Dealing with guilt, mistakes, and patient's death

[Whirlwind]

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.       

[Cideous]

I'm going to leave this one alone other than to say, part of being a good provider is not putting yourself in positions where you will be in over your head.  It's a tough and sometimes expensive lesson to learn.  Good luck.

[Whirlwind]

You don’t have to leave it alone, you can tell me.

[CVTSPA]

Sounds like these were some sick patients and who knows what would have happened if you acted sooner.  You'll exhaust yourself focusing on the "what if's".  I did that for years.  Also sounds like you are given a lot of responsibility in a small rural community hospital to be covering the ICU by yourself with phone back up with only 1.5 years of experience.  That's a tough job from an experience standpoint alone.  All you can do is learn from the experiences and how you feel now.  Look towards the future and think about what you could do better.  The first 3-5 years of being a PA are the hardest and most dangerous because you don't know what you don't know but you are starting to build confidence about your medical reasoning and feel bad about asking questions sometimes.  Fortunately or unfortunately, you graduate PA school and don't have a mandatory  training regimen for a couple of years so you just learn on the fly at the mercy of others.  The real world doesn't care as much about teaching you as it does about the bottom dollar. 

If you're motivated to minimize situations like these, you need to read as much as you can about the ICU care of patients and find a good mentor to bounce ideas off of.  Also, never hesitate to call the attending on call - they're getting paid a lot more than you to answer that phone.  Consider a one year residency which would put you light years ahead of your peers if that is a possibility. 

I think we all have bad outcomes sometimes and wish we would have handled things better at one point or another.  Don't let it keep you up at night.  You'll wonder about it but eventually you'll accept that it is what it is.  Success should be measured in how well we overcome failure and improve not how many times we did something smoothly or perfectly.

[Whirlwind]

Do you think I killed these patients? That’s just how it feels sometimes

[rev ronin]

54 minutes ago, Whirlwind said:

Do you think I killed these patients? That’s just how it feels sometimes

At worst, you failed to initiate the correct interventions to stop dying patients from dying.  That's a big difference than killing them, but it's still not what we want to be doing.  As others have noted, they may well have died no matter WHAT you did; we can't truly know.

What concerns me more is that you have no better support group than a pseudonymous internet forum to bounce these feelings of guilt off of.  Medicine is not a solo sport, and dealing with medical errors or bad outcomes--real, imagined, or suggested by a lawsuit--is something that no one should deal with alone.

Most of my patients are so low acuity that I have nothing meaningful to offer you, except that even with 8 years experience I wouldn't want to do your job without a LOT of specialized and refresher training.

You need a friend, a mental health professional, or a faith community to share these with.  Do you have no peers from PA school you keep in touch with?

[MediMike]

3 hours ago, Whirlwind said:

Do you think I killed these patients? That’s just how it feels sometimes

Maybe.  To be honest a lot of what we do in the ICU is prolonging death rather than extending life.  If you're sick enough to end up here your chances aren't very hot to begin with. Sometimes the smallest actions we take (or don't take) push them over the edge.

To be very blunt about it I agree with above, it sounds like you are in over your head...and that's ok as long as you recognize it and take whatever steps you can to do better, whether that is immersing yourself in the literature, doing a residency, taking all of the CME that you can, or spending a lot more time on the phone with your collaborating doc or in person managing the ICU patients with them.

I was going to go through your patients and discuss the management but as Rev mentioned, this probably isn't the place for it.  Would be a better discussion to have with your SP about what went wrong where and how to improve. 

[Whirlwind]

Yeah I pretty much know the management now. Just in the moment things are a lot different. And idk what to think. Like I said, I’ve had 99%great patient interaction and outcomes. But there are just sticking with me so much. I know I didn’t cause the disease, I know there were other factors way out of my control, but it’s just still making me go crazy to think of someone else had been on, things could be different.

