'Killing' a patient

Hi,


It's my last week on surgery, and I am now half way through the
rotations this year until my finals! A scary thought, as I certainly
don't feel as though I am anywhere near being ready for those exams -
but still not scary enough to start revising hard, sadly... As well as
the general surgery shenanigans I have been getting up to in the
previous weeks, this week I get to spend a day on the 'simulator', an
advanced electronic dummy that simulates medical problems and lets you
practice your diagnosis and treatment skills. This is something that
was mentioned to us at the university open day about 6 years ago, and
something I have been looking forward to since then!

Regarding the things I have been up to in surgery, I have kept on
doing ward rounds and ward jobs most mornings with the junior doctor,
who is really lovely. I also helped run a pre-op clinic where patients
were seen before their operation to check on their health, take blood
tests and so on. A very formulaic clinic where the same sort of
questions were asked to each patient, so I could be very useful here.
I also spend most afternoons in theatre, to make up for all the time I
have been missing over the last few weeks. Going to the theatre should
involve some acting talent or a lovely musical, but sadly in these
cases it involved cutting out gall bladders and a complicated
operation for pancreatitis where the necrotic 'rotten' pancreas was
removed by punching a hole all the way the stomach from the front,
using keyhole surgery, and draining out all the pus and dead tissue.
Watching the difference between the consultant and the registrar
operating was very interesting, as the difference in experience does
show. Both clearly perform safe and effective surgeries, only the
consultant does so much more quickly, and the movements he makes seem
a lot more confident and meaningful. It is almost beautiful to watch,
but I still don't want to be a surgeon and have to do that every day!

Onto the simulation training. As I said before, this was something I
have been looking forward to for ages. Imagine getting your 'own'
patient to try and diagnose and treat - its like being a real doctor
but with none of the responsibility if things go wrong. The mechanical
patient had a rising chest, pulses, heart sounds and opening moving
eyes, as well as veins which can be cannulated and lots more, meaning
loads of different diseases can be simulated, diagnosed and treated.

The way our session worked was there were four of us, and we were put
into two pairs. The idea was that one person would 'lead' a case,
while their partner assisted by doing things they asked them to do,
such as prescribing drugs and carrying out procedures such as taking
blood. In each scenario there was a trained nurse who would assist in
doing things a nurse would do, such as giving oxygen and administering
drugs prescribed. While all this was going on, the other two sat in a
different room, hidden by a one/two way mirror (why are these words
the same thing!), and watched what was going on to give feedback at
the end. The case I got was severe abdominal pain after binge drinking
in Ibiza, which I diagnosed as acute pancreatitis, (fortunate as I had
written an essay on this a week ago), initially giving fluids and
oxygen, then calling for a senior opinion. I did forget to do an ABG,
but other than that it all went very smoothly, though the 10-15
minutes the case took flew by in a whirl of activity. The excitement of
it, and how you get immersed in treating this very sick patient felt
quite real, and it makes me want to do acute medicine even more!

The case that I was there to assist my partner for did not go so
smoothly... This was a patient who had a severe respiratory infection
on top of a history of heavy smoking. She ordered all the correct
investigations and initial stabilisation of the patient was successful.
By this point we had both noticed that the patient was allergic to
penicillin, she by the wrist band on the patient and myself by
flicking through the 'admission notes'. Despite this, when working out
the CURB-65 score (a score used to see how severe pneumonia is), she
used the result to prescribe co-amoxiclav, which was an appropriate
antibiotic to give the patient. Other than the fact that they were
allergic to penicillin. Despite the fact that I knew about this
allergy, and had in fact only just written down on the drug chart that
the patient was allergic to penicillin, I went on and wrote up the
co-amoxiclav to be given, pretty much with the same pen stroke. Well,
the less said about this the better, but I can definitely say that
after making such a horrible mistake, that will stay in both of our
memories and we are very unlikely to make such a mistake again!
Despite having found out all the evidence (and knowing that we
shouldn't give co-amoxiclav, which all med students know is penicillin
based) we didn't link the two and gave it anyway. We were very lucky
it was only a dummy - but it does show how easy it is to make mistakes
in medicine, and the dire consequences that can come about if mistakes are made...