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It was 3:00am during a peaceful skeletal-shift duty on Christmas Eve. The St. Barbara Hospital Delivery Room (DR) Complex was occupied by 2 patients and being manned by 3 interns and 5 residents who unknowingly, were about to have a very eventful night.
While this was happening, Aakash, an intern rotating in the Obstetrics and Gynecology department, was on post to man the Recovery Room of the DR Complex during this adrenaline-filled night. At that time, he was tasked to monitor only one postpartum patient following a successful normal spontaneous vaginal delivery. 30 minutes later, while measuring the vital signs of this patient, Aakash noticed that her BP was decreasing and HR was slightly elevated. He panics a little and decides to remeasure the patient’s vital signs after a few minutes, only for them to have gotten worse. Aakash, now at the tip of his toes, is unsure and on the verge of panic. He looks around for a resident he could refer this to. The only resident available was his senior resident, Dr. Ria.

Aakash hesitates. A day prior, he was put in a similar situation where he thought he saw late decelerations in one of his patients. Thinking that this is urgent, he immediately ran to Dr. Ria, woke her up from her sleep, and reported what he saw. To her frustration, what Aakash reported was actually an early deceleration – not something to panic about. She scolds him in front of his fellow interns, telling him to be surer about situations like this next time, and to ask his fellow interns or junior residents first before running straight to the senior.

Having this vividly traumatizing memory at the back of his head, he decides to look around the DR Complex for a fellow intern or junior resident who could check his concern. To his dismay, everyone but Dr. Ria – again taking a nap – was in the Operating Room for the said procedures.

Before calling and waking Dr. Ria, he decides to go back to his patient one last time so that he could ascertain that this was something he needed to elevate. Unfortunately he finds his patient’s bed soaked with blood, and her vitals unstable. His patient was undergoing post-partum hemorrhage.

This quiet night suddenly turned the other direction as a pregnant patient was wheeled into the DR Complex. Patient was in pain, and perceiving strong contractions. History and physical exam revealed that she underwent a Ceasarian Section (CS) the year prior, is now at risk for uterine rupture, and hence is in need for a STAT CS. At the same time, another patient in the Labor Room was called to have a STAT CS due to non-reassuring fetal status. Being STAT procedures, 2 junior and 2 senior residents immediately responded and scrubbed in for the respective procedures.

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The history was already present to put Aakash at caution.

There were people in the hierarchy who might have gotten in trouble with Aakash skipping straight to the senior.

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Unclear expectations on an intern. Did he really have to elevate the situation?

Absence of mentor-mentee relationship.

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Set ground rules for mentor-mentee relationships.

Do the students know their responsibilities? Do they know the levels of supervision?

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There is undeniable self-doubt in the intern's own clinical competencies in aspects of decision-making and patient assessment as caused by the previous incident. The intern should develop a certain thick skin in moments like this and prioritize the patient above their own, and the matter of staying calm and collected, trusting in their training should help. In addition, it is an interrelated responsibility in a health team when handling a patient and there should be a matter of open-line communication between the trainees and residents to allow for centralization of patient safety.

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The first instance did not motivate the student to prepare. It may have been expected for the intern to know what he referred. He may have been unprepared to begin with. Some students come back more motivated.

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Food for thought: Is it appropriate to have the same set of expectations on students pre-pandemic vs pandemic?

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There's always a better way to mention things. There is no need to put him/her down.

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The previous unfavorable experience.

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When mistakes are done, constructive criticism plays an important role.

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Prioritization of patient.

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Lack of awareness and training - for both the student and resident. Psychological safety needs to be learned.

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Develop a framework and development program.