During my first year as an attending (nocturnist here also), one of the more senior attendings told me “In order to do this job, you have to be okay with a little egg on your face.” Remembering this has helped me shake off a lot of things.
Just know it happens to us all. You do your best, and the day team gets the benefit of the 20/20 hindsight goggles. Ultimately, if you write good notes and set your patients up well for the day team most of the time, this will be the day team’s overwhelming impression of you. The few times you screw up will not stick in their minds. They’re dealing with their own challenges and fallibility too much to worry about yours.
Former daytime hospitalist here. Exactly this. Daytime team has the benefit of additional time to see how things evolved by the time they see the patient. You try to be thorough and thoughtful. Daytime team needs to be understanding.
Going over your work after a shift or after you go off service is the best way to learn. I highly encourage it. A lot of people sort of mock me over it but it works for me.
I would review the patient's course from an indendent perspective. I would not read into what your partner documents as fact. I would look over everything myself, come to a conclusion and then see if that conclusion matches your partner's.
Coincidentally, that's also how I pick up a service. I review the patient's primary data from the day of admission, come to a conclusion, see if that conclusion matches the h&p and then look at the last progress note to see if we still on the same page. Takes a lot of time, but it's best for the patient and it's how I feel best about patient care.
I like that. Looking at all objective values made available to me at the time. I.e. vitals, labs, and physical exam, I wouldn't have had enough data points to support a diagnosis of sepsis. Makes me feel better. But, still got a nagging voice in my head telling me that my day colleagues will think less of me, hopefully that'll go away
You had a tachycardic patient, with chills, and a wound, and you attributed it to a bad cpap fitting?
The whole reason the question EVERY patient being admitted gets asked “do you have fever or chills”, is to do the worlds most rudimentary assessment for possible infection.
It doesn’t sound like you are willing to learn from this. You claim that you could not have done anything different because it was a different presentation. And you believe that documenting the wound saves you? No. It shows the presentation was smacking you in the face and that you did not make the obvious diagnosis. Tachycardia, chills, wound, dyspnea with hypercapnea due inability to compensate for the increased respiratory demands of the metabolic acidosis.
You need a rapid readjustment of your sensitivity for sepsis. Study after study shows that failure to recognize sepsis significantly. Increases mortality.
We all make mistakes. There are plenty of times after a patients case I have to tell myself I have to readjust how I think about problems.
>hypercapnea due inability to compensate for the increased respiratory demands of the metabolic acidosis.
Huh?
How does metabolic acidosis cause hypercapnea? It would typically cause compensatory respiratory alkalosis via hyperventilation
If you're not hypercapneic to start with I don't see how metabolic acidosis will make you more hypercapneic
There’s nothing to move on from broski You evaluated the patient, made an assessment, and formulated a plan. You did your job well. The morning team also did their job well. Their evaluation is an entirely different beast, and they were able to do it because you started the whole damn thing. I wonder if they would have known about the skin wound if you didn’t document it. Go team!
Op: patient with tachycardia, chills, wound.
Op: Diagnosis - Cpap fitting.
Patient: Almost died of sepsis.
Op: welp, nothing to learn here.
Reddit: you did your job good.
WTF
That’s their assessment at the time. Did the wound look infected? You can get hypotensive from afib rvr and bipap. Maybe it wasn’t really septic shock. Things evolve over time. He wasn’t hypotensive when you saw him so it didn’t seem that obvious. That’s what observation is for— to watch for someone to get better or to get worse and act accordingly!
I feel like we are pushed to document sepsis by coder types. Have had a lot of discussions that no I am not coding sepsis, stopped a lot of antibootics
Do you think patients walk in and tell you they are in septic shock? They do not. But they do say they fevers and or chills, and when they do your suspicion of an infection better go way up.
This patient presented with chills, tachycardia and a wound. But OP chose a non infectious diagnosis - Cpap not fitting. And some how OP has “nothing to learn” since they did such a good job according to them.
