I learned early on that you don’t say “oops” in the OR during an operation. Even though the patient can’t hear you (supposedly), you still never give any indication that a mistake occurred. Ever. It’s like religion. Don’t mess with it.
What I’m still coming to terms with is that you really shouldn’t say “oops” anywhere in the medical field. A trial lawyer’s favorite word is “oops”. And there’s this unspoken pressure to withhold admission of mistakes from patients because – doctors worry – the patient will lose confidence in the competency of the doc if it is clear that a mistake was made.
I once gave a patient what is generally regarded as a pretty small dose of dilaudid – a narcotic pain med commonly used on hospital floors. She was about my age and of normal weight and having excruciating headaches, we think caused by herpes virus infecting the meningeal layer of her brain.
Imagine that pain for a moment: If you’ve ever had a cold sore or fever blister…think of that happening inside your skull, but scattered all over your brain. I think I’d rather just crush my head in a trash compactor. Naturally, until we could actually do something to cure this woman (there actually isn’t much that CAN be done), I wanted to do what I could to help with the pain. Still, she was young and thin, so I ordered a fairly minimal dose range of 0.5 mg – 2 mg. The actual amount could then be determined by the nurse based on how much pain the patient was having.
The next day, I returned to the hospital to find that my patient had nearly quit breathing overnight, after just one dose of the narcotic at 1 mg. The nurses had called a “rapid response” team to her room, which is one step away from calling the “code” team, which is that group of heros in primary-color spandex who come in and bashes on your dead chest screaming, “C’mon, dammit, don’t you leave me!” So, basically, she almost died. My first thought was that I contributed to the problem because I gave the order for the narcotics. I figured I shouldn’t have given a dose range and should have just written for the 0.5 mg dose until I saw how she handled that amount. And I could have spent more time with her to determine how she reacted to narcotics. I could have avoided narcotics in general and just told her to, “Quit gripin’ you baby-faced American. It’s just a headache. They don’t have IV dilaudid in Darfur and everybody does just fine.”
So, I got up to her room quickly after morning report and found that her mom was also in the room. I should mention that I regarded both of these women as friends as well as patients. This woman’s headaches waxed and waned, so in the previous days I spent as much time talking about life and joking about all kinds of common interests with she and her mom as I did talking about her condition. We got along great and I related to them – in particular I related to my patient’s wry sense of humor and I admired her courage as she dealt with what really is a “short straw” dealt to her by life. So, naturally, when I heard she almost stopped breathing, I was concerned and dismayed. It was like being told your friend almost died but don’t worry, everything’s ok now.
Really? What happend? I need to talk to her and make sure for myself. Like any friend would. Like any doctor should.
Swooping into her room that morning, I already noted that her vital signs had stabilized over the previous few hours and that things were – from a “gonna die or not” perspective – resolved. “Jeez, what a tool of a doctor you have!” I exclaimed. “Wow, I’m really sorry about that. I never expected it at that dose.”
After checking her out and seeing that she was actually fine, I asked in all seriousness, “So, did we get rid of the headache?” The three of us laughed. “By God, if it kills me, I’m going to stop the pain!” She replied. We then seriously talked over the best plan for her…which didn’t involve the same level or type of narcotics.
The patient did well over the next couple of nights and eventually went home. It seemed to me that we were on good terms with each other and I felt like I had approached the interaction in total honesty throughout. Was her near-calamity my fault entirely? No. But I did contribute to it, and felt that admitting it was a good thing to do for the relationship between me and the pt. and her family.
So I apologized in the way that a friend might apologize to another friend. I was as much saying I was sorry for the way things turned out as I was saying that I did something wrong. It’s like I took a friend to dinner and they got food poisoning. I would apologize for that. But I would be expressing regret over the situation entirely, including whatever I may have done to facilitate my buddy sinking his head in the white throne of grace for 3 days straight. This thinking, however, met with some harsh responses among my superiors. “You APOLOGIZED? Don’t you know that’s effectively an admission of guilt? How do you know it was you? Maybe she took something else you didn’t authorize. Maybe the nurse dosed it wrong. Maybe she was dehydrated.” Blah, blah. My point was I was sorry for what happened…HOWEVER it happened.
I can’t see where the legal system has helped medicine that much. I’m certainly dismayed to work in an environment where I can’t say I’m sorry without first considering the legal ramifications of doing so. Lawyers have succeeded in sucking the notion of friendship and genuine relationship between doctor and patient entirely out of the equation. In the vacuum, they have managed to inject calculation and risk-management. If I’d been told prior to going to med school that I would be required to appraise every patient for their potential aggressiveness; to size up their projected risk to me, I most certainly would have chosen another field.
