* * Anonymous Doc

Tuesday, June 22, 2010

A few weeks ago, my team had a patient in pretty bad shape. She'd been in an accident, and was not doing well at all, unresponsive, really nothing good to say about her condition. Stayed that way for a couple of days, no improvement, no sign of improvement at all, seemed pretty futile to do much more.

Textbook case. The attending brought the family together for a meeting, told them things were not looking good, wanted them to consider withdrawing support, asked them to think about whether she'd want to be living this way, kept alive by machines, etc. His recommendation, and the recommendations of the consultants who'd seen her, and of everyone on the team, were all unambiguous. There is no good outcome here.

The family was reluctant, said they wanted everything possible to be done, keep her alive, do a high-risk, low-reward procedure to relieve pressure on her brain that we didn't think would do anything-- and in fact it didn't. Every day there'd be some conversation among the team asking why is the family torturing her, why can't they just let her go, there's nothing left, don't they see that.

I rotated off that service, forgot all about the patient. Then yesterday I'm talking to a friend in the call room, and he gets a page-- and I recognize the patient's name. "She's still here?"

"Yeah, pretty crazy story. She's alert, she's talking..."

"She's talking?"

"Yeah, we're going to move her to a rehab facility in a few days."

"This is the same patient whose family--"

"Yeah, they were right. There's definitely some issues going forward, but she's functional, she's going to get to go home."

Well, how about that, the family was right. To me, it's a lesson-- sometimes the body takes time to heal, we don't always understand it, but it's not always so clear, even to people who've been doing this for a long time. And sometimes a patient can get labeled as hopeless when maybe they aren't, and maybe the initial trauma just hasn't had a chance to resolve itself.

I don't want to overstate the lesson here-- most patients do not magically get better, and this patient isn't going home in the same state she was in before her accident, she suffered some degree of brain damage, it's a difficult road ahead-- and in maybe 99 out of 100 cases, she would not still be alive. But medicine isn't perfect, and the longer I'm a resident the more I realize we don't always know, even experienced doctors are guessing sometimes, and the body is complicated and unpredictable.

And of course it brings up another point-- I only know what happened because I was there when the intern got paged about that patient. Normally, we rotate off a service and don't find out what happened to our patients. We might see them months later when they're back in the hospital for another reason, if they happen to be on our service. Or we might hear about them in passing. But most of the time, we leave a service with 4 or 5 or 6 patients we've been treating, who are still there, and we never know what happens unless we think of them and decide to check, which almost never happens. I'm not sure that's the best system. I'm not sure it wouldn't make sense to have a more standard follow-up report system where we can quickly check the discharge notes of everyone we've followed, just so we know. Just so we know if something unexpected happened, if we were wrong, if we were right, how our decisions ultimately played out. Because we don't always know. And maybe we could learn something.


  1. Sounds like you want a 'like' button, so you automatically get updates.

  2. This seems like a coincidence-We were just talking about this at work last week. We've had several patients who have stunned us with their survival. We're afraid of giving false hope to the families, but sometimes their convictions and insistence on agressive treatments seem to work, and they get their loved one back, miraculuously.

  3. Always double check when the words "textbook case" are used. Bodies are not textbook copies. And I thought one of the reasons for having hospitals was to be able to learn from every case that goes on. If you don't get to see the patient from admission to discharge, all you learn is to follow procedure, not medicine.