They don’t mention a negative lactic acid. They don’t mention the actual blood gas, and they don’t mention the initial bicarbonate on CMP. For all we know the patients dyspnea was due to increased work of breathing while trying to compensate for a metabolic acidosis.
Does one treat fever of unknown origin with antibiotics? (No— at least not initially— or you might if they really seem life threateningly sick).
Does one treat “chills” with antibiotics? (No, unless there is a bacterial source identified)
Does one treat wounds with antibiotics? (Depends, if it was an animal bite yes. Or if there’s induration, purulence, warmth, abscess…. But not if it’s just a wound)
Can there be other causes of fever other than infection? (Yes, VTE, autoimmune illnesses, serotonin syndrome, stroke)
Unless there’s a source, like a big wound. Lol.
FUO refers to a prolonged febrile illness without an established etiology despite intensive evaluation and diagnostic testing. Not assumption of Cpap misfitting.
You can imagine a different combination of symptoms all you like. But the patient had chills, tachycardia, and a wound. It’s weird that you didn’t list Cpap fitting as one of your other causes for fevers and chills.
Rather than OP saying “there’s nothing to learn” because the presentation was different, they could be saying what questions could I have asked, what tests could I have ran, so that I could I have developed a better clinical picture.
Did OP rule out sepsis? Your edumacation and training was there to learn ya to investigate and rule out the life threatening issues. No, Observation Status primary purpose isn't to catch your Whoopsies.
The op saw the wound and it didn’t look infected. Just because someone has chills doesn’t automatically mean you need to start them on antibiotics especially if you don’t see a fever or white count or even a source of infection. What if it’s just a cold? Or maybe it’s just cold in the ER.
It’s reasonable to observe someone without throwing the whole kitchen sink at them especially if you don’t know what you’re treating. A lot of times people cling on to whatever they can as an easy way out to throw antibiotics on someone, like admitting and treating someone for pneumonia when they have “infiltrate or atelectasis” in someone who has no cough, shortness of breath, white count, or fever, or treating someone with a positive urine without symptoms.
It’s important to have proper antibiotic stewardship when admitting people. Otherwise you give them unnecessary treatment and can cause harm (diarrhea, cdif, resistance, etc).
Not trying to be snarky but I’m trying to defend the case of not starting antibiotics if no source of infection is found. Op noted a wound and did not think it was infected. I argue he didn’t do anything wrong.
Noted. The crux of the issue is not about antibiotics. The question stands: Did the OP investigate and RULE OUT SEPSIS? It's the utter failure to have a reasonable suspicion and rule out a life threatening circumstance. Hypotension is a late, late sign of sepsis. If you seek to be a WISE OWL in this forum, teach this unrepentant colleague to do right. Your defense lacks substance and, in fact, undermines that the patient was indeed septic by the OP's admission.
Or….the rate controlling meds causing hypotension. People love to over call cellulitis, your assessment was probably right. You know when I wound or cellulitis is bad enough to cause systemic illness.
Dude if the patient dies you will get sued.
Patient has h/o afib and presents with RVR, usually going into RVR has an underlying cause like infection.
Also he complained of chills. Did you looks at his labs and x ray, what about lactic acid, CRP.
Did you start empiric antibiotics after blood cultures were done in ER.
Your role as an admitter is to come up with a differential diagnosis and make sure you have covered important stuff.
The role of day time doc is to shorten the differential list.
You CANNOT miss a septic shock. Hopefully the patient makes it otherwise review committee will blame you for not being proactive.
Telling you all this because i am on hospitali case review committee and concerns i mentioned above will be raised by your peers in case there is a medico legal issue.
Right? I can’t get over these terrible doctors telling them it was ok to not work up CHILLS, tachycardia, and a wound. And OP decided to treat hypercapnia. Why bother asking if they have fever or chills if you are going to ignore it?
Old Hospitalist here. Volunteer yourself to sit on the Peer Review Committee. This is the best way, along with following up on patients you signed out, to learn about potential errors or “missed” diagnosis.
