Adverse Events

Dr. James Duthie FRACS

A year after I graduated, I was working in an emergency department when one of my colleagues killed someone.  A patient had arrived with chest pain, soon proven to be an ST elevation myocardial infarction.  As per protocol, my friend meticulously took a history of risk factors for bleeding before administering a thrombolytic drug. The patient soon suffered a haemorrhagic stroke and died within a few days.

A woman in my area that trained as a doctor also had a similar experience.  As a junior in a different emergency department, she also prescribed an appropriate drug that caused a rare, but fatal side-effect. This woman, however, decided to quit medicine and train as a naturopath instead. Her rationale was that medicine had the potential to cause too much harm, and she could not conscience it.

During many discussions with my friend about the event she forlornly made the weighty statement that she had killed a man. She was startled at my reply: “Yes, you did. You injected the drug that killed him with your own hands. But you did the right thing.” The fact was that if an identical patient presented in the same way on a different day then my friend would be inexcusably negligent if she did not give the same drug. Undoubtedly, for a young person with the most laudable intentions of serving their patients well, feeling responsible for a death or severe injury is very difficult to take. I am not sure that it gets any easier with age, and I do not think that it should. If we ever become immune to the pain of an adverse event, we should find another career. The outcome must be, however, that we capitalise on the incomparable experience we have had from the event and become better doctors. Although agonising to go through, helping a patient through an adverse event is a part of our job, particularly humbling ourselves by referring to a colleague if it is in the patient’s best interest.

I will reveal my bias: I think adverse events are worse for the surgeon than for the physician. If a patient suffers a severe adverse reaction to a drug that is appropriately prescribed, it is terrible, but truly no-one’s fault. Even though surgical complications can happen to any surgeon, there is a sense that if we had done something differently, or simply been ‘better’, things would have been different. There seems to be a unique guilt that comes from causing harm with hands that should heal.

My friend is still practicing and is now a specialist. I admire her courage, then and now, and believe our health system would be worse off had she quit. Frankly, I feel that her counterpart who became a naturopath was cowardly. I acknowledge again the pain of dealing with a fatal outcome that one feels responsible for, but she did not state both sides of the argument. She is absolutely correct that medicine has the potential to cause great harm. She did not acknowledge the enormous potential for good in medicine, when we strive to be accurate and up-to-date, are careful, responsible, and compassionate. We save many more lives than we end. We heal vastly more than we harm. Our communities benefit from our work. This is the reason why we remain confident to carry on after an adverse event; our work is objective, it has proven benefits with real, but finite, risks.

Although she may cause no harm, I suspect the doctor-turned-naturopath must wonder whether she causes any tangible good.

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