Mistake on the floor. Grounds for termination?

[Drangue]

So a 89 year old female came in with a left IT fracture, not demented, AAOx3, no other injuries. She was just complaining of some minor abdominal pain and diffuse pain on the left hip area. She was assessed, scanned and labs were taken. CT all clear other than the left IT fx, labs significant for AKI, CKD and elevated troponin. The thought that this single and isolated troponin could be secondary to CKD, so the plan was to trend the troponin and let them know the results. The nurse kept telling her that she was busy and will draw the blood and send it down as soon as she can. It's been roughly 6 hours after the next troponin was supposed to be drawn despite them being q3. He kept checking but then she got called to do floor work, do a procedure and then "forgot" about them until it was 2-3 AM (roughly 4-5 hours when they were reported last). The troponin doubled, patient had some sort of ACS event, threw a clot in the bowel. Blah, blah, blah.

In the end the patient ended up having an ischemic bowel requiring resection. There was a maximum of 4-5 hours that went by without the troponin being seen or any intervention to be done. The on call senior is threatening my colleague to take her job, have her fired and removed from the residency program. Is this something that could actually occur? I am only a PGY1 myself but having missed a lab result, even though it's important, seems more like a learning opportunity than grounds for termination. I was told by a PD when I was in medical school that to get fired from a program you have to do something really bad... really bad. He means like insulting racist remarks, assaulting colleagues, sexual harassment, causing deliberate harm, or even embezzling drugs from the hospital. I have never heard people get fired for making mistakes like forgetting to report a lab, no matter how big, or anything similar to this.

I hear all the time that residents do terrible **** all the time like put in chest tubes on the wrong patients, wrong side, through the lung, bowel injuries, debridement on patients on anticoagulation causing acute blood loss anemia resulting in death, ordering medications on the wrong patients or even forgetting labs.

The reason why I told her not to worry is that the PGY3 was in the ICU the other day and this patient was spiking fevers for 7 straight hours through the night and not a single call was made to him. Patient became septic and then expired 3 days later. The third year went to sleep without ever checking up on patients in the night. He got chewed out by the ICU attending the next day but it was more like a slap on the wrist. I feel that is way worse for a PGY3 to make a mistake like than a PGY1 to make a mistake.

I don't know though. What are your thoughts?

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[deleted480308]

Mistakes of the senior are irrelevant.

Your intern friend didn’t miss a lab from that story if I’m reading it right. They knew it was needed, kept following up and the nurse/phlebotomy never drew it. This could maybe be a lesson in appropriate times to escalate things by calling a charge nurse or going down yourself to draw the lab but not in missing a lab.

Residents literally cannot fire residents. They just can’t. They can make your life hard, they can ask the PD to fire you but they literally cannot fire you

 

[Drangue]

Mistakes of the senior are irrelevant.

Your intern friend didn’t miss a lab from that story if I’m reading it right. They knew it was needed, kept following up and the nurse/phlebotomy never drew it. This could maybe be a lesson in appropriate times to escalate things by calling a charge nurse or going down yourself to draw the lab but not in missing a lab.

Residents literally cannot fire residents. They just can’t. They can make your life hard, they can ask the PD to fire you but they literally cannot fire you

From my understanding of the story from other residents and her. She did miss the lab because it eventually came back, but many hours after it should have come back.

Can the PD fire her? Can the CMO get involved and fire her? I dunno who else can get involved. Everyone else is telling her not to sweat it, even the other seniors say this not bad at all compared to what they've encountered.

 

[deleted480308]

From my understanding of the story from other residents and her. She did miss the lab because it eventually came back, but many hours after it should have come back.

Can the PD fire her? Can the CMO get involved and fire her? I dunno who else can get involved. Everyone else is telling her not to sweat it, even the other seniors say this not bad at all compared to what they've encountered.

PD can always fire you. All the time

This is unlikely a firing thing though there is a lesson to be learned here. On shift if i have a critical lab timed, i will set an alarm for myself. If it’s not drawn, i will call the phlebotomist and set a new alarm

And i may be more direct than most but if a senior threatened to fire me i would go straight to the PD. “I screwed up last week and Joe says he’s firing me. I see that I did x wrong and this is my plan to avoid a repeat. I really want to keep training here and will jump through whatever correction you want”.

