The blame game

This is a tough post.  I’m sad this evening, but I think it’s good to write honestly about my experiences here, so here it is.

When we arrived this morning, M, one of our best nurses and one of the people involved in yesterday’s malnutrition admission, called over my translator and asked him to tell me “The girl with malnutrition died last night from hypoglycemia because Dr. Sara didn’t start IV fluids.”  I was floored.

First, I was surprised that that particular patient had died.  She’d responded well to our initial interventions.  Secondly, I hadn’t started IV fluids because it wasn’t indicated in that patient, and could have caused heart failure.  M either didn’t remember that part of the training or had disregarded it, since she’d wanted to start the fluids yesterday when the girl was admitted (I told her not to), but she clearly remembered my lecture in which I had said that patients can die from hypoglycemia during the night (if they are not fed.)

She continued – “You had said to check her glucose at 11, but she died at 10.”  I could fill in the blanks – my orders had been followed to the letter, but when the patient’s condition changed nobody thought to do anything but wait for the prescribed time to check the glucose or make any other interventions.

I asked if the patient had been getting her feeds as ordered – frequent enough to avoid hypoglycemia and to ideally allow the person giving them to detect it before it kills the patient.  I’m told she was, but somehow I doubt that she was being fed every two hours that evening, as I’d ordered.  The evening nurses often lack the follow-through of the daytime team, partly due to personality factors, but partly due to the fact that there is no pediatrician available during the night – that means for over 12 hours every day two or three nurses are on their own to deal with whatever problems arise with the 40-50 patients in our unit.  They have gotten used to bad things happening, and nobody responding.

So all I’m left with is that something changed with the patient, she didn’t receive an appropriate intervention, and the nurse saw this as my fault.  I guess if lack of availability is my fault, then yes – I’m guilty.  If lack of writing out a formal protocol for managing the patient was my fault, then yes – also guilty.  I’d written more comprehensive orders than I’ve given for any other patient since arriving, but I had not specifically indicated that they should adjust the feedings (as they’d learned earlier this week) in the case of hypoglycemia, nor had I specifically written that if the patient deteriorated they should check a blood glucose sooner than I’d asked.  We don’t have a protocol in place, and I did not specifically think of every possibility in terms of what could have gone wrong with the patient during the night. The patient’s initial good response to our interventions had lulled me into a false sense of security.  I need to learn from that.

There is a strong tendency to pin blame here – everyone is quick to point out “It’s not my fault!” if you mention a problem or something that needs improvement.  But though I know that there are systems of care which set many obstacles between my patient and good care, I can’t shake the feeling that if I’d done a better job maybe that patient wouldn’t have died last night.

I’ll write more thorough orders next time, and the nurses will become more accustomed to what to look for and how to respond to it, and we’ll implement a protocol soon, and we will get more supplies and maybe more staffing and maybe even eventually staff coverage in the evenings.  But my patient doesn’t get a next time, and that’s hard to sit with tonight.

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  1. Sara,
    I feel terrrible for you. As in any profession you can only try to do everything perfectly. Of course that is impossible. Also it sounds like your nurses have a fear of being blamed for things like that so they point their finger at someone else. In this case according to what I read you. I’m sure you have had courses on how to handle this kind of thing. All Doctor’s have to have negative experiences or they wouldn’t be human. Cheer up Sara, you are doing your very best to help these patients.
    Love, Uncle Dick

  2. Barbara

     /  February 4, 2012

    Hi Sara,
    I am Very sad that you had this difficult day. You have analyzed the situation logically and know what went wrong. I think that is admirable in view of it being an emotional issue. You Are working in less than optimal conditions and what a challenge it has been! You are a devoted and conscientious doctor who is making a significant sacrifice to help the mostly forgotten and seriously needy poor children. Most importantly now, I hope you will be able to affect some of the necessary changes to prevent a reocurrence.

    We love you, Sara, and know you are an awesome doctor and person.
    Love, Aunt Barbara

  3. Karen Stockmal

     /  February 5, 2012

    What an emotional roller coaster you are on! That anyone could blame you for anything that happens to a patient in your circumstances is cruel irony. Were you not there, these children would be so much worse off. You are giving hope to those without a chance. That you cannot save them all makes you human. That you can save even one makes you amazing.
    Hang in there.

  4. Mom

     /  February 5, 2012

    Dear Sara
    I was shocked to read your post this morning… surely didn’t reveal anything about this situation when we facetimed. Of course the nurse wanted to pass the buck, but how unfair of her to pinpoint you. Of course the kids are so much better off with you there. But you did not establish the protocol, you did not dictate that no doctors are in the hospital overnight, and unfortunately you cannot change the system. So do what you can……and then some……and accept that you are making a difference. Because you are.
    Love, Mom

  5. A bad outcome is a great opportunity for learning all around. You learn what the limits of your staff are, your staff learns through protocols what to do to avoid this in the future and slowly the culture of the work place changes from apathy, indifference, and blame to collegial cooperation. Do you remember Maureen Bisognano’s lecture this past summer about Healthcare Improvement? How docs were placing central lines in ICUs and not following infection control protocols? Once reports regarding individual docs infection rates were posted, the infection rate dropped significantly. Everyone wants to be recognized for the good work they do. Review your data. Use your data. Would posting a weekly report of deaths from hypoglycemia be helpful?

  6. Thanks to everyone. Lisbet, you raise some great points. We did review the protocols afterwards, and I am working with some of the other pediatricians at other sites to develop more support for ongoing monitoring in this area. Fortunately we don’t have enough malnourished kids in any one week for those rates to be particularly significant (nor do patients necessarily get a glucose recorded – including the patient I described here) but I agree that a public accounting of our progress (or lack thereof) would be a great motivator all around. Getting the data necessary to track those things will be one of my challenges during my time here, and I’m hopeful to continue working to figure out the best way to do so. Thanks for the reminder of our work this summer. 🙂


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