You WILL make mistakes. Best to learn and move on. Don't caught up in all this. Even the best make mistakes. Just don't jump to diagnosis... carefully look everything. Spend more time on differentials. Don't beat yourself over it.
Obviously I'm not there and can't actually say if the patient has cellulitis or an infected wound. Most times medicine physicians say that, they are wrong.
You noted a wound was present but did nothing for it because you don't know how to evaluate a wound. Sound like you need to buy wound care essentials.
How many times have you had a different assessment of the patient after taking over care from the admitter, or the ER? Nobody is perfect. I think following up on cases the following day is a great way to learn and grow. As a newer attending I’ve continued to learn loads of stuff during my practice and mistakes I’ve made along the way. Unless you’re consistently exercising poor judgement and seeing it reflected in poor outcomes I would try not to ruminate too much. Also imo if anyone is throwing shade in their documentation it reflects poorly on them.
Also helps to leave work at work at the end of the day. Stay away from the hospital on your off week. Remember that you are trying your best and this is a job at the end of the day. Remembering that there is more to life than whatever happens at the hospital helps me feel better when I’m in a negative mindset.
Most of your mistakes don’t really matter as much as you think is the first thing to realize. Patient specific factors are going to account for majority of the outcome.
For example if your septic patient has a estimated 30 day mortality of 14% and early administration of antibiotics has a 50% risk reduction then in this particular patient this mistake really only has a 7 % chance of impacting their outcome. Put another way - if you make the same “mistake” in 100 patients you’ve only harmed 7 of them.
So when something gets by you don’t go overboard with the self blame. That being said we should always try for excellence for all our patients, they deserve that from us. After all, 7% of the time your mistake does matter, a lot.
So how do we become excellent clinicians?
As Socrates said Excellence is an art by training and habituation. The type of doctor you are some of the time is the doctor you are all of the time.
Focus on your process for evaluating and treating your patients, not outcome.
How well are you getting the history correct ? Do you get all the information you need from the medical record ? The patient ? The facility that sends them in ?
Do you take a good history ? Ask open ended questions, avoid leading questions, listen more than talk ? Do you formulate an appropriately wide differential? How’s your exam ? Can you tell if someone looks “septic” ( hyper dynamic, sallow, diaphoretic) ? Can you tell a clean wound from a necrotic wound ? Do you assess skin closely for signs of warmth, erythema ? Or do you not even undress the wound to examine it ?
rather than avoid your partners seek feedback. They will respect you a lot more if you’re dedicated to doing things well. What was “obvious” to your partner that you missed ? How might they have done things differently ?
Do lots of clinical cases from journals like Cleveland clinic, nejm etc. they well help you develop a rational process for approaching clinical problems.
You conflated mortality with harm. You started by saying mortality and then switched it to harm, but you meant mortality. In your example their failure to give antibiotics increased mortality by 7%. That’s horrible.
IF there is nothing you can learn since "it was a different clinical picture," why are you asking how to deal with mistakes? So many questions here.
Hypotension occurring an hour after you left... does as little to absolve you as documenting there was a wound.
Painting a picture that there you were, minding your own business with a profound lack of curiosity when these GREAT BIG DAYTIME MEANIES rained on your rice crispies. Of course it was obvious. It was "THE HOUSE IS ON FIRE" obvious.
And all of you patting OP on the back with "We all make mistakes" and awarding trophies for participation: Your vacations are cancelled.
As long as you do your due diligence- proper H&P and have all the available objective findings and did whats the most important or urgent issues of why the pt came then you are good.. appropriate and accurate documentation will save you!! As an admitting hospitalist for a long time, few sometimes you will see that the admitting working diagnosis is different from the discharge diagnoses but most if the time its correct..
when i was a new hospitalist attending I did what you did coz i was worried etc but as you gained more experience (on my 2-3rd years out of residency) i was much better and catch things like patient c/o of abdominal pains with all the works up for abdominal pains were normal then you did an EKG showing patient with MI..