Either A) the pd is pissed at you but at least now you show some ownership and foresight or B) Joe gets his ass kicked by the PD for making threats above his paygrade

 

[Nephro critical care]

Gosh I work in a non teaching hospital and I order serial troponins all the time and rely on nurse / lab to call me or covering night MD if they are rising. Same for potassium/magnesium and hemoglobin checks. When I have 17-18 pts with 3-5 admits and the night guy might get hit with 5-6 admissions at once neither of us has time to look up labs every few minutes. I have learned to be selective with what I can sign out ; I will sign out something absolutely critical that I know the night dude will get called about but not BS stuff like a troponin of 0.11 rising to 0.32 in a patient with CKD and septic or hemmorhagic shock. If I am really worried about a lab test or imaging result I usually will speak with the nurse and tell her to keep an eye on the test and call lab if it’s not done.

 

[dadaddadaBATMAN]

So a 89 year old female came in with a left IT fracture, not demented, AAOx3, no other injuries. She was just complaining of some minor abdominal pain and diffuse pain on the left hip area. She was assessed, scanned and labs were taken. CT all clear other than the left IT fx, labs significant for AKI, CKD and elevated troponin. The thought that this single and isolated troponin could be secondary to CKD, so the plan was to trend the troponin and let them know the results. The nurse kept telling her that she was busy and will draw the blood and send it down as soon as she can. It's been roughly 6 hours after the next troponin was supposed to be drawn despite them being q3. He kept checking but then she got called to do floor work, do a procedure and then "forgot" about them until it was 2-3 AM (roughly 4-5 hours when they were reported last). The troponin doubled, patient had some sort of ACS event, threw a clot in the bowel. Blah, blah, blah.

In the end the patient ended up having an ischemic bowel requiring resection. There was a maximum of 4-5 hours that went by without the troponin being seen or any intervention to be done. The on call senior is threatening my colleague to take her job, have her fired and removed from the residency program. Is this something that could actually occur? I am only a PGY1 myself but having missed a lab result, even though it's important, seems more like a learning opportunity than grounds for termination. I was told by a PD when I was in medical school that to get fired from a program you have to do something really bad... really bad. He means like insulting racist remarks, assaulting colleagues, sexual harassment, causing deliberate harm, or even embezzling drugs from the hospital. I have never heard people get fired for making mistakes like forgetting to report a lab, no matter how big, or anything similar to this.

I hear all the time that residents do terrible **** all the time like put in chest tubes on the wrong patients, wrong side, through the lung, bowel injuries, debridement on patients on anticoagulation causing acute blood loss anemia resulting in death, ordering medications on the wrong patients or even forgetting labs.

The reason why I told her not to worry is that the PGY3 was in the ICU the other day and this patient was spiking fevers for 7 straight hours through the night and not a single call was made to him. Patient became septic and then expired 3 days later. The third year went to sleep without ever checking up on patients in the night. He got chewed out by the ICU attending the next day but it was more like a slap on the wrist. I feel that is way worse for a PGY3 to make a mistake like than a PGY1 to make a mistake.

I don't know though. What are your thoughts?

The senior has no authority to do that. I would make some effort to repair the relationship to avoid future annoyance, but sounds like a malignant twerp.

His error sounds more egregious, but honestly it’s irrelevant.

I don’t really follow the direct relationship between the trop and the ischemic gut, and I certainly don’t follow the argument that finding the trop would have prevented the bowel ischemia. Seems the argument is that stunned/immobile myocardium les to a clot that got thrown. Maybe, but I’m going to hazard a wild guess this little old woman had other medical issues like afib that predisposed to embolus. Also, didn’t you say the pt presented with abdominal pain? Clot was probably already thrown when she got to the floor then. That makes the more probable error an absence of serial abdominal exams, but gut ischemic can be difficult.

If they did find it, and everyone agreed it was a type 1 nstemi in a presumably asymptomatic pt (if they had active chest pain then yeah your friend screwed the pooch but for other reasons) then maybe they would have heparinized her.

If they had heparinized her, plavix loaded and given asa...in a patient with recent significant trauma....would that have prevented an embolus? Doubt it. Might have helped after the fact for her ischemic bowel, but honestly doubt that too if it was a significant clot burden.

Main lesson is to have a low threshold to escalate up nursing chain of command or draw a lab yourself or ask a nurse you know and trust to do it. This one was probably close to meaningless, but the next one might not be

 

[Piebaldi]

Mistakes of the senior are irrelevant.

