If you don't put your finger in it, you put your foot in it

Every junior doctor makes a first critical mistake that scars his memory for the rest of his life.

My first was on the grumpy old man with a medical background of Diabetes, Leprosy and multiple amputations on almost every limb.

Mr L had been admitted for Septic shock (low blood pressure and faster-than-normal pulse due to serious infection processes going on in the body). His blood pressure was critically low on arrival at A&E that aggressive fluid resuscitation was needed to keep him adequately perfused. Our investigations had revealed multiple sources for his ongoing sepsis so far. Bacteria in the blood, a soft tissue infection of his Right below-knee amputation, a foul smelling boggy abscess on his Left foot, and angry-looking infection of the soft tissue on his Left wrist.

To treat his numerous sources of infection, he was put on an IV drip and given Antibiotics.

Surgery was of course, needed to remove the gooey pus and foul-smelling abscess that were hidden inside the atrophied muscles in his Right leg stump.

''Just leave me alone. You doctors always want to cut this finger cut this limb. I have nothing left already, and you still want to recommend me surgery???''
(Dialect translation)

Morning pre-rounds was always a challenge with this old chap. He would fuss, complain and moan everytime I offered to change his drip, set a plug or stick a needle in his vein. After all, he was your typical proud, stoic, stubborn, and independent middle-working-class lad of the 50's that would not lower his pride to accept any form of medical advice from Western-trained doctors any younger than he was.

Mr L was insistent on refusing surgery, despite our repeated attempts to persuade him that conservative approach with Antibiotic therapy would only keep the fever down, his blood pressure stable and target the bacteria in his blood. Intravenous antibiotics was ineffective in penetrating the site of infection in his Right thigh, and that was why surgery was needed to physically scrape the abscess out.

On a thursday afternoon, I was busy consulting the Microbiologist for antibiotics advice over the phone when one of the Nurses tapped me on the shoulder.

''eh Dr Goh, patient bed 17-04 has just passed stools. We collected a sample because it looks like it has got some blood in it. Do you want to have a look?''

I cranked the phone in between my neck and shoulder, diverting my attention briefly away from waiting on the line and glanced towards the Nurse, ''Just keep the sample, I'll show it to Dr Lim tomorrow morning during ward round...''

The next morning came, and as I was doing my morning pre-rounds, it was hard not to notice that Mr L looked paler than usual. Almost as white as a sheet. I prodded him awake from his slumber, but there was no usual grumble, complaint or noise.

The Consultant was worried. We were made to check his recent blood results that was taken earlier this morning.

His Hemoglobin had dropped from 10.0 to 5.3 in over a span of 2 days.

He was seriously Anemic. In other words, there was some serious bleeding going on somewhere inside that body that could not be ignored.

An urgent blood transfusion was needed. Stat. Now. 2 pints.

The Consultant ran through a list a possible differentials that could account for this acute blood loss. He was not on any Aspirin or blood-thinning medications, had no chest pain, abdominal pain or constipation, and no past medical history of stomach ulcers either.
My train of thoughts came to a screeching halt. Impulse took over.

''Actually, there was some blood in his stools yesterday.........the nurses spotted it while the patient was passing motion.............''

My voice faltered.

The Consultant's head swivelled towards my direction, chanellling the intensity of her piercing stare towards me.

''Well? So what did you do then?''

''........I...............I...........told them to collect it the sample and store it in bottles......''

''Did you do a PR?''

I felt the colour drain from my face. I knew I could not lie.

Why did I not PR????
Why did not freaking PR?????

I shook my head and stared blankly at the floor, wishing that I could evaporate into thin air and disappear.

''This is not an excuse Michelle. In fact, this is not acceptable.
If we didn't check his bloods this morning, his hemoglobin would have dropped even further and he would probably be exsanguinated to death inside his intestines when we could have stopped in and intervened in the very first place.''

The clarity of the grave seriousness of my mistake hit me like a sudden lash of a stinging whip. I had failed to address something basic as an acute bleed, a common Red Flag that would set off alarm bells ringing. And now the repercussions from that fleeting moment of negligence had placed another person's life in danger.

''I'm sorry........I'm...sorryy...........'' I mumbled a few words of apology, barely comprehensible or audible.

''Get some gloves and do a PR on the patient now.''

If words were not enough, contrition was etched all over my face. The tension that hung heavily in the air was as uncomparable to weight of guilt that was now hanging on my shoulders. I scampered off and donned the gloves, slapped on some gel and proceeded to do a quick Per-rectal exam.

''No hemorrhoids, normal anal sphincter tone''

I paused as I inserted my finger up the patient's back-passage and gave a good dig into what felt like a generous amount of loose slimey mush. I withdrew my trembling finger, and held it up to the Consultant so that she could see.

There was no doubt about it. Fresh dark blood was streaked all over my finger glove.

''Get his consent for a blood transfusion. Watch him closely especially if he starts complaining of chest pain or dizziness. Do not ever do this again, Michelle.''

She paused. Her stern gaze softened unexpectedly. It was odd, but I sensed a slight wave of sympathy from the tone of her voice.

''I've got to finish my exit round, please settle this before you leave.....''

''I'm really really sorry..........''

The words swept past the Consultant's ear as she exited the ward.

I realized that uttering a word of ''Sorry'' is like making a feeble, ill-qualified attempt to pay penitence for a staggering blunder. No matter how many times you apologize over and over again, it is essentially what you do upon realizing your mistake that matters.

1/2 hour later, it is half past 5........
I stared at Mr L from the foot of his bed. He looks comfortably asleep, blissfully unaware of the commotion that had ensued much earlier.

I wonder what his reaction would be when I tell him that I would need to stick another needle into his veins to check blood type for his transfusion.
And what his 2nd reaction would be if when I tell him that I would need to stick another IV cannulae in his other arm because one was not enough.

The perverse truth of Medicine is that the best lessons are learnt, regretably, from the critical mistakes we make during the course of this profession. Because the punishment is harsh for slip-ups and the expectation to make decisions for the patient's best interests are high, every painful humiliating memory of one's cock-ups perpetuates every thought and action such that it is unforgivable for one to repeat the same mistake again when a similar situation arises in the future.

Be warned. For every bleeding/anemic patient I see, I will stick my finger up his arse next time.