Tuesday, October 1, 2013

Dr. Orthochick: Dilemma

Dr. Hospitalist admits a patient to the hospital with left hip pain. She consults Dr. Dream of orthopedic surgery and Dr. Dream's resident, Dr. Orthochick, diagnoses the patient with a left hip infection. Dr. Dream and Dr. PD operate on the patient the following day. They discover a large amount of pus in the hip and Dr. Antimicrobial of Infectious Diseases is consulted. Dr. Antimicrobial recommends doing a repeat irrigation & debridement of the patient's hip. She wants more cultures to be taken at that time, so she writes orders for the cultures she wants and includes it in her note. She asks the floor nurse to make sure this is done.

The floor nurse calls the ortho resident on call, Dr. Orthochick, to tell her this. Dr. Orthochick says she will tell Dr. Dream and the resident in the case.

Dr. Orthochick tells Dr. PD because he's the one following the patient. Dr. PD writes this in his note as well but he does not tell Dr. Dream.

Dr. Orthochick tells Dr. Schnoz, the resident assigned to the case. She figures that since Dr. Schnoz knows, she doesn't need to tell Dr. Dream.

Dr. Schnoz is late to the case and, as a result, he forgets to tell Dr. Dream.

Dr. Dream did not read the last note written in the chart and, as a result, he does not think he needs cultures.

The circulating nurse in the case did not notice the orders and, as a result, she does not realize that several cultures have been ordered.

Cultures are not obtained during the surgery.

So...who should Dr. Antimicrobial be the most mad at?
A. Dr. Orthochick for not telling the attending
B. PD for not telling the attending
C. Dr. Schnoz for forgetting
D. Dr. Dream for not reading the note
E. The circulating nurse for not reading the orders
F. Herself for not contacting the attending directly and for actually trusting all of us losers
G. The long-suffering ortho resident on call who gets stuck trying to explain all this, who is overworked, underpaid, and already feels kind of bad about the whole thing and really doesn't need a lecture because she is well aware that she messed this one up
H. A and G, who may or may not be the same person.


  1. I think everyone should take a little share of the blame here. No one is completely at fault, but no one is completely innocent either.

  2. Dr. Dream should take some of the responsibility for this. It doesn't seem unreasonable to expect that surgeons should talk to ID (or look at their note) before an OR to drain an infection to find out what samples they want. I'm shocked by the number of times I've seen a patient after an OR and the surgeon hasn't sent a single specimen. It's pus people...culture it!

  3. I don't suppose there is an automatic protocol for any surgery having anything to do with an infection to have cultures taken as a standard operating procedure(no pun intended)?

  4. D, E, and F should be responsible. While verbal information is one thing, there is no excuse for not reading information written in the chart or notes. Also, Dr. Antimicrobial should have ensured herself that the necessary parties were aware of her wishes.

    1. Totally agree with this!

    2. This comment has been removed by the author.

  5. As a circulating nurse, E. The circulating nurse is the ONLY person who is responsible for one patient. Everyone else is juggling several. The reason circulating nurses exist is because human error exists, especially when overworked and overburdened doctors forget or fail to read notes.

  6. - No reason why cultures shouldn't be taken every time. Assuming they aren't...
    - Dr. Schnoz was told, was there and didn't do/say anything. He/she gets prime blame
    - Circulating nurse can't be trusted for anything patient related before or after the OR

  7. Presumably the ID orders were cosigned and hence on the kardex, so there's no reasonable explanation why the circulating nurse was unaware. Dr Dream most certainly should have also been aware. And whoever cosigned those orders should inform the team, including Dr Dream and the assist. So I guess that's Dr Orthochick.