Your intern friend didn’t miss a lab from that story if I’m reading it right. They knew it was needed, kept following up and the nurse/phlebotomy never drew it. This could maybe be a lesson in appropriate times to escalate things by calling a charge nurse or going down yourself to draw the lab but not in missing a lab.

Residents literally cannot fire residents. They just can’t. They can make your life hard, they can ask the PD to fire you but they literally cannot fire you

This. Residents can't fire residents, even if senior residents, and the influence they may or may not have is variable depending on the program. It's unlikely that a resident would get fired for missing a lab even if it led to a negative event. Even in my own program, someone who graduated before my class was either misinformed or did not check up on (not sure which one it was) on a patient that supposedly was bleeding from somewhere who died the next day. Resident got trashed apparently by the nursing staff but did not get fired and graduated just fine. Another resident had a patient that had a complicated clinical picture, apparently resident missed that patient was septic (this was on call) and patient died the next day. Again resident with no punishment.

 

[Piebaldi]

The senior has no authority to do that. I would make some effort to repair the relationship to avoid future annoyance, but sounds like a malignant twerp.

His error sounds more egregious, but honestly it’s irrelevant.

I don’t really follow the direct relationship between the trop and the ischemic gut, and I certainly don’t follow the argument that finding the trop would have prevented the bowel ischemia. Seems the argument is that stunned/immobile myocardium les to a clot that got thrown. Maybe, but I’m going to hazard a wild guess this little old woman had other medical issues like afib that predisposed to embolus. Also, didn’t you say the pt presented with abdominal pain? Clot was probably already thrown when she got to the floor then. That makes the more probable error an absence of serial abdominal exams, but gut ischemic can be difficult.

If they did find it, and everyone agreed it was a type 1 nstemi in a presumably asymptomatic pt (if they had active chest pain then yeah your friend screwed the pooch but for other reasons) then maybe they would have heparinized her.

If they had heparinized her, plavix loaded and given asa...in a patient with recent significant trauma....would that have prevented an embolus? Doubt it. Might have helped after the fact for her ischemic bowel, but honestly doubt that too if it was a significant clot burden.

Main lesson is to have a low threshold to escalate up nursing chain of command or draw a lab yourself or ask a nurse you know and trust to do it. This one was probably close to meaningless, but the next one might not be

The whole drawing labs yourself is not so clear cut either - we did not draw any labs whatsoever in my program nor would we be allowed to even in emergent situations. So program dependent

 

[calvnandhobbs68]

The senior has no authority to do that. I would make some effort to repair the relationship to avoid future annoyance, but sounds like a malignant twerp.

His error sounds more egregious, but honestly it’s irrelevant.

I don’t really follow the direct relationship between the trop and the ischemic gut, and I certainly don’t follow the argument that finding the trop would have prevented the bowel ischemia. Seems the argument is that stunned/immobile myocardium les to a clot that got thrown. Maybe, but I’m going to hazard a wild guess this little old woman had other medical issues like afib that predisposed to embolus. Also, didn’t you say the pt presented with abdominal pain? Clot was probably already thrown when she got to the floor then. That makes the more probable error an absence of serial abdominal exams, but gut ischemic can be difficult.

If they did find it, and everyone agreed it was a type 1 nstemi in a presumably asymptomatic pt (if they had active chest pain then yeah your friend screwed the pooch but for other reasons) then maybe they would have heparinized her.

If they had heparinized her, plavix loaded and given asa...in a patient with recent significant trauma....would that have prevented an embolus? Doubt it. Might have helped after the fact for her ischemic bowel, but honestly doubt that too if it was a significant clot burden.

Main lesson is to have a low threshold to escalate up nursing chain of command or draw a lab yourself or ask a nurse you know and trust to do it. This one was probably close to meaningless, but the next one might not be

Agree, I don't get the direct cause and effect of this error on the outcome anyway. Think most of this was already in the works when the patient showed up from the story and they eventually figured it out when the gut ischemia took its course. I don't think figuring out this troponin was rising any earlier would have prevented the bowel ischemia.

Mistakes happen, labs get missed, images don't get reviewed, etc. Best thing to do is to learn from them. If anything, this should be a systems evaluation from the hospital side, as in why was this q3 lab not able to be drawn and why did this nurse not feel comfortable asking for assistance if she needed help drawing important labs on time?

