How to cope when you miss something serious

[pennpac]

I saw a guy in urgent care today with left sided rib pain after a fall. Not short of breath just hard to breathe bc of the pain. No fractures seen on xray, Pt sent home with diagnosis of rib contusion and told him to go to ER if worsening pain or short of breath. Overread came back as critical, 30-40% pneumothorax with lateral rib fractures. After looking at X-ray again with SP we did see the subtle line of the pneumo and she says she may have missed it too if she was busy. Cannot visualize the fractures still. Luckily we got the report right after the pt left so I was able to call and tell him to go to the ER ASAP, but I still feel like I failed and should have caught it. We send the chest X-rays for overread for a reason and I know there will be times in my career where I’ll miss things but it’s still hard to swallow. 

[sas5814]

It is always hard to swallow but sadly will happen to all of us over the course of a career. Personally I rarely x-ray ribs because, short of a significant fracture, they are nearly impossible to see. If they have had that big a trauma they probably need to be in the ER anyway.

Not 2 weeks ago I had a guy come in stating he was seen 2 days earlier with otitis media and every time he took his Augmentin he threw up and now he was sick to his stomach and had a headache.

Did a pretty thorough (normal) physical exam, told him his ears looked OK to stop the Augmentin for now and let's see what happens over the next 24 hours. 5 hours later his girlfriend found him at home confused and almost obtunded. Meningitis, mastoiditis. Had a B myringotomy and unilateral mastoidotomy, spent 3 days in ICU and then some in rehab. seems to doing OK.

Review of the chart with SP and med director didn't find any big omissions other than I didn't ask "worst headache of your life" or at least didn't chart it.

Did I miss the headache thing because I saw the easy diagnosis? Should I have drilled down more.....give better follow up instructions? All rattling around in my head. All I can do (and you) is learn from it and let it make me a better provider.

[thinkertdm]

So before this thread devolves into "I can beat your scar", here are some thoughts:

1.  Don't judge the op, or any other posters.  As sas5814 said, it *will* be you.

2.  You will feel guilty.  It's natural.  Breathe.

3.  You will feel angry, at yourself, for not doing the right thing; for doing the wrong thing.  Breathe.  Pet your dog.  Hug your loved ones.  You will be angry at the patient, for not telling you something, for hiding something, for being dumb, for seeing you.  Stop.  Breathe.

4.  For the love of God, do not ever, edit the chart, or lie.  Ever.  Even if you are in the wrong.

5. Reread number 4.  

6. If the patient is still alive, slow down, stop, think how to keep them that way.  Consider asking for help.  Now is not the time to be a hero.

7.  If the patient has died, call your supervisor. Review your notes from the case.  Read number four.

8. Stop.  Breathe. 

9. If you need to, seek help.  It's ok.  Not your spouse, pet, or SP.  A real trained professional.  The number of doctors who commit suicide is under reported and PA's are not at all, but we need resources too.

10.  Learn.  Please.  It won't keep it from happening again, but will keep you from the overwhelming guilt.

11.  Do something else.  Learn a hobby.  Something that makes you feel the beautiful being that is you.

[sas5814]

^ This....and my scar is bigger than your scar. :-)

[gbrothers98]

Like you said, you get the overread for a reason. There should be a notice provided in discharge instructions attesting to that fact for patients to be aware of. Should also be verbalized to the patient. This is part of the quality assurance that provides a safety net for the patient against poor outcomes.

Next, framework needs to be constructed in the context of if there was harm done. Harm in this case was if patient went home, never notified of finding, progressed to tension pneumothorax and died. Instead he got a call consistent with the overread process notifying him of abnormality that required a higher level of care to be sought. Only point to be covered here is was contact and relay of information to patient documented and did patient indicate understanding of severity of problem. An initial contact with the ED and follow up afterwards with involved clinicians and with patient are also worthwhile, though not necessarily essential.

