How do you go about dealing with guilt over possible contribution to patient's death. We all make mistakes, depending on the area we are in they can be big. I work as a PA in a small rural community hospital. About a year and a half experience under my belt. Responsible for MSP and ICU patients on nights with SP available over the phone. First mistake I made was a HRS patient with cirrhosis and portal HTN with small amt of ascites who went to ER and was there for about 12 hours and received suboptimal care. Received three 500 mL boluses and not even started on broad spec abx. By the time I admitted her, lactate had trended up to mid-5's around 10:30 PM. I don't know why I didn't call my SP. I sat on her honestly for about 2.5 hours before initiating transfer, I had started broad spec abx, but did not continue to bolus her and honestly did not realize what I should have done (albumin, pressors, etc.). This was all due to my inexperience. Around 1:30 lactate was around 6. She finally left hospital after I initiated transfer around 1 but didn't get out until about 3:45. By the time she got to other hospital around 40 minutes away, potassium was super elevated and she wound up passing. My thought process in the transfer was that her Cr has not improved whatsoever, no urine output, and increasing lactic acidosis despite fluids so I thought she needed dialysis or higher level of care. But I can't stop beating myself up for not calling my SP, not knowing how to tx the disease process, and not initiating quick enough transfer. She was a super sick lady no doubt and who know what outcome would have been anyway, but I cannot stop destroying myself for this.
Second case wound up being perf bowel and transmural necrosis. PMHx of GSW 4 years prior with GJostomy and lost other parts of bowel (not exactly sure). He had become worse on day shift and around 4-5 PM SP was taking call, patient became increasingly tachycardic to 130s/140s, was transferred to ICU with repeat labs and dose of Cardizem 20 (where my problem begins). Lactate was 3.9 by this point. By the time I saw patient, he was still tachycardic and it was around 8:30 PM. Called my SP who recommended bolus and starting more fluids after. I did this and patient was still tachycardic in 130s - 140s. Called SP back around 10 PM and recommended repeat CT with PO (to visualize bowels, though now I know we just needed a stat CT not to wait around on PO contrast) and then to call surgeon who had seen him earlier on day shift. I gave another dose of Cardizem 20 around 10:20 PM (probably anchor bias and I know the definite wrong thing to do now). He was not really complaining of pain at this time and was self medicating in the hospital so pain signaling was definitely off. Around 11 PM nurses called again stating he was still tachy in 140s. I saw patient and he was almost done with PO contrast but scan would have been in another hour or so. Gave in to anchor bias again and gave Lopressor 10 IV (I know usual dose is around 5 q5). HR came down to around 107-110. Throughout all of this he was normotensive. About 10-15 minutes later he coded into asystole. Lactate drawn before code then came back at 7.2. Coded him and brought him back, called my SP and we transferred him to higher level of care where he passed about four hours later. Now I know, this was a life threatening dx and he got worse and was worsening before I got there, even if we had gotten him into surgery around 12 or 1 AM, he may have had no functioning bowel left anyway and may have passed from complications. I have no idea why I treated the sinus tach, how we all did not think sooner to just call surgeon. I really just have no idea.
I have had mostly great experiences and have learned so much at my hospital. Like I said, I have had hundreds of good patient outcomes since working and I did very well on my boards and PACKRAT and definitely feel like I am good at medicine (despite these mistakes, I know very very dumb). These two instance of being involved in a bad outcome have really shaken me because I was directly involved, not fully responsible (and no litigation), but a proximal cause due to inexperience and poor management. It has made me feel like I don't take my job seriously, but in first case I thought I was doing the right thing, and in second case I flat out just made a mistake. Like I said, I have been so racked with guilt that I have wanted to tell the family. Autopsy was done and I didn't "buff" my notes so everything is in writing, if I'd have been sued or found responsible then it would have come out. But like I said, I have been so incredibly overcome with guilt. I really feel as if I want to come clean about it because of the guilt. I just don't know how to get past this.
I know we all make mistakes, I know sometimes they can be big ones. Especially with sick patients when there are other contributing factors in the setting I am in. People have supported me through this and I have talked to doctors and colleagues alike and they tell me that I must learn from this, and not to beat myself up like crazy because both patients were sick and these can often be missed diagnoses anyway. Any advice on getting over mistakes and the guilt that comes with them? Thank you for reading.