Senior sounds like a douche, I'd agree with telling the PD that this douchy senior is threatening to fire her and making her feel uncomfortable.

 

[sylvanthus]

Absolutely no way someone would be fired over this. Also I would report the senior for harassment. Telling an intern they are going to be fired over this is asinine.

 

[DarkHorizon]

Was senior the supervisor that night of that intern?

If so, ultimately it falls on him. This senior is really a piece of work. As a senior, you’re supposed to back your interns up, not to throw them under the bus like this. Interns are on thin ice. This guy needs to be reported. I usually wouldn’t recommend talking to the PD, but I’m this case, I would go to the PD and tell them that the senior threatened to fire you. Of course fess up your mistake and your plan to remidiate your deficiencies. But this guy really needs some ass kicking.

 

[Merely]

Was senior the supervisor that night of that intern?

If so, ultimately it falls on him. This senior is really a piece of work. As a senior, you’re supposed to back your interns up, not to throw them under the bus like this. Interns are on thin ice. This guy needs to be reported. I usually wouldn’t recommend talking to the PD, but I’m this case, I would go to the PD and tell them that the senior threatened to fire you. Of course fess up your mistake and your plan to remidiate your deficiencies. But this guy really needs some ass kicking.

What do u mean by “interns are on thin ice”

 

[DarkHorizon]

What do u mean by “interns are on thin ice”

They don’t know jack****, no one trusts them to make any decisions, when they **** up, they really have no leg to stand on, especially big mistakes. They haven’t shown enough and haven’t gained enough trust of their superiors. This can lead to being put under the microscope and the rest of your residency can be very difficult to navigate. OTOH, a senior is ready to graduate, has earned trust and has shown he/she is capable. So if they made a mistake, they likely will not be out on probation/get fired, unless it’s a monumental mistake.

The first thing we taught our interns was to always communicate to the senior, and for senior to own all the **** ups by the intern. If there was lack of communication by the intern, that was dealt separately within chiefs. Of course this is surgery. Different than medicine.

 

[SterlingMaloryArcher]

Mistakes happen... I sure as hell better hope I never make a mistake over the next 8 years or risk it all being for nothing

 

[Moko]

The senior was having a power trip. If people were fired due to a missed diagnosis, then quite frankly there would be no doctors. Seems like you had an appropriate plan in place that unfortunately was just not followed through by nursing and phlebotomy. This should be viewed as an opportunity for learning and improvement rather than one for punishment. Sorry that resident had to go through this.

The story would be different though if the resident had shown apathy and neglect despite others voicing concerns about the patient's clinical condition.

 

[hallowmann]

...I don’t really follow the direct relationship between the trop and the ischemic gut, and I certainly don’t follow the argument that finding the trop would have prevented the bowel ischemia. Seems the argument is that stunned/immobile myocardium les to a clot that got thrown. Maybe, but I’m going to hazard a wild guess this little old woman had other medical issues like afib that predisposed to embolus. Also, didn’t you say the pt presented with abdominal pain? Clot was probably already thrown when she got to the floor then. That makes the more probable error an absence of serial abdominal exams, but gut ischemic can be difficult...

Was thinking the same thing. Figured she already had ischemic bowel after the first few sentences.

...Main lesson is to have a low threshold to escalate up nursing chain of command or draw a lab yourself or ask a nurse you know and trust to do it. This one was probably close to meaningless, but the next one might not be

This.

 

[Top Gun]

Senior sounds like a malignant douche. First of all, no, an upper-level resident cannot fire an intern. They can complain about them, make life harder for them, but they cannot fire them. Second, this is not a fireable offence. This is definitely the sort of thing I can see happening on a busy shift. The intern was already trying to follow the troponin, the lab draw got delayed, and the intern had to attend to a procedure while waiting for the lab to be drawn. Plus, the bowel ischaemia was probably already happening, given that the patient had mild abdominal pain at the start. Not to mention nobody had reason to suspect acute coronary syndrome. The patient had no symptoms suggestive of ACS, including chest pain or shortness of breath, and the patient had AKI, which could have led to an elevated troponin. This sounds more like a learning opportunity than an egregious error. Things that might have been done differently might include calling the charge nurse when the troponin wasn’t drawn in time, or maybe the intern should have drawn the troponin him or herself. But again, not a fireable offence. The senior resident was being an a-hole and was clearly on a power trip. I would also add that the senior is even more responsible for the troponin being missed. Why wasn’t the senior following up on the troponin as well, or at the very least, checking to make sure it was being followed? An intern’s mistake is the senior’s mistake. The senior is responsible for the intern. The senior knows better and should have been supervising more. Also, a good senior has his/her interns’ back. That is what a leader does. A leader has his/her subordinates’ back. And a senior resident is supposed to be a leader. In my opinion, the senior was trying to throw the intern under the bus to cover his/her own a$$. That is in fact a failure of leadership.