Last, there is a large discrepancy between normal rib xray initial read and findings described above. That review of image yielded 'subtle' findings by 2 sets of eyes is a cause of concern and should initiate the following considerations:

1. Was the overread incorrect? Radiologists make mistakes.

2. Is there an aspect of interpretation that is affected? For instance, does the radiologist have the benefit of a large high resolution monitor and can manipulate the image with PACS while locally can only view image with a laptop? Is plain image interpretation a strong skill? if so, how did one come to that? Significant instruction and a robust case log of interpretations over time? Or rather a sense of confidence that may be overstated? Perhaps this is a metacognitive moment to provide insight into an area that requires review or a reinforcement of initial training?

Good luck.

George

[thinkertdm]

 

[lkth487]

It's hard.  It happens to everyone.  Learn from it.  People expect their healthcare providers to be perfect - but human beings cannot be.  

[cbrsmurf]

You show me a clinician who has never missed anything serious and I'll show you a liar

[Febrifuge]

Show me someone who claims they never make mistakes, and I'll show you someone who is lousy at recognizing their own mistakes. 

The trick is to embrace your mistakes. There are few more effective or memorable lessons. 

Do what you can to make them small, make them correctable, and make them once each. I only worry about people who keep making the same kind of mistake repeatedly; that's a failure to learn, and that's less okay. 

[LT_Oneal_PAC]

I wish I could tell you how to deal with it healthily, but I usually just crawl in a ball and think about how I would give anything to make my guilt end. I literally want to bang my head against a wall to beat out the stupid.

then

I try to tell myself I’m human. I will make mistakes, and hopefully this mistake will help me catch the next one that may be more serious, which has happened.

I try to remember the people I’ve helped that day.

While this is painful now, it will make me better.

Then I go back to my ball and thinking what a POS I am. 

Sometimes I have this roller coaster of emotions so long I feel numb emotionally for a day or so. Like a self defense mechanism, my emotions shut down to stop feeling pain.

i tell you all these personal feelings in case you have them as well, so you know you aren’t alone. There is no magic pill or trick that I have found to suddenly feel better. We all make mistakes, but that does not make you a bad provider and certainly not a bad person. We all feel like crap sometimes and it takes time for the hurt to go away, but it will get better. Talk with someone if you need help.

Hope that provides some respite.

last thought: I do like to play video games. It forces me to concentrate on something else and not focus on how I feel. So I think hobbies can provide brief comfort from your mind racing and replaying the event over and over.

[sk732]

I think I will put things a different way - if hearing something like his doesn't bother you, it's time to look for a new job.  

SK

[Cideous]

7 hours ago, LT_Oneal_PAC said:

I wish I could tell you how to deal with it healthily, but I usually just crawl in a ball and think about how I would give anything to make my guilt end. I literally want to bang my head against a wall to beat out the stupid.

then

I try to tell myself I’m human. I will make mistakes, and hopefully this mistake will help me catch the next one that may be more serious, which has happened.

I try to remember the people I’ve helped that day.

While this is painful now, it will make me better.

Then I go back to my ball and thinking what a POS I am. 

Sometimes I have this roller coaster of emotions so long I feel numb emotionally for a day or so. Like a self defense mechanism, my emotions shut down to stop feeling pain.

i tell you all these personal feelings in case you have them as well, so you know you aren’t alone. There is no magic pill or trick that I have found to suddenly feel better. We all make mistakes, but that does not make you a bad provider and certainly not a bad person. We all feel like crap sometimes and it takes time for the hurt to go away, but it will get better. Talk with someone if you need help.

Hope that provides some respite.

last thought: I do like to play video games. It forces me to concentrate on something else and not focus on how I feel. So I think hobbies can provide brief comfort from your mind racing and replaying the event over and over.

It's like you dictated word for word exactly how I feel when something like this happens.  Right down to the video games.  I find nothing more distracting then a good zombie head shot in Dying light to make me forget about how stupid I was...

[sas5814]

Pardon the Language but I am reading a book now called "How to Un-Fuck Yourself" and it is about getting out of your own head and circular self destructive thinking. You might give it a look.

[fireguy]

it sucks to miss something big.   My personal experience missing something had a much worse outcome. 

 

Learn from it.  modify your practice to take advantage of your new knowledge and perspective.  

 

Be self critical, but not self destructive.  