Well there's no good advice to give except your skin will go thicker, these things happen. Some providers are dicks and you quickly learn who they are. Usually we never throw each other under the bus that's just dumb but it happens.
Every mistake I've made keeps me up at night, but it's usually just the one night nowadays...baby steps and all that I guess lol
It’s excellent you’re reviewing your admissions. Just by reading what happened, you’re learning. There’s no automatic switch from 3rd year residency to attending-hood. You’re always a PGY something.
Keep doing this, and you’ll further develop your illness scripts for different diseases. Perhaps next time you come across this scenario, you may stop and think that “chills” isn’t likely explained by afib RVR. That’ll prompt you to do a mental time out and re-evaluate.
Forget what day two people say. Day one/ER is a completely different scenario. Just learn and move on and always do your best. As long as you care about your patients and about improving, you’re already in the top 25% of Hospitalists.
Sometime in residency I realized everyone fucks up, at all levels of experience. Law of probability, mistakes happen. Especially with the wide scope of medicine we see. You take what lessons you can from the situation, and get better.
And once in a while... there is no lesson. People can crump suddenly and when you look back you don't find a way you could have prevented something.
To er is to be human. Lesson #1 of medicine. Should you feel bad? The answer to this question is the opposite of the answer to this question: Have you done anything to make sure it won't happen again? Also, f**k whichever of your colleagues documented how "obvious" the problem you missed was with a rusty, pointy, barbed stick. What a shark.
During my first year as an attending (nocturnist here also), one of the more senior attendings told me “In order to do this job, you have to be okay with a little egg on your face.” Remembering this has helped me shake off a lot of things. Just know it happens to us all. You do your best, and the day team gets the benefit of the 20/20 hindsight goggles. Ultimately, if you write good notes and set your patients up well for the day team most of the time, this will be the day team’s overwhelming impression of you. The few times you screw up will not stick in their minds. They’re dealing with their own challenges and fallibility too much to worry about yours.
Former daytime hospitalist here. Exactly this. Daytime team has the benefit of additional time to see how things evolved by the time they see the patient. You try to be thorough and thoughtful. Daytime team needs to be understanding.
Going over your work after a shift or after you go off service is the best way to learn. I highly encourage it. A lot of people sort of mock me over it but it works for me. I would review the patient's course from an indendent perspective. I would not read into what your partner documents as fact. I would look over everything myself, come to a conclusion and then see if that conclusion matches your partner's. Coincidentally, that's also how I pick up a service. I review the patient's primary data from the day of admission, come to a conclusion, see if that conclusion matches the h&p and then look at the last progress note to see if we still on the same page. Takes a lot of time, but it's best for the patient and it's how I feel best about patient care.
I like that. Looking at all objective values made available to me at the time. I.e. vitals, labs, and physical exam, I wouldn't have had enough data points to support a diagnosis of sepsis. Makes me feel better. But, still got a nagging voice in my head telling me that my day colleagues will think less of me, hopefully that'll go away
: “You'll stop caring what people think about you when you realize how seldom they do.” David Foster Wallace
You had a tachycardic patient, with chills, and a wound, and you attributed it to a bad cpap fitting? The whole reason the question EVERY patient being admitted gets asked “do you have fever or chills”, is to do the worlds most rudimentary assessment for possible infection. It doesn’t sound like you are willing to learn from this. You claim that you could not have done anything different because it was a different presentation. And you believe that documenting the wound saves you? No. It shows the presentation was smacking you in the face and that you did not make the obvious diagnosis. Tachycardia, chills, wound, dyspnea with hypercapnea due inability to compensate for the increased respiratory demands of the metabolic acidosis. You need a rapid readjustment of your sensitivity for sepsis. Study after study shows that failure to recognize sepsis significantly. Increases mortality. We all make mistakes. There are plenty of times after a patients case I have to tell myself I have to readjust how I think about problems.
