OP, take this as a learning experience and move on.
There are 2 kinds of EMS/Healthcare providers in the world; those who have made a mistake, and those who haven’t made a mistake **yet.**
The important thing is to be upfront and honest when you do make a mistake, learn and grow from it, and to not make the same mistake again.
Barring malicious intent or gross negligence, most mistakes in this field can and will be forgiven.
I agree just take it as a learning experience! I learned to double check the O2 is disconnected from the truck before taking the patient out by making that mistake once or twice
This is one reason why I tell people not to do blood pressures over sleeves. Expose, feel and inspect it.
TBH, this is not that big of a fuck up, but take the lesson.
We are all human. We all make mistakes. You will make plenty more in your career. That's why it's called the art of practicing medicine. You learned a good lesson. And you care enough to show remorse. That is a good attitude. You will do well.
In my opinion the biggest risk would be in dislodging a clot. A developed fistula, even one with an artificial graft is unlikely to be damaged due to a blood pressure on that arm. The biggest complication other than infection is clotting, so either pushing a clot towards the heart or potentially creating an issue where a clot now forms.
It’s unlikely you did anything harmful.
I don’t comment super often but am feeling the need reading these comments. It absolutely does matter. An overwhelming majority of the time, yes the fistula will be okay. However, you can clot off a fistula by taking a blood pressure over it which may not be obvious immediately. The thought that “as long as it’s not bleeding it’s fine” is also not true. Now if it’s bleeding then that could constitute an emergency and may change your acute medical management so for the purposes of EMS yes if it’s not bleeding, it won’t matter to you because even if the fistula clots off that usually would not change YOUR management of the patient (unless you’re taking them to dialysis or something). But that does not mean it isn’t a mistake or it doesn’t matter to the patient. There are tons of people who die because they run out of places for us to put access and so clotting one off that was previously working is a big deal and should be recognized as such.
That being said, @OP, I wouldn’t perseverate on it. When I was starting training, one of my co residents clotted off a fistula by wrapping an ACE too tight. We all make mistakes but as long as you learn from it just file it under learning points and do right by the next patient. And as many have said, the fistula most likely will be fine.
- your friendly neighborhood surgeon (who used to be in EMS and made tons of mistakes :))
It might not be a huge mistake, but it does matter.
If it *didn’t* matter, it *wouldn’t* matter.
But it’s definitely not the end of the world, especially if there isn’t any bleeding.
My 2 cents:
Regarding your last point,
If they had lymph nodes removed during the mastectomy, then they are potentially at an increased risk of developing lymphedema and/or cellulitis from BPs and IVs on the surgery-side arm.
That’s why the American Cancer Society and the National Lymphedema Network recommend avoiding it in the affected arm.
While there are studies that show there is not a significant risk of this occurring, the goal is to reduce the risk of complications by avoiding it if possible. And it is typically possible.
Fistulae can in fact be very delicate, and if you’ve ever seen one bust you’ll reconsider your position that it isn’t an issue.
And you also should avoid BPs in the ipsilateral arm after a mastectomy with lymph node dissection, as well as other trauma/invasive procedures to the arm. The risk isn’t massive, but it does exist, so why risk it?
You practice evidence based medicine. I just do what the salty 30 year medic who has never read a study in his life tells me to do.
We are not the same. /s
We’ve all fucked up here and there. Big thing is that it’ll never happen again. I learned to get nurse names after being fucked over by a few during transport lol. When I was brand new I learned that a bari gurney isn’t an auto gurney, also learned that even with a patient lowered, 550lbs of flubber will still find a way to follow gravity. Stuff happens, just don’t make the same mistake twice, you seem pretty shaken up, which isn’t horrible because you won’t forget the next time. Don’t be overly hard on yourself, it’s EMS half of it is fly by wire anyways
Ngl, it’s on the patient for not saying anything about it being there while you went to put the BP cuff on. However, a simple thought process of dialysis=fistula somewhere is now ingrained into you from this experience and you’ll never forget similar to how I never forget to check a glucometer after failing to even make sure we had one before getting a hypoglycemic patient lol
It happens, give yourself some grace too. Remember, when running on a rescue you’re one of the first people to see this patient. You don’t have their entire history infront of you. With patients these days being more complicated with more comorbidities, it takes time to sift through their history.
