Code Blue! My whole team took off running towards the 6th floor of the prison hospital. The adrenaline was pumping like no other time in my life and only intensified as we got closer to the room. And there we were… standing in front of the patient I had just pre-rounded on 20 minutes earlier. My heart sunk to the floor as nurses rushed in and out of the room. The world went mute and slowed down considerably as I tried to make sense of what was going on. My patient was as pale as a ghost from a massive hemorrhage.
That day was one of the worst days of my intern year. That night I questioned EVERYTHING. I questioned my competency, I questioned my career choice, I questioned God. Deep down I wondered why do we suffer? The emotional toll interns face is often overlooked and never talked about. You just kind of move on to the next case without fully internalizing things. Rarely are you asked to discuss your deep thoughts.
My patient was the same age as me. She had a family that loved her dearly. We got along very well in a very professional patient-doctor manner but at the same time I got the sense that we could have kicked it as friends under different circumstances. She had made mistakes in life that led her to prison at such a young age. She did not disclose her crime and I liked it that way since I never want to be biased in my care for a patient. The palpable irony here was the fact that this patient was a young, blond-headed, white lady while I was a young cocoa skinned, black male. We were outliers as she was nearly the only one who fit that description in the whole prison hospital and I was one of 2 black males in my entire residency program. If we were dressed in street clothes the world may have had different expectations for the two of us.
Earlier that day…
That morning, like any other day, I walked into my patient’s room and greeted her. This was my first rotation as an intern in the prison hospital. My patient was all smiles and immediately stated, “I’m feeling much better.” We had been treating her over the past few weeks for anasarca or fluid overload secondary to nephrotic syndrome. She had a number of other medical issues including diabetes and hepatitis C. The patient had a renal (kidney) biopsy the week before and we were anticipating her results. The day before, the patient was with respiratory distress and calf pain. She was miserably in pain. I presented her that day on rounds informing my team of her shortness of breath, calf pain, tachycardia (fast heart rate), and hypercoagulable state. My attending looked at me with a grin and said, “So what does she have doctor?” I smiled back and said with all the confidence in the world, “Based on her high Well’s score, she has PE!”
Unfortunately, it was Saturday morning and scans were not readily accessible at that time. We were racing against the clock since a PE can strike suddenly. We walked by the patient’s room and my attending performed a physical exam teaching the medical students how to grade pitting edema, how to auscultate the lungs, and how to conduct the Homan’s sign for DVT. “Yep, I think you are correct. Let’s begin anticoagulation,” he said. In no time, the orders were entered and the patient was started on the IV heparin drip. 24 hours later, I was dripping in sweat performing chest compressions on her during the code. It turns out that the patient was suffering from a retroperitoneal bleed stemming from the renal biopsy performed a week or two earlier. We resuscitated her and she regained consciousness but only enough to get her to the ICU for a few days. The patient expired.
As I mentioned earlier, I really struggled with this case for some time. I believe every intern has that one case that sticks with them. It’s hard to move on. You think about the young life that was lost and all those who loved her. You wonder if you did the right thing. You become disgusted at the confidence you had behind your decisions. But somehow you have to keep going. There are more patients to treat (that’s if you are even worthy). Thank goodness I had a wonderful attending who recognized this was something I was struggling with. He pulled me aside and had a one-on-one meeting with me. We walked through the case step-by-step and he assured me that we took an evidenced-based approach to arrive at our decision. I thought back and agree that 9 out of 10 times I would make the same decision. Later that month, we presented this case at the monthly morbidity and mortality (M&M) conference. There was a consensus that this was ultimately the right decision despite the unfortunate outcome.
Looking back, I believe this case has made me a better physician. I know to carefully weigh all options when making a decision. I know not to be over confident in my decision and to humble myself enough to seek guidance from my colleagues when in doubt. I know that it is okay to say the words I am not comfortable with this plan of action. However, I continue to have many unanswered questions about life in general. A major one is why do so many suffer? As physicians and scientists we seek to understand everything around us but I take solace in the words of TD Jakes.
Have you faced difficult questions like this after the loss of a patient?
Make sure to check out premed student, Curtis’ PreMed Voice podcast conversation about death. Dealing with Death
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