Heavy conscience...

For the past several days, I've been walking around with a heavy conscience. It's actually quite terrible timing. My brother is visiting with my two little nieces, and I had arranged for us all to go to the Sunshine Coast for a few days for some family bonding and to getaway. I got an email from my department head at one of the hospitals I work at just before I left. There was a complaint. A patient whom I saw several months ago had felt that I missed identifying a fracture on his pinky finger. And unfortunately, it had lead to some ongoing issues and difficulty in his work. I was asked to review the chart on him and comment on the case. As I didn't quite had the chance to go to the hospital to review the electronic chart before I left for our family trip, I had to wait until I get back. It weighted on me, though, the entire weekend, despite all the innocent laughter of my nieces in their countless giggles.

I was convinced I was a careless doctor. It wasn't a surprise that I could have missed something. To err is to human, I know. And working in the ER is a set-up for countless possibilities of errors. Any given moment, your mind is being torn between the case which you are currently involved with, in the midst of countless alarms and visual plus auditory distractions, as well as the occassional questions from nurses on other matters, as well as being aware of how busy the rest of the waiting room is and how far behind you are. Not to mention, as you are also involved with the care of many other patients in the department and not just one, you mind could easily be debating topics on other cases as you work through the current one. In fact, most of us accept the fact that we work in an area of constant possible errors. Which is strange, because one would believe the ER is the one place where you hope mistakes do not happen. Now, countless efforts have been given both on a systemic level and a personal one to mitigate these possible errors. Those who follow my blog knows how emotionally attached I am on trying to be the best I can be, and how aware I am of cognitive errors and how to best reduce them.

But that is not to say that errors do not happen despite all these efforts. They do, and we accept them, and try to set up a systemic network to catch them as they happen. Occasionally, as what I thought had happened in these case, things do fall through the crack. But as we have always taught our residents, just as we have always been taught ourselves from day one, that if ever you are unsure, then good close follow-up is the key. Haven't said that, nobody likes to see things being missed. And if there's one thing that this complaint reminded me of, it was how important my work is to every single patient whom I deal with every single shift. It might seem like a minor issue, having a broken pinky. But, our hands are one of the most complex and functional part of our bodies, and is intricately involved with every single minute of our livelihood. It reminded me that, sometimes, seeing patients after patients, shifts after shifts, months after months, I might loose sight of how important every single complaint is to that very person making them.

Every single decision that we make in the ER, could have life altering consequences. And we literally make hundreds of them every shift. That is the nature of our job. That is the nature of being a doctor.

And so I was humbled, bothered, saddened, and concerned about the complaint. As soon as I got off the ferry and back in town, I excused myself from my family and went to the hospital to look up the chart.

And I was surprised by what I saw.

I had told him I thought it was likely broken. In fact, even the radiologist report of the initial x-ray wasn't sure, but clinically I told him I thought that it was. Protect it, I said, with a splint, and follow-up with your doctor in 1-2 weeks to recheck to be sure. In his complaint, he had said that I reported no fracture, and the he could follow-up with his doctor in about 4 weeks after using splint. I always never tell a patient to follow-up with their doctors in such a long duration. Perhaps he could have misunderstood me. But that was not what I intended for him, and clinically I had told him I was suspicious.

I ran the case by a colleague who used to handle patient complaints in another hospital. I showed her the complaint letter, and my note. She said I did nothing wrong. I told her I still felt terrible. She told me to detact myself from the emotion of the moment and just stick to the facts of the case.

Sometimes, no matter what you do, people will get mad at you. Personally, I hate that, but there's nothing I can do to mitigate that. Are there things I could have done better at this case, possibly. But at the time I think I did what I felt was the right thing, and even looking back, I couldn't really say that I did anything particularly wrong. I'm not pleased the patient had a poor outcome. I'm not pleased that perhaps that could have been more I could have done. But at the end of the day, we see countless patients each day, all we can try to do is put forward our best focused efforts on each one. One teacher used to tell me, if I debate endlessly on each case before moving on, I'd be paralyzed by my thinking process, and would not be able to run the department effectively. Our job is to make quick decisions. We can only try to continue to thrive for thinking clearly in making those quick judgements, and believing in ourselves, and continue move on.

There is no winner when there is an unhappy patient. All I can do when the haze settles, is to continue to do my best, on every case big or small. Because every single decision, I know, can impact someone for life.