The 6am case!

My nightshifts are always a big adventure. It is the time where I learn the most, where I feel more independent, but also the more dangerous for the patients, by letting a recent graduated alone, responsible for more or less 80 people.

On my 4th shift the nurses paged me at 6am. Someone had fallen at the toilet. After a quick physical examination, my heart rate went down. There were no reasons for alarming (I thought). Relevant was only a small bruise on her head, the fact that she felt dizzy when she got up from the sink and a mild melena. Because within 1 hour, the Consultants would be at the ward, I left further care for their decision.

This patient, a 85 years old grandma came to the hospital because of a biliary colic. She was jaundiced at admission, and an ERCP for the extraction of the stone was performed without complications, but with the need of a papilotomy.

I went home that morning (free day after nightshift) and on the next day I went to the geriatrics ICU, where I have been working for the past weeks. The patient that fell at the toilet was there, she had been admitted at the same morning I examined her.

What went wrong? What did I do wrong? Those were the first questions in mind. I went through her documentation and, for my surprise, there was a fallen in the Hemoglobin concentration from about 140 to 68 g/l, which i missed when I examined her. The near-syncope episode was already a sign of ortostatic hypotension after bleeding.

6am it is a bad time to think and to make decisions, but it was my mistake I didn't check the blood picture of this patient. I could have ordered an acute gastroscopy and save some time and suffering for this woman. Because I didn't take action, the patient had breakfast and the gastroscopy had to be delayed a couple of hours.

Of course the patient improved after two blood units and after cauterization of the bleeding source (the sphincter of Oddi), but the feeling of failing, and the thought that it could have been much worse (a patient that could not wait) almost didn't let me work the next day. One thing is certain, I will not repeat this mistake.