Shine a Light on Your Worst Mistakes. Or Make a Presentation About Them
I attended the county-wide run review online earlier this year. The case presented by our medical director initially seemed routine: the patient was an older male in assisted living. He had called 9-1-1 with numerous complaints he wished to be evaluated for: vision changes, abdominal pain, dizziness, gait changes and a rash on his hands. He had no facial droop or hemiparesis. He was a challenging historian and struggled to explain when and how, precisely, his vision and walking had changed. His blood sugar was normal, as were the rest of his vitals. Nothing changed in transport. Once at the ER, his more thorough neurologic assessment didn’t raise any alarms. His CT scan without contrast was also unremarkable.
Our medical director paused and specifically invited input. She asked if anyone had anything to say about the case so far. I asked her what in-hospital assessments would typically be done for a patient with a suspected stroke. She said that an MRI and a CT with contrast. I replied then that maybe imaging was indicated but was careful to add that, obviously, I knew this case had more to it. It was being presented at a county-wide run review. If I had simply met this man in the normal course of my shift it is plausible I wouldn’t have identified him as sick.
Then our medical director shared the grand reveal: This was her patient. She was the doctor who had assessed, and then discharged him, from the ER that day. He’d reappeared two days later, now totally unable to walk or speak. He had been sent back to his nursing home with an active cerebellar stroke. He had permanent deficits and would need to be in skilled nursing for the rest of his life. Our medical director had gone incredibly out of her way to share this miss with as many of her subordinates as possible.
My jaw actually dropped when she said this was her patient. She went on to explain: She had submitted the case for review herself. Her initial encounter with him had been towards the end of her shift. He had refused to walk so that his gait could be assessed. In both her experience and my own, patients with so many complaints from unrelated body systems typically don’t have an emergent issue.
Our medical director had always said that it was important to publicly discuss your mistakes. Before her promotion, she had been my department’s medical advisor. She did our ALS run reviews and went out of her to feature not only mishaps but also triumphs, as well as cases that were simply interesting. She would often explore what documented phenomena were a factor in an objectively wrong decision, such as anchoring or sample biases. This is both a more useful and kinder practice than just assuming that any given mistake happened because the provider was foolish and the answer is just to be smarter or better. I always felt like I could explain what I was thinking when I made a choice and be heard out. Or even admit that I had simply forgotten to take the 12-lead on my post ROSC patient, that I had been so diverted by a crashing anaphylactic’s tongue trying to escape her mouth I’d neglected to give her IV Benadryl at any point.
However, despite all the credibility her calm and reasonable style of critique gave her, it’s still one thing to instruct us to share our errors in a small if public meeting at our small, rural fire department. It’s another thing entirely to deliberately assemble scores of fire chiefs, medical service officers, paramedics, and BLS providers to go over your wrong choice with a terrible cost so publicly. Furthermore, a recording was made and it’s preserved, forever available on the server that hosts our learning videos.
It was and remains the greatest show of leadership and humility I’ve ever seen. It genuinely inspired me to go out of my way to shine a light on my own missteps when teaching.
There are, of course, several to choose from. I once gave a man who was having a heart attack multiple injections of epinephrine, believing that his wheezing was anaphylactic. I’ve started an arterial line on an overdose patient—though this was readily recognized and corrected.
In a narrow miss, a patient I declared a stable septic appropriate for BLS transport died while being loaded into the aid car. The minutes that followed were a scramble. I was the only ALS provider present on the call and the three BLS providers present had about 10 months of combined experience. We started compressions and declared a CPR in progress over the radio.
We got ROSC within one minute of chest compressions.
His initial blood pressure following ROSC was in the 60s (down from the 130s prior to his cardiac arrest). I started an epinephrine drip in a 100 mL bag. It raised his blood pressure enough that I could move on to the next crisis: That he had woken up and was gagging on his supraglottic airway. I yanked it out. Despite having been pulseless less than a minute ago, he made eye contact with me and told me he didn’t feel well.
What I forgot was this: we were at the bottom of a winding driveway surrounded by trees and bushes barely wide enough for an ambulance to come one way. When we’d declared a CPR in progress, we’d triggered three more units in the area to come barreling our way to help. We got ROSC, so didn’t need all the extra manpower anymore. All they could do for us was block our exit.
Furthermore, I knew this patient was septic, as the source of his infection was external and couldn’t be missed. Norepinephrine would have been a more appropriate pressor drip, considering his cause of arrest. It would have more directly addressed his vasodilation without putting so much strain on his heart. However, I got stuck in the “ROSC hypotension” algorithm and didn’t consider that.
Beyond that, I understood that we needed to emergently transport him to the hospital for IV antibiotics, infection source control, and central line access. Unfortunately, due to my failure to consider the driveway, we were instead hemmed in by three units that then had to painstakingly back out to release us.
He died again while we were playing Tetris with the rigs. That arrest didn’t last, either, and he awoke in less than four minutes. He returned to being completely alert and oriented. Again, we yanked out the supraglottic airway before he vomited from it.
Finally, we were driving code to the hospital. He had fluids and a pressor flowing. One EMT was dedicated to listening to his heart with a digital stethoscope while simultaneously palpating a carotid pulse. Someone else was swapping the monitor battery and the third person was adjusting the seat belts because he kept sliding down the gurney mattress. I was calling the hospital to give them a heads up about the entire situation.
The EMT monitoring the pulses said, “Hey, it’s really slowing dow … Oh no.”
I looked up at the empty drip bag and realized what happened. I was task saturated and had let the drip run out. His pulse, thankfully, came back immediately after a preload of code epinephrine.
He had two more cardiac arrests in the hospital but recovered every time. He survived with an intact neurologic status and went home as himself to his family.
Ultimately, we did well to deliver him alive.
We—and as both the sole ALS provider and the individual present with tenfold more experience than everyone else combined, I mostly mean me—could have done better. My primary mistake was that my focus was 95% the medicine and only 5 % logistics. An 80/20 split would have served me better.
As I’ve yet to learn to change the past, I can use these moments I still cringe to recall to both learn myself and, perhaps our most sacred calling as experienced EMS providers, teach others.
As a bonus, you don’t lose respect by simply owning it and demonstrating integrity and humility. You will earn credit and respect by openly and repeatedly bringing up things you personally should have done differently as a learning tool. And hopefully I’m teaching providers who are learning from me to do the same when it’s their turn to teach.
