I'm a year 6 medical intern (the equivelant to M3) currently rotating at the internal medicine ward a busy tertiary teaching hospital in a large city. For clarification, 6th year interns in my university take night calls and are basically made to be hospitalists at night. That means we admit the patient, take their history, check their labs, plaxe orders for tests and medications and contact the needed apecialists.
I was doing my morning pre-round on my patients (I am responsible for 6 patients) before the resident arrived and preparing the patients for presebting them at the walking round with the resident.
There was a new case that was admitted yesterday by a fellow intern who was on-call last night. The case was a 59 years old male patient known to have COPD, DM2 that presented with a 3-day history of difficulty breathing, shortness of breath and non-productive coughing. The patient had bilateral crackling on lung auscultation and his chest xray revealed bilateral pulmonary infiltrates and bilateral pleural effusions. His labs revealed an elevated WBC at 10.49 and an elevated CRP at 13.6.
The patient was first seen by the Emergency Medicine resident at the ER, where the patient was made to stay for 4 hours while a bed was made available at the medicine ward. The admission order included Clarithromycin and Ceftriaxone, bronchodilator nebulizers and inhaled corticosteroids and furosemide diuretic. A cardiologist was also supposedly informed about the patient and had put an order for a cardiac ECHO tomorrow.
So, it was clear to me, based on the history recorded by my fellow intern and from the admission order by the EM resident that the patient was suffering from a COPD exacerbation secondary to pneumonia, which is a very common reason for hospital admission during the Winter season.
Fast forward to when I am doing the walking round with the resident and we meet attending physician who admited this patient, a pulmonologist/intensivist. We discussed the patient briefly and the attending remarked that he asked the ER physician yesterday to take a troponin level for the patient, as he suspected he might be having a silent MI. Apparently, this troponin level was not taken for sme reason before the patient was admitted to the medicine ward yesterday. So, I go ahead and order troponin level and continue rounding on the other patients with resident.
A few hours later ( I have no idea why it took so long, probably some nurse decided it wasn't too urgent and decided not to promptly take it), the troponin level returns at a whopping 34 units. An ECG was ordered immediately, which showed HUGE ST-elevations fron V1-V4. The patient was having a major anteroseptal MI. He was immediately taken to to coronagraphy unit, where a proximal LAD total occlusion was detected in addition to an RCA occlusion. Towards the end of the cardiac cathetirization, the patient started to crash and went into cardiac arrest (probably due to cardiogenic shock). We performed CPR and ACLSfor 45 minutes, but to no avail and the patient passed away.
Now, here's the kicker. Upon reviewing his file while writing the mortality report, I discovered that the patient had an ECG done in the ER yesterday before being admitted to the foor and IT FUCKIN HAD THE SAME ST ELEVATIONS AS TODAY'S ECG. The patient was having MI ever since he presented to the ER 24 hours ago, but somehow no one checked his first ECG, not the EM resident, not the intern who admitted him yesterday and not me when I was preparing for the my morning round.
I can't speak for what happened with my colleagues, but for me, I just don't know why I did not take a look at the ECG. Maybe it was because the history and the medical orders on the patient and his lab findings were all pointing towards one thing and I just had tunnel vision. Maybe its because I assumed everyone did their job and the patient was properly triaged at the ER. Maybe it's because I just assumed the intern who admitted the patient yesterday saw it.
I feel very confused. This patient died because of a medical error and I feel was part of that error. I should have made sure to check all the tests that were made and not assume the diagnosis made at the ER and by my colleages was correct. I shouldn't have assumed that this patient was properly triaged and deemed stable to be admitted to the regular floor, because he wasn't. I definitely feel like I did not do my job properly and I am partly to blame for what happened to the patient. I usally do take a quick look at ECGs if they were made, but it never crossed my mind search for this patient's ECG because hisbwhole clinical picture pointed to a COPD exacerbation and a lung infection.
Legally, I can't be put to blame because I'm only a trainee intern, but from a humane POV, I definitely feel like I made an error. It doesn't help that some of my fellow interns are implying that it was my mistake for not seeing the ECG in the morning pre-round. I would really appreciate your insight into the matter and if you could share your experiences. Ultimately, I want to turn this into a learning experience for later on.
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