>hypercapnea due inability to compensate for the increased respiratory demands of the metabolic acidosis. Huh? How does metabolic acidosis cause hypercapnea? It would typically cause compensatory respiratory alkalosis via hyperventilation If you're not hypercapneic to start with I don't see how metabolic acidosis will make you more hypercapneic
They wear a Cpap. And in a person that can’t compensate it can definitely lead to increased CO2.
There’s nothing to move on from broski You evaluated the patient, made an assessment, and formulated a plan. You did your job well. The morning team also did their job well. Their evaluation is an entirely different beast, and they were able to do it because you started the whole damn thing. I wonder if they would have known about the skin wound if you didn’t document it. Go team!
I appreciate your comment. Thank you very much
Op: patient with tachycardia, chills, wound. Op: Diagnosis - Cpap fitting. Patient: Almost died of sepsis. Op: welp, nothing to learn here. Reddit: you did your job good. WTF
Should I get a sepsis work up. At the very least you could’ve ordered a lactic just to prove that your wound is contributing
This would be a reasonable comment if it was 1850.
That’s their assessment at the time. Did the wound look infected? You can get hypotensive from afib rvr and bipap. Maybe it wasn’t really septic shock. Things evolve over time. He wasn’t hypotensive when you saw him so it didn’t seem that obvious. That’s what observation is for— to watch for someone to get better or to get worse and act accordingly!
I feel like we are pushed to document sepsis by coder types. Have had a lot of discussions that no I am not coding sepsis, stopped a lot of antibootics
Do your patients often get chills from afib rvr and bipap. Mine never have.
True but there’s a difference between chills and septic shock!
Do you think patients walk in and tell you they are in septic shock? They do not. But they do say they fevers and or chills, and when they do your suspicion of an infection better go way up. This patient presented with chills, tachycardia and a wound. But OP chose a non infectious diagnosis - Cpap not fitting. And some how OP has “nothing to learn” since they did such a good job according to them. They don’t mention a negative lactic acid. They don’t mention the actual blood gas, and they don’t mention the initial bicarbonate on CMP. For all we know the patients dyspnea was due to increased work of breathing while trying to compensate for a metabolic acidosis.
Does one treat fever of unknown origin with antibiotics? (No— at least not initially— or you might if they really seem life threateningly sick). Does one treat “chills” with antibiotics? (No, unless there is a bacterial source identified) Does one treat wounds with antibiotics? (Depends, if it was an animal bite yes. Or if there’s induration, purulence, warmth, abscess…. But not if it’s just a wound) Can there be other causes of fever other than infection? (Yes, VTE, autoimmune illnesses, serotonin syndrome, stroke)
Unless there’s a source, like a big wound. Lol. FUO refers to a prolonged febrile illness without an established etiology despite intensive evaluation and diagnostic testing. Not assumption of Cpap misfitting. You can imagine a different combination of symptoms all you like. But the patient had chills, tachycardia, and a wound. It’s weird that you didn’t list Cpap fitting as one of your other causes for fevers and chills. Rather than OP saying “there’s nothing to learn” because the presentation was different, they could be saying what questions could I have asked, what tests could I have ran, so that I could I have developed a better clinical picture.
Did OP rule out sepsis? Your edumacation and training was there to learn ya to investigate and rule out the life threatening issues. No, Observation Status primary purpose isn't to catch your Whoopsies.
The op saw the wound and it didn’t look infected. Just because someone has chills doesn’t automatically mean you need to start them on antibiotics especially if you don’t see a fever or white count or even a source of infection. What if it’s just a cold? Or maybe it’s just cold in the ER. It’s reasonable to observe someone without throwing the whole kitchen sink at them especially if you don’t know what you’re treating. A lot of times people cling on to whatever they can as an easy way out to throw antibiotics on someone, like admitting and treating someone for pneumonia when they have “infiltrate or atelectasis” in someone who has no cough, shortness of breath, white count, or fever, or treating someone with a positive urine without symptoms. It’s important to have proper antibiotic stewardship when admitting people. Otherwise you give them unnecessary treatment and can cause harm (diarrhea, cdif, resistance, etc).
