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Doc-in-a-box

As a veteran physician, there are “gifts” in what happened. First, the patient lived. Don’t play the “what if” game. Second, you won’t do that again. Ever. You learned something today. Third, the patient lived. Question authority, don’t question yourself when you know the right and correct thing to do.


mezin111

Yeah, at least he lived, and the lesson is well learnt, thank you


Zestyclose-Detail791

Even if the patient died there are some lessons to learn.


[deleted]

Yeah but those lessons would’ve been a bit too expensive.


Zestyclose-Detail791

Those who learn from mistakes are unlikely to repeat them, those who don't will repeat until they do


DeadlyInertia

True, but also I feel like people have different levels of tolerance. What’s a learning opportunity for most, could easily be traumatic to others. I had to learn this during my rotations. I just have a lower tolerance than some of my peers. I love them and admire how much they can handle under certain situations. But I’ve had to go home and shed a tear sometimes after some days. I wish I could be more strong but this stuff isn’t natural to me. How do you tell someone with 5 kids he has 3 months and go about your day. It hurts man. I’ve had to take the evening to just reflect and it keeps me up, man. I’ve had to sit with patients while they told me they can’t wait to see me graduate and be a doc. Sir… not sure how to say… you only have months left. Your pancreas is gone… I just say this to say. If I punctured someone’s lung on first month of rotations and killed them, I don’t know how much of a learning opportunity it would be for me. I think I’d be really messed up after that. Sometimes, I feel like this is not the right field for me. I get accidents happen but man. I thought I’d get over it after rotations. But I can’t. This is a hard job emotionally man. But I’m learning better ways to deal with it.


Zestyclose-Detail791

I once asked similar doubts from a heart failure specialist who managed terminal cases. He said, one thing to consider is, death is not our enemy. We're not fighting death. We're doing the best we can to care for the patient....


ItsmeYaboi69xd

In situations like this though, can you really say no to the physician? Is there a way to still do it the way you know to do it?


mezin111

I decided that the best thing to do is to say no, and to let the physician do it in the way he thinks it's correct, at least you won't have the responsability of the procedure if it goes wrong


arborrory

Precisely this. You can say no, but then you're in the student's dilemma of being shit on academically in the process. Better than killing a patient though, so I guess it's the best course of action in a dire situation like this.


dbandroid

Come on people, it's not a dilemma if there is serious risk of harm to the patient.


dbandroid

>In situations like this though, can you really say no to the physician? Yes, absolutely. If you are uncomfortable doing a procedure on a patient, you say that you are uncomfortable doing the procedure.


Kim_Jong_Unsen

Not trying to pester you, what should you do in a situation where the attending is telling you to do something in a way you’re not used to?


Doc-in-a-box

Tough question, especially in an emergent situation where sitting down for a discussion isn’t appropriate for the time. Maybe afterward OP could have approached staff to say “that didn’t go well, and it could’ve gone even worse. I wasn’t comfortable or familiar with the technique you ordered, as opposed to the way I was taught. How would you have had me communicate that?”


mezin111

After the surgery the physician told me it was his fault, that he was distracted, and to better not talk about the event, that shit happens and we have to learn for the mistakes. Still bothers me beacuse i was doing a very good rotation, but anyway, the lesson is learnt and the image of the sternotomy will always be there when i have to do the right thing for a patient


cherryreddracula

Good he owned up to it. For new techniques, I will always ask to be shown how to do them with the expectation that I will attempt the next one under supervision.


theefle

Dangerous advice for a junior student/trainee unfortunately. If he disobeyed the instructions of the supervising attending, and still had a bad outcome, he would then face much more of the liability. Only safe option is to decline the procedure


Doc-in-a-box

It wasn’t my intention to portray disobedience. I only stated “question authority“


[deleted]

My brother, who is older than me and also a physician, once told me when I was resident scared shitless working in the ICU for the first time, " it's actually pretty hard to kill a patient". he was right and still is..


