August 23, 2013

everything that goes wrong

As an intern, any time there's a debate about whether something actually IS wrong vs. you DID something wrong, you always think it's the latter (at least I do).  The dressing is soaked? maybe I didn't close the wound or dress the wound correctly.  Her pap smear came back abnormal? Maybe I didn't do it correctly. The medication isn't working? Maybe I prescribed it incorrectly.  She's bleeding? Maybe I forgot to give her medications/ didn't do something completely.  This constant underlying mindset of "everything that goes wrong is my fault" is important in understanding this story.

It is one such struggle to find the right plane that this story takes place - I was running around in clinic, per usual, and my senior resident calls me into his patient's room to do an ultrasound so he can evaluate and teach me. Every new obstetrics patient needs an ultrasound to date the pregnancy.  One cool thing (well, obviously I think it's cool) about the developing fetus is that in the first, and really even in the second trimester, most fetuses are about the same size, giving us the ability to measure different body parts (head, abdomen, thigh bone) and accurately determine how long the woman has been pregnant.

For this patient, I introduce myself to the patient, explain what I'm going to do, she gives me an excited nod like "yes! show me my baby!" (women love their first ultrasound and I don't blame them) and I place the ultrasound on her belly.  By her last menstrual period, she should be about 20 weeks pregnant, which means the fetus should be pretty easy to see and measure.  I'm trying to scan quickly because I've already done 10 ultrasounds today and I have three patients waiting in rooms for me to get back to them, but also accurately so I can show my senior resident that I am capable of independence, so when it's difficult to find the right level of the head to measure the BPD, I get a bit impatient with myself for being so incompetent and slow.   Then I decide to try to measure the femur instead, because it's actually the more accurate measurement anyways, and can get a pretty good view of the femur, but it's measuring small - about 14 weeks.  I think to myself, "man, I'm such an idiot that I can't even measure a femur correctly" but decide after trying for a few minutes to move onto the abdominal circumference - but I just cannot get a clear picture of the fetal abdomen - everything seems a bit...squished.  At this point, my senior resident has been trying to correct my verbally for about five minutes (try moving your hand to the left, don't push as hard, make sure your angle is correct, no that's not quite it) and finally gets frustrated enough to just take the ultrasound probe from me and try himself.  I step away from the machine feeling like a complete and utter failure, not only because I somehow couldn't measure any part of the fetus correctly, but because I still have 3 patients who I'm keeping waiting in other rooms.  I mentally beat myself up for a moment and then a thought occurs to me:  "Elias!" I say calmly, "Can you check for FHM?"  this is code for fetal hearth movement, a tell-tale sign that a baby is alive and well.  I say this in code because I just realized I didn't do that at the start of the scan and reflecting on what I did see, there wasn't much movement at all.  Then, as Elias scans through the patient's uterus,  he and I both realize at the same time that this fetus is not alive, has not been alive for probably over a month.  The patient,still craning her neck to better see the ultrasound, asks us if we can tell if it's a boy or a girl.  Elias and I look at each other, and then, as the senior resident and the person ostensibly in charge, he says, "we are having a hard time seeing the baby's heart beat.  we need to check with a better machine."

He and I both know that no machine is going to show us a beating heart in this fetus, but as the doctors in training, we have a responsibility to the patient and to our attending physician, to make absolutely sure that we have not gotten something wrong.

As I stood explaining the next steps to the patient, I wished two things: first, that I did make an error and therefore there was some other explanation other than her baby had died, but second, angry at myself for being so self-doubting, so certain that all inaccuracies were from my lack of skill or knowledge that I didn't even stop to think: what if I am scanning this correctly and this baby is 6 weeks behind its dating with anatomy that doesn't look quite right.

It is an important lesson of intern year that I keep learning over and over again - yet can't seem to get quite right: trust in the knowledge that I do have and at least consider the possibilities if I assume that I do know what I'm doing some of the time.

*an instagram original of me staring into my coffee cup at 5am 
wondering what this day has in store for me*

 "Gilean threw his head back and laughed 'a mistake? one mistake? you should be so lucky.  you'll make dozens!  I made four or five on my first day alone! Of course you'll make mistakes.  Just don't make any of them twice.If you do mess things up, don't try to hide it. Don't try to rationalize it. Recognize it and admit it and learn from it. We never stop learning, none of us."
-John Flanagan, Erak's Ransom

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