Friday, May 28, 2010

After Finishing MOAS

The Final BLOG Question: Dr. Nolen describes various medical errors that are made by surgeons as they learn their craft. Choose one example, describe it and then discuss who is ultimately responsible – the hospital, the Chief Resident, the Attending Surgeon, the Intern?

Post a response by Thursday, June 3rd.


  1. There have been many medical errors described by Dr. Nolen, however one that baffles and blows me away is the error of Ray Hogan. I know this is not really a surgical error, but it is still a medical error and is simply too interesting to ignore. This situation is the one described on pages 236-8; the patient was Mrs. Swan. What happened was that Dr. Frank Jenkins suggested that Ray Hogan obtain feces from a patient at Bellevue and give it (orally) to a patient who was suffering from intense diarrhea. Although this suggestion was completely illogical and insane, Hogan actually went through with it, and gave Mrs. Swan (who was completely unaware of the situation) and glass full of chocolate milk mixed with stool, which had not even been sterilized or made safe. Any person who would do this is completely out of his or her mind, but the fact that Hogan spent hours "giggling" about the controversial treatment shows his immaturity and shows that he is not cut out for the job. Even though Dr. Jenkins was the one who suggested the procedure, anyone in their right would have known that the idea was silly, disgusting, and not sanitary. And, if the resident was somehow tempted enough to do something that stupid, he should at least be smart enough to talk it over with smarter medical personnel, instead of secretively carrying it out like a mischievous, immature child. Anyway, in this case I feel that there is no question that Hogan, the assistance resident, is to blame. There were so many things he could have done other than what he did, and he should have at least talked it over with his superiors first! I feel that it was only right that he was chastised and let go after that year.

  2. Of the many medical errors discussed in "The Making of a Surgeon," the one on page 119 to 122 stands out in my memory as good example of responsibility in surgery gone wrong. Nolen is now an assistant resident, and is in-charge of interns and such. He has to do a tracheotomy on a patient with broken ribs. The patient has a small and thick neck, which makes it more difficult to do this normally easy operation. Nolen was simply assisting the procedure and letting the intern do the dirty work. Unfortunately, he screwed up the actual putting in of the tube into the trachea, and the neck ended up filling with air. Some quick thinking and taking over the surgery from the intern prevented disaster. Now, the interesting thing about this particular case is that the fault was not with the intern who was actually doing the surgery, but with Nolen, who was overseeing the surgery. As a Resident, he was expected to simply help with the operation as the intern needed, but the situation spun out of hand, and he was forced to step in.

  3. I think one of the most profound medical errors mentioned in the book was the terrible failure to psychoanalyze Abe Fredman, the man with intense cancer phobia. Fredman was admitted to Bellevue with blood in his stool, and Nolen suspected it was only hemorrhoids. However, Fredman was soon hysterically depressed with the fear that it was some sort of deadly cancer, so Nolen had no choice but to call the psychiatric department over. Too busy to admit Fredman, the psychiatric examiner prescribed him phenobarbital (an anticonvulsant and sedative drug) and left him alone. The next day, Fredman jumped out the hospital window and committed suicide.

    I think that the most fault in this case lies with the psychiatric ward, but a small amount of fault lies with Nolen. I believe that as assistant resident if he had put more pressure on psych to admit Fredman, a life could have been saved. That said, it's extremely difficult to have a 100% success rate, and often times the dangers of a person's psychological condition can simply go ignored.

  4. I would love to rant about how much the tragedy of Abe Fredman pisses me off, but since Matt already did that, I guess I can't any more.

    One other error Dr. Nolen describes is brain-death of the six-year-old African American. The boy was on the table for a cystic hygroma, but he didn't die from it. What he DID die from was the fact that the anesthesiologist wasn't pumping enough oxygen into his blood.

    This is the kind of error that most upsets me. As Nolen states, it's one of those things that could easily have been corrected with just a little forethought. If EITHER the surgeon or the anesthesiologist had noticed the color of the blood, that kid would most likely have been perfectly fine, as the surgeon managed to correct the cystic hygroma without any problem. Instead he suffered irrevocable brain damage and never woke up.

    The responsibility for this problem lies with both the anesthesiologist and the surgeon. Though the anesthesiologist is the one technically in charge of the pumping of the lungs, Nolen does note that it is a relatively simple action for the surgeon to keep an eye on the color of the blood of the person whose body his hands are currently in. Thus, both men are at fault.