[ventana]

5 hours ago, CVTSPA said:

Sounds like these were some sick patients and who knows what would have happened if you acted sooner.  You'll exhaust yourself focusing on the "what if's".  I did that for years.  Also sounds like you are given a lot of responsibility in a small rural community hospital to be covering the ICU by yourself with phone back up with only 1.5 years of experience.  That's a tough job from an experience standpoint alone.  All you can do is learn from the experiences and how you feel now.  Look towards the future and think about what you could do better.  The first 3-5 years of being a PA are the hardest and most dangerous because you don't know what you don't know but you are starting to build confidence about your medical reasoning and feel bad about asking questions sometimes.  Fortunately or unfortunately, you graduate PA school and don't have a mandatory  training regimen for a couple of years so you just learn on the fly at the mercy of others.  The real world doesn't care as much about teaching you as it does about the bottom dollar. 

If you're motivated to minimize situations like these, you need to read as much as you can about the ICU care of patients and find a good mentor to bounce ideas off of.  Also, never hesitate to call the attending on call - they're getting paid a lot more than you to answer that phone.  Consider a one year residency which would put you light years ahead of your peers if that is a possibility. 

I think we all have bad outcomes sometimes and wish we would have handled things better at one point or another.  Don't let it keep you up at night.  You'll wonder about it but eventually you'll accept that it is what it is.  Success should be measured in how well we overcome failure and improve not how many times we did something smoothly or perfectly.

 

4 hours ago, rev ronin said:

At worst, you failed to initiate the correct interventions to stop dying patients from dying.  That's a big difference than killing them, but it's still not what we want to be doing.  As others have noted, they may well have died no matter WHAT you did; we can't truly know.

What concerns me more is that you have no better support group than a pseudonymous internet forum to bounce these feelings of guilt off of.  Medicine is not a solo sport, and dealing with medical errors or bad outcomes--real, imagined, or suggested by a lawsuit--is something that no one should deal with alone.

Most of my patients are so low acuity that I have nothing meaningful to offer you, except that even with 8 years experience I wouldn't want to do your job without a LOT of specialized and refresher training.

You need a friend, a mental health professional, or a faith community to share these with.  Do you have no peers from PA school you keep in touch with?

 

2 hours ago, MediMike said:

Maybe.  To be honest a lot of what we do in the ICU is prolonging death rather than extending life.  If you're sick enough to end up here your chances aren't very hot to begin with. Sometimes the smallest actions we take (or don't take) push them over the edge.

To be very blunt about it I agree with above, it sounds like you are in over your head...and that's ok as long as you recognize it and take whatever steps you can to do better, whether that is immersing yourself in the literature, doing a residency, taking all of the CME that you can, or spending a lot more time on the phone with your collaborating doc or in person managing the ICU patients with them.

I was going to go through your patients and discuss the management but as Rev mentioned, this probably isn't the place for it.  Would be a better discussion to have with your SP about what went wrong where and how to improve. 

 

 

really read these three post

this sums it up exceptionally well

 

yes you had a hand in another persons death, but this is medicine and the great thing is you care and are reflecting on your actions and skill set - this will make you a great provider

 

 

I will share my only claim to fame-----When searching for a differential on something you are unsure - always think of the school. MIT (Mass Institute of Technology)

M = Medical

I = Infectious

T = Trauma

 

develop 2 option for each of these and then treat....  avoids tunnel vision or anchor bias

[sas5814]

There is a lot to unpack here and, as previously stated, this may not be the best place to work it out though talking to others with experience can be helpful.

I'll suggest what hasn't been said.... talk to a therapist. That will be about managing your mood and emotions and helping you move forward instead of hammering on the medical questions. You still need to work through those with your SP and others with more experience but you need some help with yourself as well. With virtual medicine booming, and psych being one of its better uses IMHO, it is easier than ever to get some help.

Been there, done that. The magic is to learn from it and not repeat it.

[Cideous]

I agree with Scott.  It's a strong move to get counseling and/or therapy for issues as difficult as these.

These guys are free.

https://www.emotionalppe.org

Edited October 16, 2020 by Cideous

[ohiovolffemtp]

I do EM at at CAH and respond to needs from our in-patient floor at night.  However, our in-patient unit is a med/surg that will take some step-down level patients, not ICE.  I feel for you.  Especially as a new grad, you were in over your head.  That's NOT a criticism: we all have to pay a learning curve.  It sounds like you are actually doing pretty well.