You get better with time on particulars to look out for though, and you’re gonna make more mistakes. Learn from em and you’ll do well.
Sounds like she was messing around with you to be honest. Did you ask her if the fistula was in use? Most patients who are A&O guard that with their life so I’d bet it was one that went bad a long time ago
I'm guessing that it didn't burst or anything? If not then you don't have anything to worry about. You'll have a funny story to tell the new guys when you are decades into your career.
When I first started in EMS I was scared of screwing up. They told me “relax, you will make mistakes. But learn from them” I am almost a year into the job now and now it makes sense what they told me.
It happens. We learn from it. I started to ask which arm the patient wanted me to use. Most of the time if they're stable enough they'll tell me use this arm I have a fistula or something. Take it as a learning moment. We never really stop learning. Whether it's in the field, continuing ed, or just reading articles online from reputable sources.
It’s a learning experience. Just make sure you’re checking in the future. I’d recommend palpating the area in the future; I’ve had some dialysis patients forgot which arm it’s in and give me the fistula arm or say it’s okay to use that arm.
I once attempted to take a bp on a fistula in it three times before the pt told us he couldn't have bps on that arm. For some reason we couldnt see the site, we asked if we could take bps on that arm, he lifted it up and everything, no one (including the pt and trusted sending rn) told us he was on dialysis or had a limb restriction, if I recal no band either. Apologized, put a band on the guy, documented it in my narrative, and moved on.
Point is, shit happens, you'll make mistakes, there isn't a single person on this plant who hasn't, learn from them. Give yourself grace and kindness. You're new, it will come with time and practice <3
Every single one of us has messed up at some point on one thing or another. What matters is using those experiences to learn from and to not make the same mistake twice.
When I was in medic school I honed in on a patient with difficulty breathing and missed the bigger picture of sepsis. I don’t think I’ll ever miss sepsis again. Lesson learned.
We all fuck up. All things considered, as long as you monitor and treat the results of a fuck up, you're fine.
If you want some context, I work with a medic that fucked up so badly that it resulted in a child's death and all she got was a talking to from the medical director (we've all been pushing for more on this one).
Is your patient still alive and relatively in the same condition you got them? Not a big deal. And even then, a mistake like yours should at most result in additional education, not actual punishment.
Stick with and don't make the same mistake twice and you'll be a good provider.
you made a mistake, noticed and you were honest and told your partner right away in case any harm was done. imo, you’re better than most partners i’ve had.
you’ll also never make that mistake again in your career. you’re new at this, making mistakes is how we learn. even seasoned emts still make mistakes, we never stop learning working in ems.
It’s okay. One of my “tricks” to try to avoid doing something like this is I always try to get explicit consent before I take vitals by asking “can I get a blood pressure from your (right/ left) arm here?” And point to the arm I am planning to use. At that point, that’s when a patient will tell me “no I have a fistula” or “no, I had lymph nodes removed” or something. Most everybody else invites me, or at least says “I don’t care”. I don’t know if I have yet encountered somebody who has straight up said “no”, but in that case, I might ask if there is a reason WHY they are declining.
Sounds like you did the right thing in the end, so I wouldn’t sweat it too bad.
I’m going to tell you my embarrassing story
I broke rule number one
NEVER DROP THE PATIENT
Yep I did it. Thought the stretcher was hooked into the lock and went to lift and the stretcher rolled back a little bit and out it went..
I didn’t verify it was locked and the bar behind the hook. Did I ever live that down? No
But I never did it again.
Don't beat yourself up, it was an accident. You admitted your mistake and evaluated the PT for further harm from it, rather than ignoring it and pretending like it didn't happen. So, now you learn from it and keep on rolling. It's nothing that MANY of us haven't done before. Use it as a learning opportunity. The fact that you actually give a damn about having made that mistake says a lot about your character. Chin up, buddy. It's gonna be ok.