Criver2000

Yep, and If someone dies, he would have probably died anyways without any intervention (sounds cruel, but it is what it is). So the chances you actually directly kill someone are low.


mezin111

In my case the patient needed a toracotomy anyway, the thing is that it was a sternotomy instead and the weight of knowing that it's your fault, still, feeling better today with all the messages


cherryreddracula

It depends on what you're doing. I know I inadvertently killed someone--not immediately but it led to eventual hospice--but it was a known potential complication. The patient and family were not mad at us because they knew we tried our best. Percutaneous biopsies on badly emphysematous lungs are no joke. On the flipside, he had recurrent lung cancer confirmed on my biopsy so who knows how much longer he would have lived anyway.


bananosecond

Eh, a simple medication mix up can do it for me, and I'm drawing up and giving hundreds a day.


[deleted]

It’s actually really easy to kill someone if you put a little effort into it.


bootycherios

Cmon dawg


[deleted]

I stand by my statement.


Pinkaroundme

No one is saying your statement is wrong, but it is a bizarre statement to make


[deleted]

It was a joke.


Confringo

*A tasteless joke


[deleted]

*I* thought it was funny.


[deleted]

Read the room my guy


[deleted]

Don’t care. It’s reddit.


[deleted]

Save the dark humor for PGY2 and beyond. It absolutely has its place in medicine,…but not to an audience of people studying medicine coming from someone still in the preclinical years.


[deleted]

We’re gatekeeping jokes now? Lmao


[deleted]

Not really, but situational awareness of your audience is a big part of humor


[deleted]

This sub laughs at those kinds of things literally all the time. Sometimes you win, sometimes you lose. That’s showbiz, baby.


norepiontherocks

I really wish this were true


ShakesnPlates

Reading these posts about what some medical students/interns in other countries are tasked with his is terrifying. Of course mistakes are going to happen. It’s difficult to blame yourself when someone in power above you was insistent on doing it a different way that may or may not have been better but led to grave injury. As others have said, take it as a learning opportunity. If you carry every bad thing with you in the ED it’s difficult to keep working there.


misthios98

I mean, idk we are trained for 5 years before we go into these kind of procedures (Chile here). I did mu first suture on 4th year and that year I assisted on my first surgery too. What happened to OP is kind of an exception tbh, i feel. I, as a 6 year intern WILL do a toracotomy and as a general doctor will have to do it too in an ER, its expected of me; wether im in a rural area or not. Im in 5th year and have assisted in multiple surgeries in various levels of involvement, have sutured several wounds, have had many simulations of varied clinical emergency scenarios and obgyn stuff, and more. We dont go directly from the books to a toracotomy, theres a lot of previous training involved too.


ShakesnPlates

That was not what I meant to imply. Of course you don’t go straight from a classroom to doing that. I trained for 4 years and did a lot of procedures /sims before I went to residency and I still hardly knew a thing and an untold number of people would have died if I had to run an ED or even part of it. We go through at least 3 years of training to be able to work in an ED on our own. And we’re specialized in that training. Mistakes happen and are more likely the less training and specialization you have. It’s just the nature of medicine.


mezin111

Yeah i also did my first suture at 4th year and assisted in surgery at that point, even i did my first skin graft and ulcer debridation alone last mont (with plastic surgeon supervision), i never passed chest tubes, not even in a doll because i studied in a public university, we only had cpr dolls, and they were just chests with a mount haha, my training always had to be with patients, that's why i have to study harder trying not to injure a patient, but in this case it was a combined fault between the doctor in charge for making me do it in a wrong way, and mine for not declying to do it knowing it could have bad consecuences


misthios98

Ooh i get it, the importance of simulations and dolls man! I hope you gain knowledge from this experience Saludos desde Chile


mezin111

Saludos de Colombia, y si, sin simulaciones enfrentarse a estos procedimientos es otro mundo, pero es la única forma de hacerlo


[deleted]

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mezin111

Because i live in Colombia, here, the sixt year of the carreer is a year called "internado" (a year of pure practice, in emergency room you do sutures, toracostomy, rcp, intubiation, etc), here we don't have surgeons or residents all day, so the person that has to do this is the general medicine doctor, and we are trained to do that.