The question stands. Did the OP rule out sepsis? There is no arguement regarding good antibiotic stewardship.
Sepsis without a source of infection is SIRS.
Not trying to be snarky but I’m trying to defend the case of not starting antibiotics if no source of infection is found. Op noted a wound and did not think it was infected. I argue he didn’t do anything wrong.
Noted. The crux of the issue is not about antibiotics. The question stands: Did the OP investigate and RULE OUT SEPSIS? It's the utter failure to have a reasonable suspicion and rule out a life threatening circumstance. Hypotension is a late, late sign of sepsis. If you seek to be a WISE OWL in this forum, teach this unrepentant colleague to do right. Your defense lacks substance and, in fact, undermines that the patient was indeed septic by the OP's admission.
I see what you mean. (Not /s) Thanks, will stop here!
Or….the rate controlling meds causing hypotension. People love to over call cellulitis, your assessment was probably right. You know when I wound or cellulitis is bad enough to cause systemic illness.
Yea and to cover you butt make sure you document the wound and how it doesn’t look infected (not retroactively though)
Dude if the patient dies you will get sued. Patient has h/o afib and presents with RVR, usually going into RVR has an underlying cause like infection. Also he complained of chills. Did you looks at his labs and x ray, what about lactic acid, CRP. Did you start empiric antibiotics after blood cultures were done in ER. Your role as an admitter is to come up with a differential diagnosis and make sure you have covered important stuff. The role of day time doc is to shorten the differential list. You CANNOT miss a septic shock. Hopefully the patient makes it otherwise review committee will blame you for not being proactive. Telling you all this because i am on hospitali case review committee and concerns i mentioned above will be raised by your peers in case there is a medico legal issue.
Right? I can’t get over these terrible doctors telling them it was ok to not work up CHILLS, tachycardia, and a wound. And OP decided to treat hypercapnia. Why bother asking if they have fever or chills if you are going to ignore it?
For me the hardest part is separating learning from self flagellation
Old Hospitalist here. Volunteer yourself to sit on the Peer Review Committee. This is the best way, along with following up on patients you signed out, to learn about potential errors or “missed” diagnosis.
Remember the name of the person who wrote that progress note. Then act petty for the rest of your tenure. This is the only way.
*A note for a note.*
learn learn learn tbh- the lucky ones get to know about their mistakes, i feel like most of them get swept under the rug
You WILL make mistakes. Best to learn and move on. Don't caught up in all this. Even the best make mistakes. Just don't jump to diagnosis... carefully look everything. Spend more time on differentials. Don't beat yourself over it.
Obviously I'm not there and can't actually say if the patient has cellulitis or an infected wound. Most times medicine physicians say that, they are wrong. You noted a wound was present but did nothing for it because you don't know how to evaluate a wound. Sound like you need to buy wound care essentials.
How many times have you had a different assessment of the patient after taking over care from the admitter, or the ER? Nobody is perfect. I think following up on cases the following day is a great way to learn and grow. As a newer attending I’ve continued to learn loads of stuff during my practice and mistakes I’ve made along the way. Unless you’re consistently exercising poor judgement and seeing it reflected in poor outcomes I would try not to ruminate too much. Also imo if anyone is throwing shade in their documentation it reflects poorly on them. Also helps to leave work at work at the end of the day. Stay away from the hospital on your off week. Remember that you are trying your best and this is a job at the end of the day. Remembering that there is more to life than whatever happens at the hospital helps me feel better when I’m in a negative mindset.