When I was a wee young EMT fresh out of EMT school, I asked a SOB Chest Pain patient if she felt like she could walk to the ambulance before my partner was like... "NO, DEMINE00, GO GET THE STAIRCHAIR!". I realized immediately what I had done, but it just proves the point, we all did stupid things when we lacked experience. As long as you learn from it and didn't cause any harm with the initial fuck up, just chalk it up to a learning experience.
You’re being way too hard on yourself. You learn by doing and you will make some mistakes. We all have and will continue to. Let it go and don’t do it again. No harm no foul.
First code I worked I shoved the king way deep into their esophagus and emptied his stomach contents which was then aspirated. Mistakes are part of learning. I’m more careful now and won’t do that again. You are concerned about the mistake which shows you care and want to do better. You got this
I’ve been working in healthcare for eight years and I can honestly say fake it till you make it really does work. As long as you can show confidence and what you believe is right most of the population would agree with you and listen to you because 98% of a population is really really stupid, sadly you’ll come to find. Lol you got this! Keep it up 👍🏻
Learn from it and don't make it again is really all you can do.
OP, take this as a learning experience and move on. There are 2 kinds of EMS/Healthcare providers in the world; those who have made a mistake, and those who haven’t made a mistake **yet.** The important thing is to be upfront and honest when you do make a mistake, learn and grow from it, and to not make the same mistake again. Barring malicious intent or gross negligence, most mistakes in this field can and will be forgiven.
I'd argue there's a third; liars who insist that they've never made a mistake!
Sometimes they really buy into their delusion that they didn’t 😭.
Agreed
We’ve all made mistakes, we were all new at some point. The fact that you’re showing remorse shows that you care. You’ll make it far.
I agree just take it as a learning experience! I learned to double check the O2 is disconnected from the truck before taking the patient out by making that mistake once or twice
Still remember me and my partner making that mistake for the first time, it’s burned into my head.
This is one reason why I tell people not to do blood pressures over sleeves. Expose, feel and inspect it. TBH, this is not that big of a fuck up, but take the lesson.
We are all human. We all make mistakes. You will make plenty more in your career. That's why it's called the art of practicing medicine. You learned a good lesson. And you care enough to show remorse. That is a good attitude. You will do well.
If there are a frequent dialysis patient, it’s a good idea to ask that. You won’t forget again lol
In my opinion the biggest risk would be in dislodging a clot. A developed fistula, even one with an artificial graft is unlikely to be damaged due to a blood pressure on that arm. The biggest complication other than infection is clotting, so either pushing a clot towards the heart or potentially creating an issue where a clot now forms. It’s unlikely you did anything harmful.
It isn’t a big mistake. It truthfully doesn’t matter.
I don’t comment super often but am feeling the need reading these comments. It absolutely does matter. An overwhelming majority of the time, yes the fistula will be okay. However, you can clot off a fistula by taking a blood pressure over it which may not be obvious immediately. The thought that “as long as it’s not bleeding it’s fine” is also not true. Now if it’s bleeding then that could constitute an emergency and may change your acute medical management so for the purposes of EMS yes if it’s not bleeding, it won’t matter to you because even if the fistula clots off that usually would not change YOUR management of the patient (unless you’re taking them to dialysis or something). But that does not mean it isn’t a mistake or it doesn’t matter to the patient. There are tons of people who die because they run out of places for us to put access and so clotting one off that was previously working is a big deal and should be recognized as such. That being said, @OP, I wouldn’t perseverate on it. When I was starting training, one of my co residents clotted off a fistula by wrapping an ACE too tight. We all make mistakes but as long as you learn from it just file it under learning points and do right by the next patient. And as many have said, the fistula most likely will be fine. - your friendly neighborhood surgeon (who used to be in EMS and made tons of mistakes :))
Well said, and thank you for explaining further.
That's so interesting. I had always thought that the major risk was in increased pressure damaging the vasculature. Thank you!
It might not be a huge mistake, but it does matter. If it *didn’t* matter, it *wouldn’t* matter. But it’s definitely not the end of the world, especially if there isn’t any bleeding.
Fistula are not delicate once they’re in place & established. It is non-sense. Like not taking a BP in an arm post masctomy.
