In emergency medicine, no one ever wants to make a mistake. We assume worst first because at any minute a life could be at stake. As a resident, I was no stranger to making some mistakes. I had cases with bad outcomes, yet the impact of the cases seemed to always be shielded by the umbrella of working with another attending. I don’t think I ever appreciated how high the stakes were until my name was the sole one on the chart. My first “miss” as an attending made me understand the gravity of even the smallest decisions I make as a physician.
Explore This IssueACEP Now: Vol 39 – No 10 – October 2020
The patient was a middle-aged woman with a history of chronic pain, fibromyalgia, and bipolar disorder who presented with constipation and abdominal pain. She was over a week out from a laparoscopic appendectomy. Prior to her emergency department arrival, she had an outpatient CT for abdominal pain that was negative and she had met with her surgeon the day prior. She reported three days of constipation, two episodes of nonbloody and nonbilious vomiting, and diffuse abdominal pain. She was taking an oral opioid around the clock for pain. Her last bowel movement was the night prior, and she was tolerating liquids. On exam, she was mildly tender to palpation throughout, and her abdomen was slightly distended. My initial thought was that she was suffering from an opioid-induced ileus. I considered a small bowel obstruction, but she was still passing gas, tolerating oral intake, and having bowel movements. Her exam wasn’t worrisome, and she didn’t have any concerning signs of a deeper infection.
Her labs were reassuring, and she had a kidney, ureter, and bladder test that seemed consistent with an ileus. She remained in the emergency department for some hours and, after a few attempts, still could not have a successful bowel movement. I discharged her home with return precautions. Several hours later, she came back in distress. A subsequent CT scan showed a high-grade obstructed volvulus with perforation and a large amount of intraperitoneal air. She was rushed to the operating and had almost 70 cm of necrotic bowel removed. She had a prolonged and complicated hospital course. She would ultimately survive and leave the hospital, but her life was never the same after.
I was devastated after hearing the news of this case. I kept thinking I shouldn’t have let her go. At that point, I was a year out of residency and had no outcomes like this. My confidence was crushed, and I needed to find a way to rebuild. An attending once told me that I would make more mistakes than I could remember and would be named in at least one lawsuit in the course of my career. I remember being skeptical of this as a resident—more so at the notion of making so many mistakes rather than being sued. Of course, no one can expect a physician to make the right decision 100 percent of the time. To err is to be human, of course.