As folks have said, ICU patients are for the most part very sick.  The ones you've described sound like rapidly evolving sepsis.  They were already at the edge of the cliff.  You didn't kill them - they were actively dying already.  You just missed a small chance to possibly save them.  Whether they would have survived with perfect care is unknown.  The only thing that is certain is that you wouldn't be beating yourself up if your care had been "perfect" and they still died.  One thing that medicine (or EMS) will teach you is that all serious cases have an element of "cluster ..." in them.  In time you'll re-calibrate your standards to "I did all the major stuff right, the misses probably didn't matter, and whatever happens is mostly because of how sick or injured the patient is".

I think you've learned 2 things:

• what sepsis looks like and how quickly it can go bad
• what the boundaries of your knowledge are and how you need to quickly call for help

Those are critically important lessons for the future and will guide you well.  You could even talk to your SP about how to get used to these things.  I bet he or she went through this in their residency.

[GetMeOuttaThisMess]

Ah, the days of sl nifedipine.  Great numbers (BP) while standing at the side of the bed looking at a patient that you just additionally gorked (their body had grown accustomed to a high "normal" BP).  Didn't help that pt. had received thrombolytics earlier and you do a sternal rub to check responsiveness.

In these cases, the patient is already at the edge of the cliff and you're trying to pull them back.

Edited October 16, 2020 by GetMeOuttaThisMess

[Whirlwind]

3 hours ago, ohiovolffemtp said:

I do EM at at CAH and respond to needs from our in-patient floor at night.  However, our in-patient unit is a med/surg that will take some step-down level patients, not ICE.  I feel for you.  Especially as a new grad, you were in over your head.  That's NOT a criticism: we all have to pay a learning curve.  It sounds like you are actually doing pretty well.

As folks have said, ICU patients are for the most part very sick.  The ones you've described sound like rapidly evolving sepsis.  They were already at the edge of the cliff.  You didn't kill them - they were actively dying already.  You just missed a small chance to possibly save them.  Whether they would have survived with perfect care is unknown.  The only thing that is certain is that you wouldn't be beating yourself up if your care had been "perfect" and they still died.  One thing that medicine (or EMS) will teach you is that all serious cases have an element of "cluster ..." in them.  In time you'll re-calibrate your standards to "I did all the major stuff right, the misses probably didn't matter, and whatever happens is mostly because of how sick or injured the patient is".

I think you've learned 2 things:

• what sepsis looks like and how quickly it can go bad
• what the boundaries of your knowledge are and how you need to quickly call for help

Those are critically important lessons for the future and will guide you well.  You could even talk to your SP about how to get used to these things.  I bet he or she went through this in their residency.

Did you go through this in your residency? Did you ever have experiences similar to mine where you feel responsible or partly responsible?

[ohiovolffemtp]

Another thought and a "story":

As a new PA, I was embarrassed to call consultants, thinking that calling someone for advice vs just giving them an admission meant my knowledge wasn't what it should be.  After doing EM for awhile, I saw how often attendings call consultants.  The consultant:

• certainly knows the subtleties of their area of medicine better than EM or IM (hospitalists) will
• may well know that patient from treating them for that or a related condition
• will often know when it's time to punt to a higher level of care.

So, it's good practice to consult specialists.

The story:

The greenhorn was sitting next to the old cowboy in the bar, asking him how he handled a bad situation very well.  "Good judgement", said the old cowboy.  "Where does that come from?", asked the greenhorn.  "Experience", replied the old cowboy.  "How do you get experience?", asked the greenhorn.   "Bad judgement" was the answer.

Your judgement is getting better through the normal process of getting experience.

Just saw your message.  No residency, though I admire folks who did one.  I needed to get back to family and income.   I've had my share of "experience".  Yes, absolutely, I've had times when I felt responsible for a bad outcome.  Went through those periods at least 3 times: as an EMT, as a paramedic, as a new PA.  Still feel that way sometimes.  Disease, injury, and patient stupidity are incredibly creative in terms of what they can surprise you with.

Edited October 16, 2020 by ohiovolffemtp

[Mayamom]

My thoughts are with you.  My first day of PA school over 30 years ago the instructor said "something you will do will help a patient and something you will do will hurt a patient".   I never forget this because it is so true.  I was involved in a death that took me a long time to get over.  Feel free to PM me anytime. Hugs.