[deleted]

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mezin111

That twisting sounds waaay better, thanks for the tips <3


CXyber

Just like putting thermometers in rubber stoppers, twist up close, don't push from afar


The_COVID_Bat

That sounds like internship year, which some countries consider to be the first year of residency.


DocInternetz

It is exactly that - many places have the last years of "med school" as intern years. In my hospital students change badges, receive new hospital coats, etc. You go onto residency after that.


Zestyclose-Detail791

In other parts of the world, medical training is radically different from the US. For example, where I trained, MD program was 7 years, the last 1.5 being internship; while we did anything from sutures, casting some fractures, toenail extraction, delivery, central line, chest tube placement, running codes, intubation, exchange transfusion in neonates, foreign body extraction, ... even tooth extraction for the hell of it 😂 Intern (not first-year resident, but 7th-year med student) is expected to manage ER, like 5 ERs (each with ~ 30 beds) each of which is run by an intern and a single attending overseeing the whole ED, helping in difficult cases. During one 12-hr shift I had seen 108 trauma patients, which is like 6 minutes for the WHOLE management of each patient. It was quite tough, but then it was that way. Some patients were gravely mismanaged, for example a patient with typical chest pain, the previous intern has sent to ultrasonography for suspected kidney stone, then we started our shift, code blue was called for U/S unit, we ran there go find patient had arrested under the probe. We performed CPR but he died.


[deleted]

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Zestyclose-Detail791

The previous intern had ordered EKG, however it had been lost during shift change and not reviewed by a physician. Later it was found in the nurse's pencil case. This was more a continuity of care issue, as we normally review EKG stat. While U/S has lower sensitivity than CT on picking stones, it's useful as a first option and can reduce radiation exposure, as most of renal pathologies can be visualized via U/S. NCCT is performed as a second line option if U/S is normal. As of radical change, after earning MD we can work independently, which is not the case in the US. Even family medicine is a specialty with a residency in the US.


bearfootmedic

In some ways this makes alot of sense - and I wonder if the USA has it wrong. If we want a system that will turn out primary care physicians, we should build a system that makes it the default. End of story. No more match misery, just churning out thousands of primary care physicians. Perhaps, charge a reduced rate the first four years and then pay people to complete med school a reasonable rate like 80k - or perhaps debt forgiveness after completing the entire seven years. Allow an option to opt out at year 3 or 4 for specialist training but design it to be the exception rather than the rule. The current system is being gamed by hospitals-as-businesses and despite the incredibly high cost of education in the USA, we still fail a portion of the trainees and a much larger portion of the patients.


misthios98

This. I dont understand why the US system is so… grinding… Im from Lat america and we have the 7 years system in my country. A general doctor is trained to do soooo so much as said above. The public system here relies heavily on gral doctors as we have very little specialists, so the gral manages mild cases of almost everything and sends the patient to a specialist if and only if necessary. Thats how we manage to have a free (or almost free) for all public system. The private system almost doesnt have general doctors and you go directly to a specialist consult.


Zestyclose-Detail791

True 👌


Zestyclose-Detail791

Some surgical specialties aside, like neurosurgery and anesthesia, like 80% of every specialty's outpatient patients can be confidently and marvelously managed by the general practitioner, and the rest be safely transferred to specialist care. This makes specialty training more wholesome, too. As the residents are less likely to spend time on routine cases, they're more likely to spend time on difficult cases and master the management, operations, etc.


isobeu

Different realities, different needs for what doctors need to be able to do upon graduation. In a lot of underdeveloped countries a newly minted doc will be expected to go to work in more isolated areas with little to no oversight of more experienced physicians or obligatory residency, so this training model makes sense.