By the way, did anyone check a CPK? Given that the patient had a fracture, it sounds like s/he had a fall. Lying on the ground for a long time after a fall could lead to rhabdomyolysis, which could explain the AKI. Also, rhabdomyolysis could, at least in theory, cause an elevated troponin.

 

[CopaceticOne]

@Top Gun - why the necrobump of a thread 5 years old?

 

[Top Gun]

@Top Gun - why the necrobump of a thread 5 years old?

Because I didn’t realise it was five years old. My mistake.

 

[Crayola227]

Because I didn’t realise it was five years old. My mistake.

Sometimes the algorithms especially suggested threads at the bottom, especially if you click by accident, can end you up in interesting spaces here

 

[Redpancreas]

So a 89 year old female came in with a left IT fracture, not demented, AAOx3, no other injuries. She was just complaining of some minor abdominal pain and diffuse pain on the left hip area. She was assessed, scanned and labs were taken. CT all clear other than the left IT fx, labs significant for AKI, CKD and elevated troponin. The thought that this single and isolated troponin could be secondary to CKD, so the plan was to trend the troponin and let them know the results. The nurse kept telling her that she was busy and will draw the blood and send it down as soon as she can. It's been roughly 6 hours after the next troponin was supposed to be drawn despite them being q3. He kept checking but then she got called to do floor work, do a procedure and then "forgot" about them until it was 2-3 AM (roughly 4-5 hours when they were reported last). The troponin doubled, patient had some sort of ACS event, threw a clot in the bowel. Blah, blah, blah.

In the end the patient ended up having an ischemic bowel requiring resection. There was a maximum of 4-5 hours that went by without the troponin being seen or any intervention to be done. The on call senior is threatening my colleague to take her job, have her fired and removed from the residency program. Is this something that could actually occur? I am only a PGY1 myself but having missed a lab result, even though it's important, seems more like a learning opportunity than grounds for termination. I was told by a PD when I was in medical school that to get fired from a program you have to do something really bad... really bad. He means like insulting racist remarks, assaulting colleagues, sexual harassment, causing deliberate harm, or even embezzling drugs from the hospital. I have never heard people get fired for making mistakes like forgetting to report a lab, no matter how big, or anything similar to this.

I hear all the time that residents do terrible **** all the time like put in chest tubes on the wrong patients, wrong side, through the lung, bowel injuries, debridement on patients on anticoagulation causing acute blood loss anemia resulting in death, ordering medications on the wrong patients or even forgetting labs.

The reason why I told her not to worry is that the PGY3 was in the ICU the other day and this patient was spiking fevers for 7 straight hours through the night and not a single call was made to him. Patient became septic and then expired 3 days later. The third year went to sleep without ever checking up on patients in the night. He got chewed out by the ICU attending the next day but it was more like a slap on the wrist. I feel that is way worse for a PGY3 to make a mistake like than a PGY1 to make a mistake.

I don't know though. What are your thoughts?

Im writing this first because it’s most important. These are patient’s lives. You shouldn’t be seeking to validate less than optimal care by citing examples of egregiously bad care. This isn’t a race to the bottom. There’s right and there’s wrong and having gone through medical school you should know the difference and always strive for the former when you have control.

In terms of the actual event you cite, the events as described sound like a possibly sub-optimally managed but also high risk NSTEMI. In an elderly female, there for a femoral fracture with abdominal pain, with her comorbid and risk factors there is a decent risk for this to be an ACS event but it’s not a STEMI. Standard of care is a medical treatment for cardiac ischemia (heparin, aspirin, etc.) with an urgent but not emergent catch that could be altered if clinical status changes. Whether or not this was bad care depends on whether these were started and the degree of troponin I elevation matters. 0.08 can be explained by advanced CKD, maybe 0.5 is Rhabdo… 2 can’t be. It’s also more than just the troponin: Usually a change in vitals or patient symptoms would warrant making the cath more urgent. The troponin not being drawn didn’t harm the patient. If cardiac NSTEMI tx. wasn’t initiated at the first troponin with risk factors and possible cardiac chest pain in the setting of moderate troponin elevation, that’s the bigger blunder. Not drawing the trop at 6 hours instead of 3. The patient should also have been being monitored closely for changes in clinical status. The senior to me sounds to be trying to oversimplify to rationalize the event.

