The Case of the Internal Jugular Line
Last week, I received a page. It was not an ordinary page – not like the other million and one pages that I normally receive from nurses asking for Tylenol or from my students giving me an update on their patients. The extension that appeared on the tiny LCD screen of my Motorola pager indicated that somebody was paging me from the sixth floor, where all the offices of the administrators and attending physicians are housed. My heart skipped a beat. I braced myself and dialed the extension.
“This is Dr. Lee, I was paged,” was my automatic greeting. I immediately recognized the voice of one of my attendings from General Surgery. At that moment, a myriad thoughts flashed quickly through my mind: “I’m on Pediatrics now . . . Why is he calling me? Did I do something wrong? Am I in trouble? Did I violate my work hours by going over eighty hours per week? What could he possibly want?”
He began the conversation by firing a series of questions at me. With his characteristic southern drawl, he asked, “First, I just wanna ask you, were you on call for Trauma on September 29?”
I replied, “If my name was on the schedule for that day, then, yes, I was on call for Trauma on September 29.”
Without skipping a beat he asked, “Then, the next thing I wanna ask you is, do you remember if there was anything special or different about that day? I ask because there was a particular progress note with only my signature on it by the student’s note, but there was no intern or senior resident signature. Do you remember if on that particular day the senior resident was not present or if I happened to round with just the students or if there was anything else unusual about that day?”
I answered, “I honestly do not remember if there was anything unusual. I do know that a resident does not always sign the progress notes, but that does not necessarily mean that we were not present.”
He then asked, “And the next thing I wanna ask you is, do you remember a lady with an arm amputation and a C2 fracture?”
I replied, “There were actually several arm amputations that I took care of on Trauma Surgery that month, so can’t for sure say that I remember that lady in particular.”
My attending proceeded to tell me, “Well, the problem is that that patient died. And she was apparently discharged with a central line still in her neck. And she was also discharged after being on IV morphine here in the hospital without being switched over to oral medications. ” He continued, “Do residents on the SICU generally let you know when they are downgrading a patient to the floor if there is a central line in place in that patient?”
I answered, “No, they don’t.”
“Or are you aware of a policy somewhere stating that that piece of information should be relayed?”
“No, sir, I am not aware of such a policy.”
“And aren’t patients usually converted over from IV morphine to oral pain medications to see if they can tolerate it before they are discharged home?
“Yes, they are.”
The attending continued, “I am not in any way trying to say that you are at fault or did anything wrong in this case. I am simply trying to get a better understanding of what happened on that day. If you think of anything or have any more information after you take a look at the chart, call extension 01055. Anything you think of might be helpful in this situation.”
I replied, “Thank you for informing me of this situation. I will try to review my personal records as well as the chart to see if I can think of anything.”
“Thank you, Dr. Lee. Bye.”
Thoroughly confused and somewhat taken aback, I hung up the phone. A few days later, as I reviewed the chart and spoke with the administrative assistant who was investigating the case, I realized what had happened. The patient had been recently downgraded from the SICU to the Trauma service a few days before her discharge, and she still had an IJ line (central line in the internal jugular vein) in place under her C-collar (neck brace) at the time. My co-intern was assigned to this patient, but on that Friday, September 29, a new intern came on service and inherited the patient that day. She was discharged with her IJ line still in place. Later that evening at a motel, her husband noticed that she had something dangling from her neck, and so he brought her back to the hospital. At that time, it seems that they asked for some oral medications, and someone apparently prescribed her MS Contin in a dose that was three times what she had been taking at home for chronic pain. The mystery lies in who prescribed the MS Contin; the handwriting is clearly different from that on the discharge paperwork, and there is no documentation anywhere in the chart of anyone having given it to the patient. My question: could the night float intern have prescribed that when the couple returned to the hospital for the IJ removal? Only time will tell.
Anyways, after her discharge (I do not know how long afterwards), the patient subsequently went into respiratory failure. At first it was feared that it may have been a complication of having been given too large a dose of narcotics. Although the cause of death remains unknown, administrative secretary stated that the respiratory distress clinically fit the picture of a pulmonary embolism. The patient was taken to a nearby hospital, where she eventually died. And now the disgruntled husband is planning to sue.