But, hey, the system demanded 300k in loans from me, so I’m stuck. Therefore, I’m practicing a stable of post-error responses akin to: “Too bad that happened. Must suck to be you, but good thing you have an infallible doctor that didn’t contribute in any way to what happened. The nurses around here are pretty air-headed, by the way. Did I mention that before? Anyway, not to worry. I’ll find that nurse and rest assured I won’t sleep until I can be certain you get the correct dose next time.”
secretwave101 
It sounds like the PATIENT and her family were quite accepting of the adverse event, and you remain on good terms. Have you considered discussing this further with her at a later date, for example asking, “You know, some of my colleagues criticized me later on for apologizing for what happened to you. They said doing so made it look like it was my fault, and that I shouldn’t have done it. Did you find that my apology helped you feel any better about the event? Do you think you might have reacted differently if I had not said what I did?”
My own experience has been that patients feel MUCH better after an apology is received, are happier with the care you provided, and are less likely to want to sue anyone.
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If I read you correctly, the patient was understanding of the situation and the relationship was not seriously damaged.
FWIW, *you did the right thing.* Overwhelmingly, the evidence shows that when physicians apologize and show concern when something goes wrong, patients are less likely to contact a lawyer. Your superiors *were wrong* and my advice to them is to get their heads out of their asses.
This is a hard message to convey. Even if you didn’t have to worry about the constant threat of litigation, health care culture is highly perfectionistic and secretive. It’s hard to change this culture and start being more open with patients and families when there’s an adverse event. It needs to be done, though.
I’ve been on the receiving end of a medical injury that caused some permanent damage, and no one ever apologized or explained what happened or even showed any concern. I’m sure they were afraid, but you know, it destroyed my relationship with the physician and with the hospital.
You sound like a great, caring doctor. The way you handled this incident is exactly how I wish my former physician had handled what happened to me. I would hate to see you becoming bitter.
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There are ways to apologize without admitting anything. Politicians do it all the time – or just apologize for something minor – look at Kwame Kilpatrick in Detroit.
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Outstanding post, if I may say.
The British NHS complaints system is clogged up beyond belief because of the hospital adminsitrators policy of “never say sorry” “say nothing and it might go away” and, above all else, hide the notes (charts)
John
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MLO – Hear hear. Just read about that “apology” last night and was not impressed. Guess he needs to keep his job, though.
Dr. Crippen – Thanks for the feedback. Never heard of hiding the charts, but I can see how that would be very expedient for a hospital.
One – Appreciate the support! I suppose I’m more cynical that I would wish to be. I hope that until I actually find myself wearing a tie and sitting in a courtroom, I’ll still risk it and own up for my part in things that go poorly with my patients.
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Does “hide” = “shred”?
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very interesting post. I myself being a (student) Nurse, I feel compelled to criticize and rant on your superficial view of nurses. But I don’t need to. You should know that blaming the nurse never solves anything.
Medicine, as far as I have seen so far, is definitely a field of the unexpected. Probably the nurse did give the right dose, but neither she/he, or you could have known that your patient would have an adverse reaction. These things happen. Its one of the first things they teach us in Nursing: be prepared for the unexpected. ‘Always have the Naloxone and the epinephrine ready. Remember the anaesthetists number by heart. know where to find the fire extinguisher…etc’
Another thing they teach us nurses is sincerity. I am actually very surprised that Physicians are still stuck in old etiquettes. Please note, I am not pointing any fingers at you, I am rather pleased that you handled the situation the way you did. I guess that is what makes you a good doctor.
I would like to still say one more thing, and that is: When a patient is admitted to hospital, it is the ENTIRE staff that is responsible for the care of that patient. Doctors, consultants, nurses, social workers, cleaners and kitchen staff all play an equally important role. I for one make sure that I don’t treat anyone above anyone else. I always appreciate it when a doctor treats me as a colleague, and not as some petty little student who just changes the diapers.
By the way…was the patient on acyclovir treatment? when you wrote ”there actually isn’t much that CAN be done”, that just came to my mind that although acyclovir does not cure anyone from herpes, it can help to reduce the infection. Does one need 100% concrete proof of herpes infection before administering the drug?…just wondering 🙂
I really like discussing medicine, more than normal nurses do.
Cheers.