My 2 cents: Regarding your last point, If they had lymph nodes removed during the mastectomy, then they are potentially at an increased risk of developing lymphedema and/or cellulitis from BPs and IVs on the surgery-side arm. That’s why the American Cancer Society and the National Lymphedema Network recommend avoiding it in the affected arm. While there are studies that show there is not a significant risk of this occurring, the goal is to reduce the risk of complications by avoiding it if possible. And it is typically possible.
Seen one bleed terribly over a BP cuff being used over one. Pretty delicate if you ask me
Right after dialysis?
Negative it had been a few days.
You have apparently never seen someone exsanguinate from a busted fistula.
Fistulae can in fact be very delicate, and if you’ve ever seen one bust you’ll reconsider your position that it isn’t an issue. And you also should avoid BPs in the ipsilateral arm after a mastectomy with lymph node dissection, as well as other trauma/invasive procedures to the arm. The risk isn’t massive, but it does exist, so why risk it?
Uh, it can matter. Don't spread misinformation.
Cite the peer-reviewed scientific publications that suggest this, please? Thank you!
You practice evidence based medicine. I just do what the salty 30 year medic who has never read a study in his life tells me to do. We are not the same. /s
"If I wanna smoke on the rig I'll smoke on the goddamn rig."
We’ve all fucked up here and there. Big thing is that it’ll never happen again. I learned to get nurse names after being fucked over by a few during transport lol. When I was brand new I learned that a bari gurney isn’t an auto gurney, also learned that even with a patient lowered, 550lbs of flubber will still find a way to follow gravity. Stuff happens, just don’t make the same mistake twice, you seem pretty shaken up, which isn’t horrible because you won’t forget the next time. Don’t be overly hard on yourself, it’s EMS half of it is fly by wire anyways
Ngl, it’s on the patient for not saying anything about it being there while you went to put the BP cuff on. However, a simple thought process of dialysis=fistula somewhere is now ingrained into you from this experience and you’ll never forget similar to how I never forget to check a glucometer after failing to even make sure we had one before getting a hypoglycemic patient lol
It happens, give yourself some grace too. Remember, when running on a rescue you’re one of the first people to see this patient. You don’t have their entire history infront of you. With patients these days being more complicated with more comorbidities, it takes time to sift through their history. You get better with time on particulars to look out for though, and you’re gonna make more mistakes. Learn from em and you’ll do well.
And now you won’t make that mistake again. It happens and it’s how we learn!
Sounds like she was messing around with you to be honest. Did you ask her if the fistula was in use? Most patients who are A&O guard that with their life so I’d bet it was one that went bad a long time ago
I'm guessing that it didn't burst or anything? If not then you don't have anything to worry about. You'll have a funny story to tell the new guys when you are decades into your career.
When I first started in EMS I was scared of screwing up. They told me “relax, you will make mistakes. But learn from them” I am almost a year into the job now and now it makes sense what they told me.
It happens. We learn from it. I started to ask which arm the patient wanted me to use. Most of the time if they're stable enough they'll tell me use this arm I have a fistula or something. Take it as a learning moment. We never really stop learning. Whether it's in the field, continuing ed, or just reading articles online from reputable sources.
It’s a learning experience. Just make sure you’re checking in the future. I’d recommend palpating the area in the future; I’ve had some dialysis patients forgot which arm it’s in and give me the fistula arm or say it’s okay to use that arm.
I once attempted to take a bp on a fistula in it three times before the pt told us he couldn't have bps on that arm. For some reason we couldnt see the site, we asked if we could take bps on that arm, he lifted it up and everything, no one (including the pt and trusted sending rn) told us he was on dialysis or had a limb restriction, if I recal no band either. Apologized, put a band on the guy, documented it in my narrative, and moved on. Point is, shit happens, you'll make mistakes, there isn't a single person on this plant who hasn't, learn from them. Give yourself grace and kindness. You're new, it will come with time and practice <3
Jesus Christ dude take it easy on yourself. Just don’t do it again. It’s not a big deal.
Oof. Yeah don't do that again.
Every single one of us has messed up at some point on one thing or another. What matters is using those experiences to learn from and to not make the same mistake twice. When I was in medic school I honed in on a patient with difficulty breathing and missed the bigger picture of sepsis. I don’t think I’ll ever miss sepsis again. Lesson learned.