What a disaster. Every surgeon's nightmare. I am just thankful that I was not the one who wrote those discharge orders (or any orders on the patient during her hospital stay, for that matter). I would just as soon stay out of trouble with the law this early in my medical career.
And I have learned my lesson always to check for central lines before I discharge my patients home.
“This is Dr. Lee, I was paged,” was my automatic greeting. I immediately recognized the voice of one of my attendings from General Surgery. At that moment, a myriad thoughts flashed quickly through my mind: “I’m on Pediatrics now . . . Why is he calling me? Did I do something wrong? Am I in trouble? Did I violate my work hours by going over eighty hours per week? What could he possibly want?”
He began the conversation by firing a series of questions at me. With his characteristic southern drawl, he asked, “First, I just wanna ask you, were you on call for Trauma on September 29?”
I replied, “If my name was on the schedule for that day, then, yes, I was on call for Trauma on September 29.”
Without skipping a beat he asked, “Then, the next thing I wanna ask you is, do you remember if there was anything special or different about that day? I ask because there was a particular progress note with only my signature on it by the student’s note, but there was no intern or senior resident signature. Do you remember if on that particular day the senior resident was not present or if I happened to round with just the students or if there was anything else unusual about that day?”
I answered, “I honestly do not remember if there was anything unusual. I do know that a resident does not always sign the progress notes, but that does not necessarily mean that we were not present.”
He then asked, “And the next thing I wanna ask you is, do you remember a lady with an arm amputation and a C2 fracture?”
I replied, “There were actually several arm amputations that I took care of on Trauma Surgery that month, so can’t for sure say that I remember that lady in particular.”
My attending proceeded to tell me, “Well, the problem is that that patient died. And she was apparently discharged with a central line still in her neck. And she was also discharged after being on IV morphine here in the hospital without being switched over to oral medications. ” He continued, “Do residents on the SICU generally let you know when they are downgrading a patient to the floor if there is a central line in place in that patient?”
I answered, “No, they don’t.”
“Or are you aware of a policy somewhere stating that that piece of information should be relayed?”
“No, sir, I am not aware of such a policy.”
“And aren’t patients usually converted over from IV morphine to oral pain medications to see if they can tolerate it before they are discharged home?
“Yes, they are.”
The attending continued, “I am not in any way trying to say that you are at fault or did anything wrong in this case. I am simply trying to get a better understanding of what happened on that day. If you think of anything or have any more information after you take a look at the chart, call extension 01055. Anything you think of might be helpful in this situation.”
I replied, “Thank you for informing me of this situation. I will try to review my personal records as well as the chart to see if I can think of anything.”
“Thank you, Dr. Lee. Bye.”
Thoroughly confused and somewhat taken aback, I hung up the phone. A few days later, as I reviewed the chart and spoke with the administrative assistant who was investigating the case, I realized what had happened. The patient had been recently downgraded from the SICU to the Trauma service a few days before her discharge, and she still had an IJ line (central line in the internal jugular vein) in place under her C-collar (neck brace) at the time. My co-intern was assigned to this patient, but on that Friday, September 29, a new intern came on service and inherited the patient that day. She was discharged with her IJ line still in place. Later that evening at a motel, her husband noticed that she had something dangling from her neck, and so he brought her back to the hospital. At that time, it seems that they asked for some oral medications, and someone apparently prescribed her MS Contin in a dose that was three times what she had been taking at home for chronic pain. The mystery lies in who prescribed the MS Contin; the handwriting is clearly different from that on the discharge paperwork, and there is no documentation anywhere in the chart of anyone having given it to the patient. My question: could the night float intern have prescribed that when the couple returned to the hospital for the IJ removal? Only time will tell.
Anyways, after her discharge (I do not know how long afterwards), the patient subsequently went into respiratory failure. At first it was feared that it may have been a complication of having been given too large a dose of narcotics. Although the cause of death remains unknown, administrative secretary stated that the respiratory distress clinically fit the picture of a pulmonary embolism. The patient was taken to a nearby hospital, where she eventually died. And now the disgruntled husband is planning to sue.
What a disaster. Every surgeon's nightmare. I am just thankful that I was not the one who wrote those discharge orders (or any orders on the patient during her hospital stay, for that matter). I would just as soon stay out of trouble with the law this early in my medical career.
And I have learned my lesson always to check for central lines before I discharge my patients home.
posted by janie and paul =) at 8:51 PM
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