- Evaluate the performance of individuals and systems and identify opportunities for improvement.
- Demonstrate an understanding of the role of the student and physician in the improvement of the healthcare delivery system.
- Identify one’s own strengths, weaknesses, and limits;
- Seek and respond appropriately to performance feedback
I was on my third day of night shift on the labor and delivery floor. A familiar set of initials, “SW”, gleamed on the monitors. I opened the hospital course I had written last night to refresh my memory on her case. SW was a patient seen in the high-risk OB clinic due to multiple medical problems. She had a history of tobacco, heroine, and cocaine use, gestational diabetes, asthma, and COPD at 30 years of age. Her substance use meant multiple medical comorbidities would have to be managed during delivery. She would need respiratory monitoring, oxygen supplementation, and imaging around the clock to make sure the baby kept a stable blood supply. The resident scribbled down “PSA” on a crowded page of notes, short for polysubstance abuse patient.
We received a call from the nurse at 11pm for concerning fetal heart tones. When I entered the room, the nurses were crowded around the bedside. Gauging from her exasperated complexion, she was losing stamina quickly. I scrambled to recall what her biggest comorbidities were—COPD, cocaine, diabetes… and something else. With diabetes, she could have shoulder dystocia. With cocaine use, she could have placental abruption. I threw on scrubs and rushed to the bedside. With prolonged labor, we had to keep vigil for heavy bleeding after the delivery.
She gathered her strength, pushed once more, and swiftly delivered a baby boy. In my hands he was pink and healthy appearing, and within a minute of being placed on his mother’s stomach he began to cry. The nurses swaddled and examined the baby, leaving me and the resident to take care of the mother. She laid back exhausted as we removed the placenta and worked to slow down her bleeding. Minutes passed, but the bleeding continued. We saw no lacerations to explain the bleeding and called over the chief resident.
The labor had gone on too long. “Let’s get some methergine here and someone get a shot of hemabate!” she shouted. To the husband, she explained, “We just want to give her some medicine to help stop the bleeding from her uterus.”
Hemabate. It struck me then belatedly that I had written in asthma in the litany of her past medical history. But did I have the right patient? I honestly couldn’t remember in the rush since being called if I had the right patient. Reflexively, I asked the husband if she had asthma. He confirmed.
“Wait then, no hemabate!” the chief yelled. “We can’t use that, it will give her an asthma attack.” She motioned at me to say, “Hey good catch there.”
I was relieved I had remembered the details correctly. On a busy night of complicated deliveries, it was just one small detail. With the recent shift change and the long list of patients, her asthma was overlooked. I like to think that one of the nurses would have picked this up had I not reacted as promptly. Still, I left happy to have made the call at the right time. Crisis averted.
We didn’t make a near mistake for lack of knowledge, but for lack of insight at the appropriate time. With high risk obstetrics, we watched for critical constellations of signs and symptoms over an unpredictable time course. Although the history was written in her chart as a reminder, we had so many patients and unpredictability that the finer details blurred together in our short-term memory. We remembered polysubstance abuse and stopped there. The challenge was to stay attuned to the individual patient, to not think in labels but notice the individual intricacies.
It’s easy to use labels as a shortcut when we’re inundated with problems to fix in a short period of time. Finding care that is best for each patient, however, means breaking out of an industrial, disease-centric mindset. My goal as I work on my assessments and care plans is to not lose sight of human details—small details that don’t fit neatly into frameworks, that distinguish one patient from another I’ve seen in the past. It means staying curious about the uniqueness of our patients.
The other lesson I took away from this was the power of my own voice. During my first two weeks of obstetrics, I was intimidated and shy and tried to not interrupt the hectic workflow. The residents were uncertain if I was shy or disinterested and wrote this as a point for constructive feedback. When I returned two weeks later to start on night shift, I told myself that I would practice speaking up and asking questions, despite feeling out of my depth. Realizing that I was able to make a positive difference for a patient by speaking up at a critical moment was empowering. Although I was worried the residents would be upset with me disrupting care, they responded just the opposite.
Teamwork is crucial for safe and error-limited patient care. In the future, I will remember to speak up when my gut feeling tells me something is not right. And when I’m a resident, I will make time to listen to the medical students so their voices are heard and they’re prepared to respond to critical events.
*Patient identifiers have been changed to protect patient privacy