Scrutiny, Support & The Second Victim

Around a decade ago, I was nearing the end stages of my formative training in Emergency Medicine, and was feeling more confident in my clinical acumen and skills. I was working overnight into Christmas Day in the Emergency Department at the Royal Infirmary of Edinburgh, which is a shift that can be eerily quiet, but sometimes is absolutely manic. 

This shift it was the latter: I was the only registrar in the Department, and we had 11 cases through our resuscitation room between midnight and 8am, with lots of activity in our majors and minors areas at the same time.  My “happy Santa” face was even less forthcoming that night.

I went to see an elderly lady, Ethel, who was lying on a trolley in our majors area.  Ethel* had been brought in from her sheltered housing complex after five days of vomiting and appearing drowsy to her once-daily carer.  She was frail, looked dehydrated, and had low blood pressure when her observations were recorded, but was not actively complaining of anything specific. 

At that moment in time, she had unfortunately had to wait for 60-minutes or so before a cubicle was available for her, and a further 30-minutes before I got around to seeing her. She was a little drowsy, but responded to some questions.  She was disorientated and mildly confused, was unable to tell me what medications she was taking or any concurrent medical conditions.

Having examined her, I was called away to another emergency and then returned to put a cannula into a vein, take some blood tests, and start some IV fluids to rehydrate her.  In the interim, the nursing staff had taken the initiative to do an ECG (heart tracing), and they handed it to me as I re-appeared from the cubicle.  It did not show a healthy looking heart.  In fact, it looked completely bizarre.  I went back in to see my patient, wanting to ask specifically about any previous heart conditions or any pains in her chest, but she was still too confused to answer me clearly, though she did deny any pain at that moment.

I couldn’t piece it all together.  I wondered if she might have an elevated potassium, one of the salts in the body, but quickly discounted that as vomiting normally lowers your potassium.

Could she have accidentally or purposefully taken some extra medications that may have poisoned her? 

Could she be having a “silent” heart attack? 

I remember struggling to concentrate on this specific case whilst being repeatedly interrupted and called for other things in the hubbub of activity that continued around me. I also still remember that very uncomfortable feeling that there was something I was missing, but couldn't find the mental space or time to try and work out what it was.

About 30-minutes had passed. I got a phone call from the laboratory – Ethel’s blood tests revealed that she had gone into severe kidney failure and that her potassium level was dangerously high.

I felt that terrible flush up my neck and into my face. My heart was pounding my chest like a sledgehammer. I realised my mistake. 

The ECG was trying to tell me that this was the situation and I had failed to read the signs correctly. I made a hasty assumption on the basis of ‘what might normally happen’ without understanding what the patient was showing me, and I had now delayed the opportunity to start protecting Ethel’s heart from the effect of the high potassium and to begin correcting the other abnormalities.  Idiot!

I alerted the nursing staff as to the urgency of the condition and we moved her into the resuscitation room to monitor her more closely, and start all the required treatment as quickly as possible.  We stabilised her enough to be transferred to the renal unit and thanks to the expertise of those other specialist medics and nurses, who essentially brought her back from the precipice, she was finally discharged 18 days later. 

*Patient names have been changed for the purpose of confidentiality.

Scrutiny and support

I often find myself thinking back to this case and, at the time, I dragged myself over the coals trying to understand all the various factors that contributed to my error and the subsequent delay in diagnosis that nearly caused this patient to die. 

There are many factors and not all are easily solved.  At the time, there was no widely-used mechanism for either reporting it or learning from it.  Nowadays, we operate very differently, with regular meetings where difficult cases are discussed, and learned from, and we all have a focus on safety in our daily work.

However, humans are complex, and healthcare is too, and mistakes will continue to be made. If we are really aspiring to have a truly excellent health service, the first step on that path is to, as a society, allow all mistakes and ‘near-misses’ to be declared openly without fear, so that individuals as well as systems can learn how best to avoid them. 

If we scrutinise and vilify, we will never really achieve a safer system, just better ways to conceal the inevitable. 

Society needs to support as well as demand improvement.