Title - The worst mistake I’ve ever made Tags - story
I slammed open the door and threw up in the toilet.
Then I stood there shaking.
“What have you just done?” I asked myself.
Ten minutes earlier, a critically-ill baby was rushed into the CT (CAT) scanner on a bed, surrounded by paediatric doctors and nurses. Their faces and the tense atomosphere told me that this was as serious as it got.
It was 3am and I was the duty Radiographer, responsible for every patient in the hospital who needed imaging during the night.
I’d been asked to perform a head scan on a baby. The Consultant Paediatrician knew that the girl had a neurological problem but didn’t know exactly what.
Therefore, we were to do two head scans - one before and one after an injection of “contrast”.
Contrast essentially “lights up” tumours and other cells that would otherwise go unnoticed.
Equally, the contrast can make it harder to see other conditions. So both scans are important.
Anyway, after completing a checklist with the Consultant to see if there were any contraindications to using contrast, we carefully but quickly transferred the baby to the scanning bed.
I positioned her head so it was comfortable, secure and straight. I’d already prepared the contrast and the baby had a canula in place, so I went ahead with the injection.
Then we all raced into the operating room to begin the scan. Everything was going smoothly at this point. The scan came out nicely. She was in a good position, hasn’t moved, and the contrast had reached her brain.
The Consultant asked to see the scan so he could identify any obvious explanations for the baby’s condition.
“Ok,” he said, “can I see the pre-contrast scan now?”
“Umm,” I mumbled.
That’s when it hit me…
I’d forgotten to do the pre-contrast scan.
I sat - and he stood - in silence.
The implications of my mistake were beginning to dawn on both of us.
We couldn’t do the pre-contrast scan until the contrast had flushed through her system, which can take hours.
If the post-contrast scan didn’t reveal the problem, the team would have to figure it out, or delay treatment for hours and wait for a pre-contrast scan.
That might have been too late.
As the doctors and nurses transferred the baby back to her bed, I ran out of the operating room, headed straight for the toilet, and vomitted.
Best case scenario was that I’d just made it much harder to diagnose the baby’s life-threatening condition and delayed her treatment. The worst case scenario is still difficult to think and write about 6 years later.
When I arrived for work the day after, I went straight to the office of the Consultant Radiologist responsible for reporting on the baby’s head scan.
He told me that she was ok, had begun treatment, and was on the road to recovery.
You might think that I’d be relieved by this news.
But to be completely honest, relief isn’t the right word.
I was truly happy that the baby was ok and recovering.
That was the most important thing.
At the same time, I was still in shock.
I hated myself for putting the girl, her family and my colleagues in that position.
And I didn’t really know how to respond.
So I just carried on with my job and buried it.
To this day, I still feel physically sick whenever the memory pops into my head, especially when I think about how I’d feel if it were my daughter in that position.
When I began writing this, I did so intending to share what I’d learnt from the experience.
Looking back, the pain that came with the mistake had a profound impact on the decisions I made afterwards - both good and bad.
But it just doesn’t feel right to share what I learnt from a mistake that put a baby’s life at risk.
The truth is that it’s just helpful to get it out of my head.
It happened 6 years ago and this is the first time I’ve ever shared the experience with anyone other than my colleague and wife.
I wonder: what difference would it have made if I’d spoken about it sooner?