[cinntsp]

CXR is not that sensitive for pneumothorax and if the guy was asymptomatic from a respiratory standpoint then I wouldn't sweat it too much.  It's easy to miss.  It may have resolved on its own...or it would get worse and he would start having difficulty breathing and go to the OR.  You gave him the appropriate instructions.

Next time you'll put an extra 30 seconds into your CXR read and maybe catch it.  If you want to be a super PA, get some instruction on diagnosis of a pneumo with ultrasound.  It's easy and way more sensitive/specific than CXR.  Just throw the probe on the person's chest next time you have a fall with potential rib fx and any respiratory sx(which wouldn't have applied here).  You can bill for it as well.

 

[Guest ERCat]

Bless your heart. I really, really feel for you and it is something that happens to all of us. For those who say it hasn’t happened to them - well, they haven’t missed something that they know of but there are inevitably things that slipped under the radar. Breathe, it is going to be OK.  I actually had a similar case. It was a 60-year-old guy who fell off a horse. He walked into the emergency department with pain in his ribs. He denied abdominal pain or shortness of breath. Just pain in his ribs. Vital signs were normal. I have been lectured about chest trauma patients by an attending in the past - he said that in cases like these I should get a chest CT. I was working with a different doctor that evening who was actually angry that I wanted to get a chest CT and said that a chest x-ray should suffice. I got the chest x-ray and it showed only rib fractures and I discharged the guy. Well, he ended up coming back a few hours later because he felt worse and had a giant hemothorax.

[Cideous]

14 hours ago, ERCat said:

Bless your heart. 

You know what that phrase actually means in Texas right?    lol

[camoman1234]

On 4/19/2018 at 10:23 AM, Cideous said:

You know what that phrase actually means in Texas right?    lol

Oh another great "TEXAS" meaning like we don't hear enough about how GREAT Texas is and better than every other state...Not that I dislike people from Texas, but geeeez Texans talk about themselves A LOT and it gets soooooooo annoying. That's my 2 cents about "Texas People."

BTW it means different definitions in different parts of any southern state as well as the TONE you use it in the sentence. Not a Texas original.   

[Guest ERCat]

LOL - I thought it just is a compassionate way of saying I feel sad that happened to you, so sorry, etc. What does it mean?

[sas5814]

Its a joke that in the south you can say anything ugly you want as long as you close with "Bless your heart". Like ....did you see how ugly her baby was? Bless her heart.

[cinntsp]

On 4/19/2018 at 10:56 AM, camoman1234 said:

Oh another great "TEXAS" meaning like we don't hear enough about how GREAT Texas is and better than every other state...Not that I dislike people from Texas, but geeeez Texans talk about themselves A LOT and it gets soooooooo annoying. That's my 2 cents about "Texas People."

BTW it means different definitions in different parts of any southern state as well as the TONE you use it in the sentence. Not a Texas original.   

Totally disagree.  I think we should be hearing more about Texas.  Full disclosure: I'm a Texan.

[camoman1234]

53 minutes ago, cinntsp said:

Totally disagree.  I think we should be hearing more about Texas.  Full disclosure: I'm a Texan.

Of course...

[Cideous]

JoLeen:  "I think Marleen has developed a bit of a drinking problem...don't you?"

BobbyJoe:  "...and gained a few pounds.."

 

All together:   "Bless her heeeearrrrt...."

 

The phrase is the anti-septic spray people down here use after saying ugly things about each other.  It's actually quite funny.  My wife uses it all the time just to make a point.

[sas5814]

Yea it is actually a code phrase we use at work when discussing difficult or angry patients. All someone has to say is "bless her heart" and we all hear "what an asshole".

[GetMeOuttaThisMess]

I document such in my charting here in N. Texas:

"Patient refuses to give up nicotine usage to assist with their cough.  Pt. declines usage of nasal saline lavage.  Pt. states that they don't ever improve without an antibiotic."  Informed pt. that antibiotic would not be helpful and that they would just have to suck it up and deal with it, just like two months ago, six months ago, and eight months ago.  Pt. cursed upon leaving and I advised them "Y'all have a good day now."  Bless their heart.