 

[Crayola227]

Im writing this first because it’s most important. These are patient’s lives. You shouldn’t be seeking validate less than optimal care by citing examples of egregiously bad care. This isn’t a race to the bottom. There’s right and there’s wrong and having gone through medical school you should know the difference and always strive for the former.

In terms of the actual event you cite, the events as described, it sounds like a possibly sub-optimally but also high risk NSTEMI. In an elderly female, there for a femoral fracture with abdominal pain, with her comorbid and risk factors there is a decent risk for this to be an event but it’s not a STEMI. Standard of care is a medical treatment for cardiac ischemia (heparin, aspirin, etc.) with a cath as soon as feasible ans urgent but not emergent that could be altered if clinical status changes. Whether or not this was bad care depends on whether these were started and the degree of troponin I elevation matters. 0.08 can be explained by advanced CKD, maybe 0.5 is Rhabdo… 2 can’t be. It’s also more than just the troponin: Usually a change in vitals or patient symptoms would warrant making the cath more urgent. The troponin not being drawn didn’t harm the patient. If cardiac NSTEMI tx. wasn’t initiated at the first troponin with risk factors and possible cardiac chest pain in the setting of moderate troponin elevation, that’s the bigger blunder. Not drawing the drop at 6 hours instead of 3. The patient should also have been being monitored closely for changes in clinical status. Senior to me sounds to be trying to oversimplify to rationalize the event.

Very excellently said.

I think of all the necrobumps, this was a better teaching one, as it addresses some common issues interns deal with, not only medically, but interpersonally and systems issues. As far as threads about, don't worry about being fired, I also think this was packed with more useful information than the typical reassurance. Interns silently read these threads so posting and bumping for posterity, if there's more to say, is great.

As far as a learning moment and not grounds for termination, you should be more afraid of hurting someone than losing your job.

Setting aside nuance, and this is the way I was taught, is that certain things, if you order them, then your attitude has to be to follow it close. This is probably even more important for interns, who are going to be less able to use their medical knowledge to triage important vs unimportant tests or values.

If something that seems like it should happen isn't happening and you're an intern, you need to make some reasonable calls to get it done, and failing that, make the senior aware. Maybe some seniors would eyeroll being bothered about this, but we said interns don't have the best judgment, so calling the senior even when you think they might be mad, can avoid some issues.

Sometimes we order things on reflex or thinking it will be negative or NBD, but the reality is that it's a better reflex especially for an intern, that they need to be timely with reviewing things like EKGs troponins and lactate, etc. Think of WHY you order those things. MI, sepsis, it's a big deal. Anything abnormal you need to show awareness, and watch it. Anything that might reveal something time critical, even if you don't expect to catch something. Because it's the surprises that get you.

Setting aside the actual medical facts of this case, you have the legal aspects. If there is a really bad outcome, I mean some things can get lost and it's trivial and even a jury might understand that. But some things not having follow up just looks really bad. Not just to a jury, but to your senior and program etc.

The intern should be on top of a test like this. Sure, this time it wasn't a big deal, but how does anyone know for sure that you understand that distinction? What if this had been a STEMI?

Also, you can't rely on nurses of all people to distinguish between the troponin that they can drag their feet on, and one that really does need to be trended closely. So again, the concern might be how the intern is supervising and staying on the nurses.

So there is a teaching point here. I think the senior was out of line, especially the way he phrased it.

I probably would have left it at, I need to see you are following up certain tests as though they are time critical. Some might not be, some may be. I don't expect your judgment to be developed enough to tell the difference right now. Your job is to follow values like this and to get tests done. Then what Redpancreas said. These are human beings. Sometimes missing a test does mean someone dies or is hurt. I have seen certain missed things lead to someone being fired. I don't want that to be you.

My point being the fear of God (and missing some tests) I think is a fine thing to instill. But that's difficult than someone having a god complex and acting like they call the shots.

