When I was a second year medical student I was taking one of my courses in PCM (principles in clinical medicine), which placed me in the ED (emergency department) for a term. A level one trauma center was an exciting place to be as a student, and I was always eager to to see what I would learn on any given week. One evening the resident was seeing a man who had been sick from some time. His home health nurse insisted that he come in as he had been febrile and he had a cough that produced yellow brown. He came in and his chest x-ray show that his entire left lung was completely filled with pneumonia. He was started on antibiotics, but as the night wore on he began to feel that his breathing had become more and more labored. After a while it was decided that the pt would be intubated. The resident prepared for the procedure and the patient was induced. This involved giving the patient medications to sedate and paralyze him. The resident inserted the mac blade and tried to visualize the vocal cords to insert the endo-trachal tube. She couldn't see them. She tried again, but she couldn't see the cords and ended up putting the tube into the esophagus. The patient was bagged, and his oxygen saturation was brought back to normal. Another attempt was made for intubation and this time the tube was placed in the trachea. The respiratory technician began bagging the patient, and pus started coming out of the tube, occluding it. The tube was suctioned, and with the next breath the tube agian filled with pus. At this time the patients heart stopped and I began compressions. He was resuccetated, and rushed off to the ICU. After he had been passed off to the ICU the resident went to the hall and cried, totally crushed that she couldn't do better for the patient. At the time I didn't understand the feelings that she was having. The attending gave her some words of encouragement, and she returned to finish her shift. She likely returned home that evening and cried. The patient spent a hard night in the ICU, coding another two times. Three days later the patient passed away. It came out during the ICU stay that the patient had been treating his pneumonia with cocaine delaying his presentation, and sealing the end of his life.
Of course, this experience left a distinct impression on me. Now I'm the resident. I knew that some time during my training and professional life that I would at some point be the resident that had to make a hard choice. I have been a resident now for just over six months. I have seen many people pass away. Some that I have known for a very brief time and some for a longer time.
This being said, I had a patient this last week that has effected me in a way that I haven't previously felt. The case isn't as complicated as most. The pt was a elderly man who had a very bad heart. However this wasn't the cause for his presentation to the hospital this time. This winter a very nasty virus has been going around causing gastroenteritis (I got it, see my posting on 1/13/09). He was very dehydrated, and he was placed on observation status by the emergency department. We replaced his fluid losses, checked out his heart, and fixed and electrolyte deficits. When someone is placed on observation status they can only stay in the hospital for 24 hours and then they have to be admitted or be sent home. As this patient's time was running out we couldn't find a reason to admit him so we had to send him home. The patient asked to stay one more day, and I spoke to his wife making the same request. I reassured the patient and his wife that even thought he wasn't feeling back to baseline that he was ready to go home, and I discharged him. The next morning I received a phone call informing me that the patient had passed away in his sleep at home.
This news sent me into shock and self doubt. I began to doubt my dissensions and my abilities. In the end I now look differently at the work that I do, but I have to continue. It is unlikely that the outcome of my patient would have been different if he would have been in the hospital. At best he would have coded and we would had preformed CPR, which is far more brutal than anything you see on TV. He would have ended up in cardiogenic shock and had a long stay in the CCU. At his age he would have less than 5% chance of surviving that episode intact. And aboug a 5% chance of surviving with neurological impairment or life support dependent. All in all he was able to pass in peace at home.