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I didn’t actually blame the nurse. I was giving an imagined example of what happens so often in American medicine today…where blame rolls “downhill” and everyone points somewhere else as the culprit. The nurse gave the right dose.
Acyclovir is only helpful within about 48 hours from the time of the outbreak. This pt. was on the antiviral just in case we were in that window and in case it really was HSV. But it wasn’t helping. At all.
Thanks for the comments!
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Ran across a link to this post on Kevin MD. Nice of him to include it but I thought he misrepresented the content a bit in the teaser — came across as another “damn lawyers and lawsuit-happy patients” testimonial, whereas there are no lawyers directly involved here and the doctor-patient relationship described seems like a model one.
I’ve been fortunate to have only one unproductive relationship with a doctor, and that (from my perspective) resulting entirely from very, very, very bad communication. Tough to resolve any differences when one party won’t talk.
Doctors have extraordinary power over their patients. If a physician thinks he or she has a reason to distrust you, all it takes is one quick termination letter — no evidence of patient malfeasance necessary — to block your access to every physician in his practice, including those you’ve never met and those who may join in the future. And there’s nothing the patient can do.
Which is why I think doctors have to take very seriously their responsibility to communicate well with patients, avoid jumping to potentially erroneous conclusions, and not — as I think Kevin MD did — take a story which could well have been used as illustrative of excellent doctor/patient communication and instead stretch it into another poke against irresponsible malpractice attorneys (who, by the way, get no support from me either).
There’s plenty of bile against lawyers out there already. Can’t we just enjoy reading about a good relationship?
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I think Kevin MD was pointing out that I was attacked by numerous other doctors for my “admission” of “guilt”. In the past, good communication was simply good communication. Now it’s risk managment.
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Understood, but it seems to me that this kind of “risk management” actually increases your risks rather than reduces them. I don’t understand why so many of you good people in medicine let risk management attorneys define your behavior with patients. I don’t think it’s helping you.
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http://www.boston.com/news/nation/articles/2004/11/12/apology_a_tool_to_avoid_malpractice_suits/
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I believe you that you weren’t really blaming anyone. And I am glad to hear that the nurse did give the right dose. Although dosage mistakes happen often and easily, with nurses being overworked and burned out.
Thanks for the info on acyclovir!
By the way, I like your writing style.
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Thanks for the support anjasmith!
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Thanks for the comments.
I was recently badly injured by a doctor doing an unecessary exam. She was running late, failed to take a history and grabbed ahold of me without explaining what she was doing. The hospital chose to ignore my phone repeated calls, as I was in agony. I finally got back in to see the Doc, and she instead acted as if I had never called and blamed me for the “reaction.”
So…I’m crippled and its my fault. Why does that hospital expect that I wouldn’t be increadibly bitter and feel compelled to sue?
~S:)
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Suz,
Sounds like your experience supports my feeling that hospitals and clinics need a better system for making things right with their patients without the direct involvement of lawyers.
I suspect a genuine and heartfelt apology, and medical care of your injury free of cost, would go a long way to resolving your situation better than lawyers, courts and some gigantic financial sum that will be siphoned off by a long list of enterprising capitalists.
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I have received an apology from my dr. who ‘oops’ started the wrong procedure – ‘oops’ – he said it only took a few extra stitches – bandages are still on. If a mechanic ‘hurt’ YOUR auto – YOU would expect it to be made right – without legal intervention. Sadly, because my injury was ‘minor’ and there is no $$$$ in it for the legal sys. – I am left to lick my own wounds and wonder how do people get by with this? I endure needless pain, am scarred, but I AM INSIGNIFICANT! So, this is how minorities feel – LOUSY…..
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I am glad this had a happy ending, my daughter was given dilaudid. The ending is very sad.
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My husbands Dr. has been treating my husband with the shot delaudid, unknowing to us my husband became addicted, he would be sent home and becoming very sick. He was going cold turkey and didn’t know. His Dr knew..would order all kinds of test. When the test came back with nothing wrong with him, his Dr would then tell him the insurance company would not pay anymore and he was sent home..after he was sent home he became soooo sick I just so happen to get a dr who told us he was going through withdrawal and the the hospital and the Dr would take full responsibily. He was put in the hospital and again was given delaudid. I questioned his dr why was he still giving my husband dedaudid. and that I was told by the er dr that he was addicted to the shot. His dr didn’t want to admit it to me and
tested him again (more radiation). of course the test came back nagative. my husband was sent home again.. I went back to the hospital and spoke to the er Dr. which he didn’t back down from the addiction…Now my husband is at home going thru hell. what can I do.
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