 

[Radetzky]

The only teaching point in this necrobump is that troponin doesn’t equal MI. The pt had ischemic bowel, where trop elevations are common and irrelevant.

Drawing troponins at 6 hours is pretty common practice and doing it at 3 hrs doesn’t make much difference if the history does not sound like an MI.

Unfortunately if you’re 89 and have ischemic bowel and a hip fracture, you’re in trouble.

 

[Top Gun]

Im writing this first because it’s most important. These are patient’s lives. You shouldn’t be seeking validate less than optimal care by citing examples of egregiously bad care. This isn’t a race to the bottom. There’s right and there’s wrong and having gone through medical school you should know the difference and always strive for the former.

In terms of the actual event you cite, the events as described, it sounds like a possibly sub-optimally but also high risk NSTEMI. In an elderly female, there for a femoral fracture with abdominal pain, with her comorbid and risk factors there is a decent risk for this to be an event but it’s not a STEMI. Standard of care is a medical treatment for cardiac ischemia (heparin, aspirin, etc.) with a cath as soon as feasible ans urgent but not emergent that could be altered if clinical status changes. Whether or not this was bad care depends on whether these were started and the degree of troponin I elevation matters. 0.08 can be explained by advanced CKD, maybe 0.5 is Rhabdo… 2 can’t be. It’s also more than just the troponin: Usually a change in vitals or patient symptoms would warrant making the cath more urgent. The troponin not being drawn didn’t harm the patient. If cardiac NSTEMI tx. wasn’t initiated at the first troponin with risk factors and possible cardiac chest pain in the setting of moderate troponin elevation, that’s the bigger blunder. Not drawing the trip at 6 hours instead of 3. The patient should also have been being monitored closely for changes in clinical status. The Senior to me sounds to be trying to oversimplify to rationalize the event.

OK, the point of my “necrobump” above was not to excuse not following the troponin. I highly agree that we must always put forth our best efforts because patients’ lives are at stake. However, I’m also aware that interns are still in the learning process. I agree that the intern should have been called out on the missed troponin by the senior. And that error should not be repeated. But threatening to complain to the program director and have the intern fired? That seems kind of extreme. The same senior who made that threat probably made mistakes that were just as boneheaded when s/he was an intern. So it seems kind of hypocritical. Not to mention the senior was just as if not more responsible for the missed troponin because it was his/her responsibility to supervise the intern. Frankly, it comes across as the senior trying to throw the intern under the bus, which is not okay.

Now if there was a pattern where the intern was consistently not following up on labs, that might call for termination. And that after attempts at remediation and probation have already been made.

 

[DOFOSHO]

this is a systems failure. the doctor ordered the lab. its not the doctors job to draw the lab. just like its not the nurses/phleobotimist job to interpret clinical information and devise detailed evidence based treatment plans. some how the hospital/nursemanagemtn/or something prioritzed other duties for the nurse and the system failed. sounds like the doctor was being a doctor and didnt do anything wrong.

 

[dozitgetchahi]

this is a systems failure. the doctor ordered the lab. its not the doctors job to draw the lab. just like its not the nurses/phleobotimist job to interpret clinical information and devise detailed evidence based treatment plans. some how the hospital/nursemanagemtn/or something prioritzed other duties for the nurse and the system failed. sounds like the doctor was being a doctor and didnt do anything wrong.

I agree with this.

I have worked at institutions that were just a quagmire of confusion, and where getting anyone else to properly do their job was not easy at all. Obviously you can try to go get other people to do what they’re supposed to be doing, but there is often only so much you can do to make that happen as a doc.

 

[Top Gun]

this is a systems failure. the doctor ordered the lab. its not the doctors job to draw the lab. just like its not the nurses/phleobotimist job to interpret clinical information and devise detailed evidence based treatment plans. some how the hospital/nursemanagemtn/or something prioritzed other duties for the nurse and the system failed. sounds like the doctor was being a doctor and didnt do anything wrong.

It depends on where you work. Ideally, it shouldn’t be the resident’s job to draw the blood. But if you’re training at one of the New York City hospitals, where the nurses are unionised, then drawing the blood can unfortunately become the resident’s job because either the nurses won’t do it, or they’ll claim that they already attempted the blood draw and were unsuccessful. And in those cases, you just have to draw the blood yourself because it’s not worth an argument with the nurse.