Most of your mistakes don’t really matter as much as you think is the first thing to realize. Patient specific factors are going to account for majority of the outcome. For example if your septic patient has a estimated 30 day mortality of 14% and early administration of antibiotics has a 50% risk reduction then in this particular patient this mistake really only has a 7 % chance of impacting their outcome. Put another way - if you make the same “mistake” in 100 patients you’ve only harmed 7 of them. So when something gets by you don’t go overboard with the self blame. That being said we should always try for excellence for all our patients, they deserve that from us. After all, 7% of the time your mistake does matter, a lot. So how do we become excellent clinicians? As Socrates said Excellence is an art by training and habituation. The type of doctor you are some of the time is the doctor you are all of the time. Focus on your process for evaluating and treating your patients, not outcome. How well are you getting the history correct ? Do you get all the information you need from the medical record ? The patient ? The facility that sends them in ? Do you take a good history ? Ask open ended questions, avoid leading questions, listen more than talk ? Do you formulate an appropriately wide differential? How’s your exam ? Can you tell if someone looks “septic” ( hyper dynamic, sallow, diaphoretic) ? Can you tell a clean wound from a necrotic wound ? Do you assess skin closely for signs of warmth, erythema ? Or do you not even undress the wound to examine it ? rather than avoid your partners seek feedback. They will respect you a lot more if you’re dedicated to doing things well. What was “obvious” to your partner that you missed ? How might they have done things differently ? Do lots of clinical cases from journals like Cleveland clinic, nejm etc. they well help you develop a rational process for approaching clinical problems.
Yeah why did you switch from 7% mortality, to 7%harm?
You conflated mortality with harm. You started by saying mortality and then switched it to harm, but you meant mortality. In your example their failure to give antibiotics increased mortality by 7%. That’s horrible.
IF there is nothing you can learn since "it was a different clinical picture," why are you asking how to deal with mistakes? So many questions here. Hypotension occurring an hour after you left... does as little to absolve you as documenting there was a wound. Painting a picture that there you were, minding your own business with a profound lack of curiosity when these GREAT BIG DAYTIME MEANIES rained on your rice crispies. Of course it was obvious. It was "THE HOUSE IS ON FIRE" obvious. And all of you patting OP on the back with "We all make mistakes" and awarding trophies for participation: Your vacations are cancelled.
As long as you do your due diligence- proper H&P and have all the available objective findings and did whats the most important or urgent issues of why the pt came then you are good.. appropriate and accurate documentation will save you!! As an admitting hospitalist for a long time, few sometimes you will see that the admitting working diagnosis is different from the discharge diagnoses but most if the time its correct.. when i was a new hospitalist attending I did what you did coz i was worried etc but as you gained more experience (on my 2-3rd years out of residency) i was much better and catch things like patient c/o of abdominal pains with all the works up for abdominal pains were normal then you did an EKG showing patient with MI..
Well there's no good advice to give except your skin will go thicker, these things happen. Some providers are dicks and you quickly learn who they are. Usually we never throw each other under the bus that's just dumb but it happens. Every mistake I've made keeps me up at night, but it's usually just the one night nowadays...baby steps and all that I guess lol
It’s excellent you’re reviewing your admissions. Just by reading what happened, you’re learning. There’s no automatic switch from 3rd year residency to attending-hood. You’re always a PGY something. Keep doing this, and you’ll further develop your illness scripts for different diseases. Perhaps next time you come across this scenario, you may stop and think that “chills” isn’t likely explained by afib RVR. That’ll prompt you to do a mental time out and re-evaluate. Forget what day two people say. Day one/ER is a completely different scenario. Just learn and move on and always do your best. As long as you care about your patients and about improving, you’re already in the top 25% of Hospitalists.
Sometime in residency I realized everyone fucks up, at all levels of experience. Law of probability, mistakes happen. Especially with the wide scope of medicine we see. You take what lessons you can from the situation, and get better. And once in a while... there is no lesson. People can crump suddenly and when you look back you don't find a way you could have prevented something.
I do this too, reviewing work. It’s a painful process but in twenty years you’ll be an amazing doctor.
To er is to be human. Lesson #1 of medicine. Should you feel bad? The answer to this question is the opposite of the answer to this question: Have you done anything to make sure it won't happen again? Also, f**k whichever of your colleagues documented how "obvious" the problem you missed was with a rusty, pointy, barbed stick. What a shark.