Anytime I think, “Boy, I’ve really gotten good at this,” something happens to remind me how hard the job is: an unknowable number of illnesses presenting in an infinite number of ways.
My cardiac tamponade was diagnosed as gall stones because of a fixed dot on the scan. TThey were about to take me to surgery when the surgeon said we have to figure out what’s going on with her liver first. There was a “shadow” on my liver on the scan. No one caught my muffled heart sounds or distended jugular vein until 5 abdominal scans later the picture happened to catch a glimpse of my engorged pericardium. The shadow on my liver was a distended portal vein. A needle in my chest cured me 5 days later than when I first saw the NP in my PCPs office with excruciating pain in the lower middle of my chest. My PCP was on vacation. Once I was put on the GI track, no one reassessed my heart. Not even a listen.
If filling out a death certificate, contemplate how your answers will impact the family and public health statistics. Do not guess but be as precise as possible. Never write "cardiac arrest".
Thank you so much for this. These advices apply just as well to nurses! Both directions, meaning in our work with doctors and in our own practices with our patients.
I have been so blessed in my 70 years to have doctors & ER people who have listened to me & not pooh-poohed me when I suggested a reason for what ever my pain or symptom was.
I usually tell the nurse or doctor, "I may be smiling, but look at my eyes...my smile & laugh is how I deal with pain & I have a HIGH pain level...I wouldn't be in the ER wasting our time if it wasn't necessary!!!"
Thanks for your honesty.
It is a genuinely WoNdErFuL trait that we should all have, no matter what our profession is in life!
I sent this to all my residents. E regime makes mistakes - we are human. It is so important to learn from them. I too have kept a record during my 25 years practicing. A lot of mine are similar to yours.
As an RN of greater than 40years experience, I too have made mistakes and had near misses. Everyone has. I have always told new Nurses that until they go home after their shift and know to the bottom of their heart that but by the grace of God or whatever entity they believe in, some precious human entrusted to their care would have died or been grievously injured, they do not know what it is to be a real Nurse! This will happen and any Medical Professional who denies it is either blind or a liar.
This! Reminded me of when my husband had a DVT which became a PE. He had several medical visits with inconclusive dx. It nearly killed him a couple months later. We realized later that it likely developed after a long car trip. If we had put two and two together, he likely would have been spared the miserable two months.
Another comment. When our (then) 17 yr old son was admitted to the ER with a heart attack we were told that it happened because his lungs filled with fluid they were adamant that he was on steroids (very muscular) or drugs. He was not. Anywho they were also adamant that it was his heart that was the issue and inserted a Swann-Goetz catheter. We over and over again asked them to check his head (he had a shunt at birth and a third ventriculostomy at 10) but of course the heart docs were SURE what the issue was. He was given last rights in the ICU. They FINALLY consulted the neurologists and guess what! His fluid in his head WAS the issue. Inserted another shunt and VOILA out of the hospital in 9 days!!
ALL OF THIS!! As a nurse, I do have a bias to your first point. I have fought many neonatologists to advocate for "my" babies. Even if my spidey-senses are off, I always learn something and sometimes my neos do too. I also remember most of my errors, having the call a parent to tell them of an error is extremely humbling and a lesson not soon forgotten. Thank you for sharing.
Thank you for sharing this. I myself have made errors that I still think about but I really appreciate the suggestion of writing them down. I’m sure I have had near misses that I can and should refer to and writing them down I think is such a great idea. Thanks again for this article.
My cardiac tamponade was diagnosed as gall stones because of a fixed dot on the scan. TThey were about to take me to surgery when the surgeon said we have to figure out what’s going on with her liver first. There was a “shadow” on my liver on the scan. No one caught my muffled heart sounds or distended jugular vein until 5 abdominal scans later the picture happened to catch a glimpse of my engorged pericardium. The shadow on my liver was a distended portal vein. A needle in my chest cured me 5 days later than when I first saw the NP in my PCPs office with excruciating pain in the lower middle of my chest. My PCP was on vacation. Once I was put on the GI track, no one reassessed my heart. Not even a listen.
“Boy, I’ve really gotten good at this.”
In 20 years of being an airline pilot, I’ve said this a few times as well only to come to a similar conclusion. Humbling indeed.
This is a beautiful reflection. Thank you Dr. Cifu. I'm a big fan of your books.
Good list. I would add another:
If filling out a death certificate, contemplate how your answers will impact the family and public health statistics. Do not guess but be as precise as possible. Never write "cardiac arrest".
Really appreciated this. Good reflections for all of us. I admire your humility and am sure it has served you well! Thanks
Thank you so much for this. These advices apply just as well to nurses! Both directions, meaning in our work with doctors and in our own practices with our patients.
Thank you once again for your contemplation.
I have been so blessed in my 70 years to have doctors & ER people who have listened to me & not pooh-poohed me when I suggested a reason for what ever my pain or symptom was.
I usually tell the nurse or doctor, "I may be smiling, but look at my eyes...my smile & laugh is how I deal with pain & I have a HIGH pain level...I wouldn't be in the ER wasting our time if it wasn't necessary!!!"
Thanks for your honesty.
It is a genuinely WoNdErFuL trait that we should all have, no matter what our profession is in life!
Well said. I wish you were my Doc. Keep up the good work.
I sent this to all my residents. E regime makes mistakes - we are human. It is so important to learn from them. I too have kept a record during my 25 years practicing. A lot of mine are similar to yours.
As an RN of greater than 40years experience, I too have made mistakes and had near misses. Everyone has. I have always told new Nurses that until they go home after their shift and know to the bottom of their heart that but by the grace of God or whatever entity they believe in, some precious human entrusted to their care would have died or been grievously injured, they do not know what it is to be a real Nurse! This will happen and any Medical Professional who denies it is either blind or a liar.
As a mom and a past patient, I can tell you that you give me hope. Absence of evidence is not evidence of absence.
Shared with my DIL who is a NP, associate professor. Maybe she will share with her students.  Also shared with my son who is a resident.
Never underestimate the ripple effect. You are reaching many! Thank you.
This! Reminded me of when my husband had a DVT which became a PE. He had several medical visits with inconclusive dx. It nearly killed him a couple months later. We realized later that it likely developed after a long car trip. If we had put two and two together, he likely would have been spared the miserable two months.
Another comment. When our (then) 17 yr old son was admitted to the ER with a heart attack we were told that it happened because his lungs filled with fluid they were adamant that he was on steroids (very muscular) or drugs. He was not. Anywho they were also adamant that it was his heart that was the issue and inserted a Swann-Goetz catheter. We over and over again asked them to check his head (he had a shunt at birth and a third ventriculostomy at 10) but of course the heart docs were SURE what the issue was. He was given last rights in the ICU. They FINALLY consulted the neurologists and guess what! His fluid in his head WAS the issue. Inserted another shunt and VOILA out of the hospital in 9 days!!
MOMS do KNOW!!
Really enjoyed this read!!
ALL OF THIS!! As a nurse, I do have a bias to your first point. I have fought many neonatologists to advocate for "my" babies. Even if my spidey-senses are off, I always learn something and sometimes my neos do too. I also remember most of my errors, having the call a parent to tell them of an error is extremely humbling and a lesson not soon forgotten. Thank you for sharing.
Thank you for sharing this. I myself have made errors that I still think about but I really appreciate the suggestion of writing them down. I’m sure I have had near misses that I can and should refer to and writing them down I think is such a great idea. Thanks again for this article.