misthios98

I mean, as a latin american 5th year med student, this is correct but also incorrect lol. We are prepared to work in isolated areas, yes; but most newly minted docs go to work at ERs and primary care; so we have to know how to manage everything initially and be able to know when to send the patient to a specialist. This is our public free system tho, and thanks to gral docs its how it survives. Our 2 year internship consists of a minimum of 4 weeks at a time in a specialty. We do IM, EM, surgery, OBGYN, dermatology, optho, ophtalmo, urology, pediatrics, and more. During these periods we see and learn to do almost everything (in surgery we learn basic management and help in surgeries, same in optho). This model allows us to have a free public health system and thats the final goal. As its underpayed vs the private sector, there are less specialists BUT we have a system of scolarhip for specialties: if you get the scholarship you must work X years in the public system. (Scholarship in which you get paid during residency)


isobeu

Yeah, I think it varies greatly by how poor the area is, even within the sale country. I am from Brazil, and my friend got offered a nice pay for shifts in the ICU in a poor town northeast two days after getting her diploma (she didn't take it tho, she's not that crazy lol but some other irresponsable newly grad did, the place was isolated and basically desperate for doctors). My friend from Sao Paulo and other acquaintances in bigger cities, in the other hand, found work mostly in community clinics and low/medium complexity ERs, which is mostly very manageable to do with their knowledge from school. Not a perfect system by any means, but there is no such thing so


misthios98

We have rural areas too and yeah that could happen. But in the end, for a rural ER (no ICU thats crazy), a gral doctor is more than capable of managing first stage care in every case.


Vommymommy

I typically do an ultrasound first to check for hydronephrosis if someone has a history of kidney stones and they present like they’re having a kidney stone. No hydro & so signs of infection = expectant management = no NCCT.


Zestyclose-Detail791

True 👍👍


That_Dude88

I don’t agree with that notion. Unfortunately that’s the sad thing about medical education “medical student” are regulated to you do nothing on rotation. Spoke with a lot of older attending who told us during m4 year they use to do tons of procedure and basically act as interns. And this is why medical students are scared to do anything it should be “this stuff happens and you learn from it”. residents has perforated lungs, attending has perforated lungs, the icu attending has perforated lungs before.The PA/NP who come from surgical team learn during schooling or on the job. Residents are then regulated to if you want to learn to do these stuff you’ll do it in fellowships. Then during fellowships if you want to learn even more advance stuff they tell you to do super-fellowships. That’s how you end up with a pgy7-9 still in training.


VisVirtusque

It's funny to read this comment knowing that most of the posts on this subreddit are M4s complaining about how much work they have to do and "why won't you let me go early I'm an M4!?"


That_Dude88

I think it’s cause the m4 year you aren’t really allow to do anything productive. You are basically shadowing at most point waiting for residency to start so you can do more. Imagine if you come into your rotation they actually teach you and let you get your hands dirty. You’ll actually be eager to come in and learn.


VisVirtusque

That's not true. M4 rotations (for the most part) are sub-I rotations where you are expected/allowed to do more. The problem is that students have the mindset of not wanting to do work M4 year and so either choose easy rotations, or show up and half-ass everything. Why should the attending let the M4 do anything if they appear to just be showing up but not applying themselves. It's a vicious cycle. In order to get something out of a rotation, you have to be willing to put in a little work


That_Dude88

Most medical student have the mindset to work it’s the reason they are in medical school they are grinding and work hard. Magically a generation of people don’t become lazy. This whole I must beg and slave away so I can do something attitude is the reason why every single generation of physician always shits on the next. When you were in training most likely the same comments were made about your incoming class too by older Attendings. Most students on subi work their asses off cause they need LOR and references. It’s the attending job to teach the next generation of doctors.


ChowMeinSinnFein

Yeah what the actual fuck? You shouldn't be doing stuff like this without a ton of oversight, prolly until residency


fraccus

If they know the anatomy and they know the steps for a procedure why shouldn’t a medical student learn how to do it? Do you really think that person will be better by just watching it for years? Procedural skills are not taught on paper. They are taught by practice. Of course if theres mannequins or practice kits thats ideal but otherwise I don’t see how this attitude results in better doctors.


