You only die once

Chapter 6B A monstrous mistake

Chapter 6B

A monstrous mistake

It was very early in my career. An unforgettable incident happened. There I was, inserting a central line. This is a catheter with three lumens that would be put via the large vein in the neck (jugular) or just below the clavicle (subclavian). The procedure went well. The two nurses assisting cleared up. We did the usual chest X-ray to see the position of the line.

Then HORROR stuck. Like in a horror movie where the monster suddenly appears. The chest X-ray showed a 'monster'. A monster of a mistake that had happened. The unbelievable happened.

I had accidentally left the wire and had not removed it when the central catheter was inserted. (When we insert a catheter, we put a wire into one of the lumens in order to make it more rigid to allow insertion. Imagine if you try to insert a thin hollow hose into a hole the size of your hand while standing three metres away, you will have a hard time. But by putting a rigid wire through the hose, you can easily direct the hose into the hole.) I didn't remove the wire!!! And the X-ray showed the wire. I must have wanted to kick myself a hundred, if not a thousand, times at that moment. I had inserted at least a hundred of these without that happening. In a new working place with high expectations, I fell flat.

I knew what I had to do then. No choice. Declare the mistake, take responsibility, and pay for the 'shit' I had caused. I spoke to the family and informed that a mishap has occurred but without any adverse event to the patient yet. We needed to 'fish' the wire out before any complications developed. Thank goodness my senior colleague came to my rescue and 'fished' it out using a 'basket'-like device with a wire in an angiography procedure. My 'life' was saved. The good news, at least, was the line was in place and could be used. Nothing untoward happened.

As with my encounter with near-electrocution, my folly was not concentrating enough on the procedure. Nowadays before any medical procedure, I try to clear my mind before I proceed. Thank goodness since that incident, no untoward incident like that has occurred again.

Doctors, nurses, and health care personnel are just ordinary people. We are not infallible. Only human. Yet in health care, we have to try never to make mistakes.

There is a difference between an error like this one that I self-created versus perceived error in judgement. Many a time, we have to make decisions based on what we have in front of us. And at times, on reflection or with further information that is later available, we know it is not truly correct. At times, no such information will be available and we will never know if the decision was correct.

Just like doctors treating Covid-19. Who knows what was the correct thing to do? Only as more information is available can we act accordingly and more lives are saved. As we understand why some die, we can save the next. Trying to point fingers at the people who had to act in the beginning in whatever role is easy. But being there and doing the best you could is what we can only do. You can't do more than what you know or deduce.