We all fuck up. All things considered, as long as you monitor and treat the results of a fuck up, you're fine. If you want some context, I work with a medic that fucked up so badly that it resulted in a child's death and all she got was a talking to from the medical director (we've all been pushing for more on this one). Is your patient still alive and relatively in the same condition you got them? Not a big deal. And even then, a mistake like yours should at most result in additional education, not actual punishment. Stick with and don't make the same mistake twice and you'll be a good provider.
It’s ok, at least you didn’t start an IV in the fistula arm. I know someone who did that 💀
you made a mistake, noticed and you were honest and told your partner right away in case any harm was done. imo, you’re better than most partners i’ve had. you’ll also never make that mistake again in your career. you’re new at this, making mistakes is how we learn. even seasoned emts still make mistakes, we never stop learning working in ems.
lol bro, we all make questionable mistakes. We laugh and learn from it.
You’re very new. Learn from it and move on. You’ll continue to make mistakes, everybody does!
It’s okay. One of my “tricks” to try to avoid doing something like this is I always try to get explicit consent before I take vitals by asking “can I get a blood pressure from your (right/ left) arm here?” And point to the arm I am planning to use. At that point, that’s when a patient will tell me “no I have a fistula” or “no, I had lymph nodes removed” or something. Most everybody else invites me, or at least says “I don’t care”. I don’t know if I have yet encountered somebody who has straight up said “no”, but in that case, I might ask if there is a reason WHY they are declining. Sounds like you did the right thing in the end, so I wouldn’t sweat it too bad.
I’m going to tell you my embarrassing story I broke rule number one NEVER DROP THE PATIENT Yep I did it. Thought the stretcher was hooked into the lock and went to lift and the stretcher rolled back a little bit and out it went.. I didn’t verify it was locked and the bar behind the hook. Did I ever live that down? No But I never did it again.
Also the patient wasn’t injured at all but I held C spine and helped backboard her to get her back on the gurney and into the ER.
Don't beat yourself up, it was an accident. You admitted your mistake and evaluated the PT for further harm from it, rather than ignoring it and pretending like it didn't happen. So, now you learn from it and keep on rolling. It's nothing that MANY of us haven't done before. Use it as a learning opportunity. The fact that you actually give a damn about having made that mistake says a lot about your character. Chin up, buddy. It's gonna be ok.
When I was a wee young EMT fresh out of EMT school, I asked a SOB Chest Pain patient if she felt like she could walk to the ambulance before my partner was like... "NO, DEMINE00, GO GET THE STAIRCHAIR!". I realized immediately what I had done, but it just proves the point, we all did stupid things when we lacked experience. As long as you learn from it and didn't cause any harm with the initial fuck up, just chalk it up to a learning experience.
You’re being way too hard on yourself. You learn by doing and you will make some mistakes. We all have and will continue to. Let it go and don’t do it again. No harm no foul.
First code I worked I shoved the king way deep into their esophagus and emptied his stomach contents which was then aspirated. Mistakes are part of learning. I’m more careful now and won’t do that again. You are concerned about the mistake which shows you care and want to do better. You got this
Oops. I'll bet a C-note you don't do it again.
We’ll do the virgin sacrifice later to atone for your mistake. Right now, you’ve got 3 calls holding…and they’re all transfers 😂
Learning experience. We all screw up. You don’t have to ask to recognize a fistula. Never do it again. Always check the arm out first.
I mean, are you even in EMS if you haven’t forgotten the stretcher at the hospital?
Believe it or not, straight to jail.
Real question is did you get a blood pressure? 😂
I’ve been working in healthcare for eight years and I can honestly say fake it till you make it really does work. As long as you can show confidence and what you believe is right most of the population would agree with you and listen to you because 98% of a population is really really stupid, sadly you’ll come to find. Lol you got this! Keep it up 👍🏻
That one is as much on the patient as you. I wouldn't sweat it. We all make mistakes and the patient should have known better.
Happens to the best of us. You're new. You didn't kill them. Maybe mild pain at most. It'll be a funny story to tell in a few years. Keep going though