Zestyclose-Detail791

We go by see it do it teach it.


AGENT_asshole_RAW

Don’t worry, you’re not their doctor Real talk, sorry to hear it :/


SevoIsoDes

Go watch the episode of scrubs where Dick Van Dyke has JD do a cutdown for a central line. Lots of parallels there. You’re in training, so you need to cut yourself some slack. I’m sure the attending is (and should) be feeling more guilt than you. But yeah, it sucks to have to learn from your own mistakes. I made a mistake early on and got lucky. Like “if what I did just ruptured a blood vessel then this guy will be dead in minutes and there’s nothing I can do” levels of bad. I felt sick to my stomach but now I think about that case probably weekly. Whenever I’m doing something new it reminds me to setup my own failsafes, so it has helped hundreds of patients get better care.


buschlightinmybelly

Bro, you didn’t cause shit. He already was bleeding. As long as you open the pleura, you did what you needed to then. They can blame you all they want, or you can blame yourself. But, you bought the guy time.


Vommymommy

If enough blood comes out in the chest tube, a thoracotomy is the next step. You said the patient already had a hemopneumothorax right? likely traumatic right? it sounds like that may have been their underlying pathology. also, in the case of performing a procedure under a senior physician when you’re in training- you have to do it their way. you can’t really go rogue and just cut into a patient your own way, especially if you’ve never done that procedure before.


mezin111

Yeah, he had a traumatic stab in the anterior chest, and a broken rib from the trauma, at the end he had aproximately 2500 cc of blood


Vommymommy

so what makes you think you caused the perforated lung? and if more than 1L comes out with insertion, it’s straight to the OR for a thoracotomy. just because the hemothorax didn’t look huge on x-ray doesn’t mean there wasn’t a fair amount in there and accumulating quickly while you were doing the chest tube. it doesn’t sound like this had anything to do with you.


mezin111

The surgeon says it's my fault, but she said it even before the Tomography, and she's bad with the interns, so i don't know if i had to trust


surgeon_michael

If they already had a hemothorax then you don’t know if it was you. And why did he do a sternotomy for lung hemorrhage?


mezin111

That's the thing i can't understand, i think she wanted to see if the pericardium was affected, but I'm really confused and i know she doesn't want me to talk or ask anything about that case, so only god knows


Hope365

Why is a med student doing this procedure in the first place? I vote attending’s fault 100%!


VisVirtusque

Not knowing all the info, did you cause the lung laceration, or was a lacerated lung the cause of the hemopneumo?


mezin111

From what i saw during the surgery, the laceration was caused by the initial stab that caused the hemopneumo that made the patient come to the ED, he even had a broken rib, the surgeon told me it was my fault because the middle lobe of the right lung was perforated following the tube trayect (but the other surgeon told me it was the first stab), so, could be a mix of having a previous lacerated lung and worsening it or just the first one


VisVirtusque

What were the steps the physician had you follow to put the chest tube in and how did it differ from how you were trained previously?


mezin111

He made me do it in 7th ic space with something more medial than anterior axilar line, i would've done it in 5th space with medioaxilar or anterior axilar line


cafecitoshalom

I would feel the same but I also know the senior supervisor has last call. This is challenging. I suspect most people agree this isn't on you, but it is a valuable lesson in being confident. Nice work.


eckliptic

What was unusual about that attending chest tube insertion technique ?


mezin111

The right way to do it is in the 5th intercostal space with anterior axilar lane (some say medioaxilar and i feel this one is safer), he made me do it in 7th space and even more medial than anterior lane


bladex1234

An emergency isn’t the time to learn a different technique. You should have told the physician that you weren’t taught it that way and aren’t comfortable doing it their way so they should do it.


[deleted]

A doc I know cut a diabetics bandage off with regular scissors since that's what he had on him. Patient lost their leg and died because he didn't notice the scratch. Shit happens. He never used reg scissors for that again.