I exclaimed. “Wow, I’m really sorry about that. I never expected it at that dose.”
After checking her out and seeing that she was actually fine, I asked in all seriousness, “So, did we get rid of the headache?” The three of us laughed. “By God, if it kills me, I’m going to stop the pain!” She replied. We then seriously talked over the best plan for her…which didn’t involve the same level or type of narcotics.
The patient did well over the next couple of nights and eventually went home. It seemed to me that we were on good terms with each other and I felt like I had approached the interaction in total honesty throughout. Was her near-calamity my fault entirely? No. But I did contribute to it, and felt that admitting it was a good thing to do for the relationship between me and the pt. and her family.
So I apologized in the way that a friend might apologize to another friend. I was as much saying I was sorry for the way things turned out as I was saying that I did something wrong. It’s like I took a friend to dinner and they got food poisoning. I would apologize for that. But I would be expressing regret over the situation entirely, including whatever I may have done to facilitate my buddy sinking his head in the white throne of grace for 3 days straight. This thinking, however, met with some harsh responses among my superiors. “You APOLOGIZED? Don’t you know that’s effectively an admission of guilt? How do you know it was you? Maybe she took something else you didn’t authorize. Maybe the nurse dosed it wrong. Maybe she was dehydrated.” Blah, blah. My point was I was sorry for what happened…HOWEVER it happened.
I can’t see where the legal system has helped medicine that much. I’m certainly dismayed to work in an environment where I can’t say I’m sorry without first considering the legal ramifications of doing so. Lawyers have succeeded in sucking the notion of friendship and genuine relationship between doctor and patient entirely out of the equation. In the vacuum, they have managed to inject calculation and risk-management. If I’d been told prior to going to med school that I would be required to appraise every patient for their potential aggressiveness; to size up their projected risk to me, I most certainly would have chosen another field.
But, hey, the system demanded 300k in loans from me, so I’m stuck. Therefore, I’m practicing a stable of post-error responses akin to: “Too bad that happened. Must suck to be you, but good thing you have an infallible doctor that didn’t contribute in any way to what happened. The nurses around here are pretty air-headed, by the way. Did I mention that before? Anyway, not to worry. I’ll find that nurse and rest assured I won’t sleep until I can be certain you get the correct dose next time.”