First big screw up

If you're in the health profession long enough, there will be a time when you realize you could have killed someone, and sometimes there will be a time when you actually do. Luckily, yesterday wasn't a day of the latter, but being one of the former it really shook me up. The infuriating thing was that it wasn't due to operative inexperience, medical ignorance, or even straight up stupidity. It was due to the fact that no one ever really explains all the things you're responsible for doing as a junior resident on neurosurgery. A patient came in and had a head bleed, but the neuro ICU attending accepted the patient, the neurocritical care fellow knew about the patient, and I reviewed the patient's scan and clinical exam findings with him and thus felt the case was staffed. How was I to know that he never even bothered to look at the films, and if he did that he didn't realize that the patient had to go to the OR for emergent surgery. No one ever explained to me that every patient that comes to the ICU attending must also be staffed with a neurosurgery attending. You'd think the ICU attending would tell us what was up and what to do... but no.

The patient had fell earlier that morning and had a cerebellar bleed on CT from an outside hospital. She was awake and talking with no real neurologic deficits, so none of the warning bells went off in my head. The patient was staffed with an attending, seemingly neurologically intact despite her head bleed - nothing to worry about, the ICU team will take care of her in the morning. When my seniors came in the next morning and saw the scans they were a bit upset to say the least. She should have gone to the OR as soon as she hit the floor. I had failed to see that the bleed in cerebellum had began effacing the outflow track of the CSF in her brain, causing ventricles to swell. She was pretty old so I thought maybe she just had atrophy of the brain making her ventricles look big. If I had known we needed to staff all the patients with our team, not just the accepting physician, this would have been caught immediately. We ended up red-lining her (rushing her as an emergent surgery within the hour). She ended up doing just fine... but the obvious alternate scenario still plagues me. What if she had come in earlier and herniated while we waited for the team in the morning? It was only an hour difference, but in neurosurgery even minutes can be the difference between a full recovery and permanent neurologic deficit or death. I got lucky.

They say that good clinical judgment comes with experience, and that experience comes from bad clinical judgment. Lesson learned, no one died... I really got lucky.