A Tale of Three Young Men on a Spring Afternoon

It was one of those rare spring days in the Pacific Northwest that really was like spring, fair skies, warm breezes, and the sun.  It was also a long weekend on-call for me and two fellow medical residents at the Seattle Veterans’ Administration Hospital.  We were inside looking out. 

At that time, nine of the University of Washington second-year residents staffed the Hospital’s Medical Services.  The leader of our training program was Dr Robert Petersdorf, one of the world’s premier teaching physicians.  We considered ourselves to be among the elite.  The patients and nurses did not share that idea.

We each were assigned a service of about 15 patients, and we worked alone, without interns or medical students.  We each had an attending physician who we saw infrequently, usually three times each week for sit down teaching rounds, usually a mini-lecture on a subject within their expertise.  They were subspecialists on the faculty to do research.

During the week we were on long-call every third day for about 33 hours, and then every third weekend for two nights and two days. 

That spring weekend the three of us working on call were all white guys in our late twenties.  There were no women or people of color in the Program.  Our age and skin color is where our similarity ended.  Fred was a devout Adventist from Southern California.  He came from wealth and brought some with him.  He lived in a real house and drove a nice car.  He was perceived to be really smart, but perhaps rigid, in our parlance a tight-ass.  Mac to the contrary was an irreverent iconoclast.  He was forced to wear a necktie, as we all were, but he never really tied his properly.   I suspect his family was wealthy as well, but he did not bring it with him!  He had attended a prep school and an Eastern college and an Ivy League medical school.  I was solidly from Iowa.  There was no chance of bringing wealth with me to Seattle.  My working wife and I shared a small apartment with our toddler daughter.  She drove me to work in our Volkswagen Beetle and picked me up after call.  But, enough whining, I was a bystander to this story.

Setting the stage, most Veterans Hospitals at that time had only a few private and two-bed rooms, and most beds were in rooms of four to eight.  That afternoon, Fred, Mac and I each had a patient in the same four-bed room.  All of the patients were sick, and today would be in an intensive care unit, or at least on a nursing unit surrounded by a team of nurses, respiratory therapists, phlebotomists and others.  These patients had only us—one-on-one. 

Mac admitted a cirrhotic man with a belly full of fluid, and after inserting a large trocar and needle, he had removed bottle after bottle of clear pale-yellow fluid. Working alone, he placed the bottles on the tiled windowsills. 

The hospital rooms were cleanly tiled:  floor, lower walls and window frames.  The window ledges where Mac had placed the bottles were generously wide.  The bottles were clearly labeled, but only as vacuum bottles.  They were designed to help remove fluid from body cavities

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Shortly after Mac had removed the fluid from his patient, Fred was called to the bedside of his patient, who had been found by the nurses to have the sudden onset of confusion and a dangerously low blood pressure.  Suspecting that the patient had an infection with severe sepsis and that shock was at hand, Fred decided to give fluids intravenously.  He needed plasma or serum albumin immediately and saw the bottles on the windowsill.  They looked like serum albumin.  He gave them, first one, and then a second to his patient. 

Either Mac or I returned to the room to find the peritoneal fluid disappearing into the circulation of Fred’s patient.  Mac howled with indignation, and frankly, also with delight.  The dazzlingly self-assured Fred had made a mistake, a medical error.  I stayed back against the tiled wall:  thinking no harm—no foul. 

This was a classic medical error—it was egregious.  However, it went unreported.  Mac and I thought that it was hilarious. Fred was completely humiliated.  Mac was at fault, but Fred was not about to report him.

 

The error was both individual and systematic.  Who let these guys work without supervision?