* * Anonymous Doc

Monday, July 12, 2010

I think we're coming up on 29 hours in a row. This shift started out so easy. Weekends are slow. Very few people get admitted to the hospital on the weekend. At first I didn't understand-- certainly people are no less likely to have a heart attack, get sick, fall, etc on the weekends. And if anything, on the weekend people might have the flexibility to come to the hospital instead of having to deal with taking time off from work. But I think most of it is that a lot of people end up in the hospital because their doctor puts them there-- they have an outpatient appointment, and something's wrong, and they're sent to the hospital. Most outpatient facilities don't see patients on the weekend. Hence, they wait until Monday, and that's when they come in.

So, anyway, slow day, no admissions, thought it would be an easy night....

And then we get a 30-year-old woman, a walk-in off the street, complaining of chest pain... the ER resident moves her along to my team, nothing serious...

And then she dies.

I mean, I say that like it happened instantly. It didn't. I spent ten hours trying to keep this patient alive. We called three codes. We intubated her, we tried one medication, we tried another, we tried a cocktail of everything we have... and maybe that just made things worse, maybe it didn't make any difference at all, maybe maybe maybe maybe... but who knows. We called the attending-- two attendings ended up coming in, from home, on a Sunday evening. They couldn't do any better than the rest of us did. Whatever we did or didn't do, whatever was happening to this patient... she died. She walked in off the street, alert, talking, alive... and 10 hours later she was dead. And we still don't quite know why.

I feel like from an outsider's perspective, people expect that this is what happens all the time in the hospital-- people show up, sick, and they die. Doctors can't save everyone, people are going to die, it happens. And it does. But usually not this fast, and not with so little to explain it. We know when people are dying. We know when we can't fix things. Even if I don't know, personally, the attending knows, the fellow knows, someone knows. Yes, the progression of disease is different for everyone, and sometimes Plan A works, and sometimes Plan A doesn't work. But there's a plan. We can control the death to some degree-- or we can prepare for it-- or we can, I don't know, feel like we're one step ahead of what's happening, even if we can't change anything.

Except this time we weren't. We were nineteen steps behind. I told my intern at 9:30 last night, "I think we've finally got her stable, we'll figure out what's going on in the morning." And then by 11:00, I was calling the family to tell them things are not looking good, and they should prepare themselves for the worst-case scenario. And then at 2:00 I was telling them they should get here early in the morning to talk to the doctor. And then at 4:00 I was telling them she was dead.

I feel like all year, the mistakes I've seen have all been very tangible. The patient should have had test X, medication Y, treatment Z. Someone should have picked up on lab value Q earlier. Someone should have seen or done something, or messed up something. This case, who knows. On the one hand, I feel like of course there should have been *something* I could have done, something I missed, something that could have helped. On the other hand, we have no idea. The attending didn't know what to do differently. No one knew what to do differently. No one knew what to do at all. No one knows what we should have done.

The fact that we can see the future, in most cases-- we can predict, pretty reasonably, what's going to happen, even if we can't stop it-- is a powerful thing. I feel powerful, as a doctor, usually. I do. Even if I don't feel comfortable admitting it. It's power, to know if someone is going to live or die a day before it happens. It's sad and pointless and ridiculous power, but it's something to hang onto, something to use to say to yourself, hey, I'm a doctor, I know things, I'm actually qualified to do this job, at least a little bit.

But something like this happens and it's like, what's the use of us? We did nothing, we know nothing, we either killed someone or at least didn't prevent them from dying, we gave them zero extra minutes of life, we are... useless. Worse than that, because we hold ourselves out as being useful, good, smart.

"How did she die?" her sister asked.

"I. Don't. Know."

5 comments:

  1. Dutch MedstudentJuly 12, 2010 at 2:44 PM

    Hey,

    That just sucks. Strange, that somebody that young and (presumably) healthy can die so fast, without the doctors knowing what's the problem. Is there going to be a postmortem?

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  2. An intern I knew had a patient like that once... Some chest pain, nothing that looked serious... And she died. They told me she had an aortic dissection. The poor intern was crushed. She is a psychiatrist now... She didn't want to have anything to do with medical emergencies anymore.

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  3. A friend of mine, who is a nurse, had a similar experience when she was first starting out - a otherwise healthy-looking man in his 30s, complaining of chest pains, dead a few hours later. And same thing - an aortic dissection. The only comfort she got from the whole experience was that even if they had been able to figure out what was wrong, there wasn't much they could do. Sadly, such tragedies happen.

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  4. I have been practicing for twenty four years now, and I cannot imagine what else I would ever do. I am a psychiatrist, and I can remember every single patient I've cared for who died, several by suicide. All I can tell you is that if you keep doing this long enough, you WILL have bad outcomes. That does NOT mean you are a bad physician. Learn from the bad outcomes, the mistakes, the omissions, the uncertainties. Revel in the successes, the times that you made that once in a lifetime diagnosis that only takes up one paragraph in the textbook. You will be an excellent physician if you never stop learning, never stop caring about and for your patients, and always try to do better the next time. There will ALWAYS be a next time. Best of luck!

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  5. IT works this way, too. Most of the time, we know what's going on and how to fix it. In fact, most of the time, the apprentice can just look up a procedure in our knowledgebase. This type of problem, this procedure to solve it, this will be the final outcome, finished.

    Then there are time we end up working night shifts because something completely unexpected has happened after an external consultant made some changes he shouldn't have. We are scrambling. Testing and trying everything. Scratching our heads. It's a big system, it is impossible to know everything - yet, this is a system we have been building.

    Eventually, we come to a solution. From what we learned, we write up new procedures.

    The human body - we didn't build. We know a lot, but not all. When existing procedures don't work, it is up to science to do post mortem case studies, attempt to figure out what actually happened, and write up new procedures.

    So you're still powerful for what you CAN do, even though you can't be God, and you don't know what nobody knows yet.

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