First M&M and I'm the focus

[manowar]

Just wondering what to expect here.

So, 2 weeks into internship and I get a patient in the E.R. s/p fall, struck head on ground, questionable L.O.C., possible altered mental status (we didn't know his baseline). Hx of multiple CVAs (hemiparesis) and ESRD (had dialysis that morning). BP was 90/60 in triage and about the same when I saw him. He said that his BP is always low following dialysis. Exam was essentially unremarkable with the exception of some right thigh pain, presumably resulting from the fall, with slight anterior/posterior pressure.

I present the patient to the attending who subsequently sees him. While we're in there, his nephrologist (who originally sent the patient to the E.R. following the fall), comes in and wants to admit him and recommends us giving him a liter NSS bolus, which we do. Patient's BP remains at 90/60 as he's getting the bolus, seems stable enough and the attending is still in there, and I go on to see the next patient. Not 10 minutes later, there's a trauma alert and they're wheeling my guy into the trauma bay. As it turns out, his BP dropped to 70/40 when I was with the other patient as a result of an acetabular fracture. He dies in the ICU later that night.

No, this isn't how I was expecting my intern year to start out. Myself and the attendings were fixated on this guy's possible head injury and assumed his LBP was secondary to dialysis. Anyway, the case is being presented at this week's M&M and I really don't know what to expect. Any advice is very appreciated. Thanks.

 

[Hawkeye Kid]

i'd recommend asking one of your upper-level residents and/or staff. in my (admittedly limited) experience, m/m can be a really good learning experience, a raking-over-the-coals, or anything in between. regardless, it would probably be a good idea to read about presentations of acetabular fx beforehand, but to really know what to expect you'd need to ask people that have experienced m/m at that program. good luck.

 

[Blue Dog]

In all likelihood, your attending will be the one on the spot, not you. As you stated, you're only two weeks into your internship. Anyway, M&M conferences aren't about pointing fingers and laying blame. They're about improving care and learning from our mistakes. Still, they can be a little uncomfortable when it's your care being discussed. This too shall pass.

 

[njbmd]

Just wondering what to expect here.

So, 2 weeks into internship and I get a patient in the E.R. s/p fall, struck head on ground, questionable L.O.C., possible altered mental status (we didn't know his baseline). Hx of multiple CVAs (hemiparesis) and ESRD (had dialysis that morning). BP was 90/60 in triage and about the same when I saw him. He said that his BP is always low following dialysis. Exam was essentially unremarkable with the exception of some right thigh pain, presumably resulting from the fall, with slight anterior/posterior pressure.

I present the patient to the attending who subsequently sees him. While we're in there, his nephrologist (who originally sent the patient to the E.R. following the fall), comes in and wants to admit him and recommends us giving him a liter NSS bolus, which we do. Patient's BP remains at 90/60 as he's getting the bolus, seems stable enough and the attending is still in there, and I go on to see the next patient. Not 10 minutes later, there's a trauma alert and they're wheeling my guy into the trauma bay. As it turns out, his BP dropped to 70/40 when I was with the other patient as a result of an acetabular fracture. He dies in the ICU later that night.

No, this isn't how I was expecting my intern year to start out. Myself and the attendings were fixated on this guy's possible head injury and assumed his LBP was secondary to dialysis. Anyway, the case is being presented at this week's M&M and I really don't know what to expect. Any advice is very appreciated. Thanks.

Hi there,
Be prepared to objectively tell what happened to this patient. Put yourself in the role of the attending and be prepared to defend the decision-making. You may want to go over this with your attending to make sure that your presentation is tight.

M & M conferences are ultimately for learning so your first learning point might be along the lines of 1. Getting a Trauma consult (would have activated some protocols that would have helped here). 2. Becoming aware that the the easiest way to miss the correct diagnosis is having a patient with a previous diagnosis.

Don't get defensive and don't worry. Having your learning points objectively stated and a brief literature review to back yourself up.

Do remember that this patient with a history of multiple falls could have fractured that hip hours before presenting in your ED. Was the fall witnessed?

Nothing in medicine is obvious and you will take something away from every patient that you treat. The good thing for you here is that this M & M will be experience and you will be much better on the next one.

njbmd

 

[Hockeyguy]

As a fourth year med student I had witnessed an almost identical case and subsequent M&M. From what I remember you should always get a STAT films on long term dialysis patients s/p mechanical fall b/c secondary hyperparathyroidism leave their bones brittle. We all know how people can hide fluids in different compartments etc. The case I was in on was a 55 year old AA female, renal failure ( dialysis 7-8 years) that fell out of her wheelchair trying to get in bed a suffered a pelvic fracture. Anyway sorry to hear that happened to you and I just wanted to give you the heads up that the parathyroid issue may come up. Good luck.

Mario

 

[f_w]

Anyway, M&M conferences aren't about pointing fingers and laying blame.

Or so goes the theory.

Be sure to know about the format of M&M at your institution. Ideally, it is a learning opportunity and ideally, it is not about blaming the intern for bad outcomes. The reality at your institution might or might not look that way.

Also, make sure that your attending doesn't turn on you. At teaching institutions, attendings who lack in self-confidence like to turn on their residents once blame needs to be deflected. 'Captain of the ship' my a##.

In addition, try to find out who the 'usual suspects' are and what one question they usually ask. Academic docs tend to have their 'pet', and every question they ask has something to do with it whether it relates to the patient in question or not. So, be sure to know trivia like the patients base deficit or whether he was in a smoking cessation program. If the right characters are sitting in the M&M, you are going to get grilled about it.

 

[dobonedoc]

Some places feel that the best learning comes with a little bit (or a lot) of heat, thus you might get to experience both a good learning opportunity, and a raking over the coals - at the same time.

You're not the first. You won't be the last. So don't worry too much, But don't hide behind, or be intimidated by the fact that you have only been on the job for 2 weeks. The fact is, you are a doctor, and you were her doctor. I'd say it's time to become familiar with the facts of the case, as well as the comorbidities that go along with ESRD, head injuries, and the presentation of shock.

Finally, when working in the ER, or anywhere for that matter, if it hurts, get an image of it. If the patient says it hurts, get a picture. If the patient's relative says it hurts, get the xray . . . You get the idea. You won't know if yo don't look.

 

[southerndoc]

Some of the best learning comes from M&M cases. One of our M&M cases actually prevented a repeat M&M the same day after our M&M conference. I saw a patient that presented exactly like the M&M case, and the ony reason I knew to make this obscure diagnosis and manage it properly was because I paid attention during M&M conference only 4 hours prior.

 

[Pox in a box]

Anyway, M&M conferences aren't about pointing fingers and laying blame.

That's what they say...yet in reality, it tends to get ego-centered and power-driven. What other service can be blamed and who (besides me...the attending or resident who was in charge) can take the lashing?

 

[Pox in a box]

Or so goes the theory.

Be sure to know about the format of M&M at your institution. Ideally, it is a learning opportunity and ideally, it is not about blaming the intern for bad outcomes. The reality at your institution might or might not look that way.

Also, make sure that your attending doesn't turn on you. At teaching institutions, attendings who lack in self-confidence like to turn on their residents once blame needs to be deflected. 'Captain of the ship' my a##.

In addition, try to find out who the 'usual suspects' are and what one question they usually ask. Academic docs tend to have their 'pet', and every question they ask has something to do with it whether it relates to the patient in question or not. So, be sure to know trivia like the patients base deficit or whether he was in a smoking cessation program. If the right characters are sitting in the M&M, you are going to get grilled about it.

Looks like you stole my thunder. We must go to similar institutions.