Not my fault, but my responsibility

At my institution, we have off-service interns from other departments, who rotate through our labor and delivery unit to learn about labor management. During the day, the OB intern is in charge of labor (including primary c-sections during the second part of the year), triage, and postpartum. The upper-level OB resident (PGY-3 or PGY-4) is in charge of the antepartum service, consults, repeat c-sections, and supervising the OB intern. When we have an off-service intern, they help the OB intern with labor, triage, and postpartum.

This creates a bit of an odd dynamic – we are both interns, but by the end of the year, I have spent 6 months on L&D (3 months of days and 3 months of nights), and done close to 200 vaginal deliveries and about 30 c-sections, if you only count c-sections where I was the primary surgeon. This means that, especially as we approach July 1 and the arrival of the new interns, my upper-level residents give me a fair bit of leeway. I am able to work with much less supervision than I did in the fall, because I have more skills and experience.

It also means that my upper-level resident expects me to be supervising the off-service intern. Working with the off-service interns, every month is July. This isn’t an insult. The fact is, though, every time a new off-service intern starts the rotation, it is their first day on the floor as a resident. They finally get the hang of it, and then they move on to a new rotation.

As the OB intern, it’s odd – you’re much more experienced in OB, but you’re both interns. The supervisory relationship also creates a new level of catch-22: things happen that aren’t always your fault, but they are your responsibility. 

I recently had an experience with an off-service resident that illustrated this point perfectly. I was working with an off-service resident who was on the last day of his rotation. He had a pretty good grasp of what was going on. He saw a patient in triage, and signed her out to me. We checked her cervix together, and eventually admitted her for labor. I asked him about her history, and he said she “an uncomplicated Hispanic multip (G2P1001).” Fantastic. I looked over his H&P, glanced at the orders he had entered, and moved on. After all, after 4 weeks of labor and delivery, he ought to be perfectly capable of entering routine labor orders, right?

A few hours later, we were called for her delivery. The delivery itself went according to plan. My chief left the room, and we were getting ready to take off our gowns and start cleaning up when I noticed a trickle of blood. It stops with fundal massage, but after a few more minutes it starts right back up. I give some cytotec and it stops again, but again after a few minutes it picks back up.

I call for methergine and my chief.

The methergine isn’t in the computer. There’s no order. The off-service resident forgot to order it. I ask the nurse to pull it out on override, and she goes to get it. The chief comes, and we end up taking the patient to the OR for an emergency D&C. We start a second IV and start talking to her, through an interpreter, about the possibility of needing a blood transfusion. She calmly tells me that she understands, and that she has already had a blood transfusion.

Wait, what?? She tells me that the same thing happened with her last delivery. She received 2 units of blood. I looked at the off-service resident. He looked like he wanted to disappear into the floor. Instead, he stood in the corner while my chief did her D&C and placed a Bakri balloon in the OR, and I explained to her tearful husband that we were doing everything possible to take care of his wife.

Not my fault, but my responsibility.

This is also a perfect example of that swiss-cheese model that we all love to talk about. What went wrong? Let’s go step by step.

  • I reviewed the off-service resident’s H&P, instead of thoroughly reviewing the patient’s chart. If I had read her initial prenatal visit, or her clinic notes, I would have seen that she had a history of postpartum hemorrhage.
  • I only glanced at the off-service resident’s orders. At the beginning of their rotation, I go through every order, or I sit down with them and watch them put in the orders, so I make sure they order everything necessary. I made the mistake of just quickly glancing over the orders instead of going through them one by one.

Was it my fault that she bled? No. I didn’t give her uterine atony, and I’m not the one who placed the wrong orders. But, as the OB resident in charge of the labor floor, it was my responsibility to take care of her, and I could have done a better job of that. We always say to trust, but verify, and I should done a more thorough job of verifying.

Would it have changed the outcome? Maybe, maybe not. In the end, she lost about 1L of blood, and eventually received 1U of packed red blood cells. I probably couldn’t have prevented her from starting to bleed, but if the orders had been in the computer correctly, her meds would have been available sooner. We would have worked through our hemorrhage algorithm more quickly, and gotten her back to the OR sooner. She probably would have lost less blood. Would it have prevented her from needing a blood transfusion? Maybe.

It wasn’t the off-service resident’s fault, either, to be honest. He didn’t realize that her history of postpartum hemorrhage was important. I shouldn’t have expected him to. He apologized later for not telling me, but that doesn’t take away the fact that it was my job to know everything about her, because she was my patient just as much as she was his patient. Trust but verify. In the end, it was my responsibility, not his, and it still gives me heartburn to think about it.

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