Physicians need to openly discuss medical mistakes and near misses

Like many surgical problems, compartment syndrome must be recognized rapidly. Failing to do so may lead to a patient’s losing function in a limb, losing the limb altogether, and, in extreme cases, dying. A physician-in-training I work with missed it. Her error made me realize that medicine is suffering from its own largely unrecognized compartment syndrome.

Late one night, an emergency physician at an outside hospital called the attending physician on my hospital’s burn surgery service about a patient whose arm had been badly burned. After a brief discussion, they agreed to transfer the patient to our hospital. The trainee admitted the patient to the hospital.

Somehow, the emergency medicine physician, the burn surgeon on call, the nurses, and the trainee all missed the harbingers of compartment syndrome — the tight burned skin, the