  5. Karli said...

    There are multiple medical errors- anything from losing a sponge/tool inside a person to actually cutting a wrong organ or the like. One of the least common, but most dangerous, is definitely mis-cutting something or letting the blade slip, such as when one intern decided to help and ended up cutting through an organ. The patient could claim the Chief Resident is responsible, because it was he who allowed the person to scrub. But ultimately, it is that person who wielded the scalpel

  6. One of the numerous errors that Dr. Nolen describes to us throughout the course of his anecdote-ridden book occurs in Chapter 10 on pages 119-122. The problem arose during a tracheotomy of a Mr. Anders, a man who had six broken ribs and 4 cracked ones as well. When he was found to be having difficulty breathing, Dr. Nolen and his intern assistant, Bob Knudson, decided to "trache" him (or perform a tracheotomy). Nolen notes that though he had done a few tracheotomies in the past, he was always being supervised and instructed by an assistant resident. Now, however, he was the assistant resident and he needed to show an intern how to do things. Everything was going fine until the tracheotomy tube, a metal hollow metal tube used to remove mucus, got plugged. Upon inspection, it was revealed that the tracheotomy tube had not actually been inserted into the trachea and was instead directing air into the tissues of Mr. Anders' neck. Nolen managed to reposition the tracheotomy tube but not without letting much blood and mucus spurt all over the place, and not to mention scaring the hell out of the patient.
    I chose this error because the person that is responsible for it is not entirely clear. Yes, Dr. Nolen is ostensibly the immediate choice for someone to pin the blame on because it was he who didn't insert the tracheotomy correctly but perhaps this isn't his fault. As mentioned earlier, Dr. Nolen was not taught the proper method for performing a tracheotomy and was never given the opportunity to do one on his own during his internship for this reason, one could place the blame on the assistant residents who failed to teach Nolen the procedure sufficiently so that he would be able to repeat it unassisted in the future.

    ...aaaand I just realized that I did the exact same one as Patrick. -_-'

  7. In the chapter "Blood" Nolen makes a crucial if not understandable mistake when diagnosing a new patient in the hospital. Nolen sees the woman, who appears to be crazy, being carted into the ward and immediately dismisses her as someone who he can treat later. At this point in the book Nolen has already talked about how he doesn't respect the people who pretend to be sick or crazy to get access to the hospital's resources.

    Shortly after the woman is stationed in a room a doctor on the ward comes to Nolen telling him that the woman's symptoms have worsened. Nolen rushes to her room and sees her body going into shock. He and his team rush her into the OR and call for the Chief resident. When the CR arrives he looks at the woman for several seconds and then turns to the other doctors

    "She just needs blood."

    It's amazing that something as little as mistaking a patient going into shock because of a lack of blood as a patient with mild pyscosis could almost cost that patient his or her life.

  8. One medical error that was described in the book was when Nolen and Larry Evenson, chose to operate on a man whom they though had an intestinal obstruction that was a result of previous operations. They took the man into the operating room and began surgery where they soon discovered, after opening him up, that he had paralytic ileus. He had this condition where his bowel simply stops working without anything blocking it and the surgery they had attempted to perform was useless. Since they unnecessarily operated on him, they significantly delayed his healing process. In this case, I would blame Nolen and Evenson because they chose to make hasty decisions without performing the proper prior procedures and tests.

  9. One of the many errors made by Dr. Nolan is described in "Patients and Patience." A homeless man, Larry, often comes into the hospital to enjoy the luxuries of a nice bed and warm meals. He uses the hospital almost like a vacation house.Larry has had many bad ulcers on his leg. Although patients usually do not get hospitalized for ulcers, Larry was hospitalized for a particularly bad case. When his stay was about to end, Larry tore open his wound to exacerbate his condition. He was allowed to stay a few extra days. then, suddenly, things started going really badly for Larry. He complained of a pain unlike the others. Nolan ignored him, thinking that Larry was just trying to get more time in the hospital. After three long, agonizing days, Larry got an x-ray. It turned out he had a broken rib. I would put Dr. Nolan at fault for this because he made a cruel assumption and ignored the needs of his patient.

  10. Mrs. Fleischer was being operated by Dr. John Rankin, and the operation appeared to go over smoothly. However, Dr. Rankin had completely forgotten to remove a sponge, which was revealed by the postoperative x-ray that showed the sponge. The mistake here was Dr. Rankin not being careful enough to properly clean and close up postoperation, which caused her to have another surgery to remove the sponge. Dr. Nolen, posing as a witness, learned a valuable lesson from both Dr. Rankin and Dr. Steele that time isn't as important as a complete job.

    On a tangent, one thing that really intrigued me was the fact that Dr. Nolen mentioned some doctors don't even tell their patients they made a mistake, which dumbfounds me. If a doctor makes an error, he or she should immediately stand up and admit their mistakes, otherwise it costs both the patient and the doctor their time, and conscience. The temptation to lie should never be present in the doctor-patient relation. ever.