Progress Notes

The first time your patient dies

Anup ShahBy Anup Shah, MS4

(Author’s Note: It has been over a year since this patient passed, but I continue to remember this as one of the most significant events in my medical school career.)

Mr. F didn’t seem like he had anything wrong with him. He just seemed paranoid. When I saw him in the emergency room, he sat in his bed wide eyed, visibly disheveled and confused. When I conducted my review of systems (asking him yes or no questions about  his symptoms), he said yes to everything. Chest pain, shortness of breath, blood in the urine, blurry vision, and on and on.

Traditionally, when we see patients who endorse every symptom in the book, we tend to disregard that part of our history and physical and try to focus on the most pressing issue. So we addressed his urinary concerns, since the first thing he mentioned was how he couldn’t pee, and that when he did it was full of clots of blood. When we ran several labs on him, we found that his cardiac enzymes, generally checked if we are concerned about a heart attack, were severely elevated. Poor Mr. F was truly suffering in more ways than one, and he was admitted shortly to the Medicine Intensive Care Unit (MICU).

We later found that he had complete blockage of three of his coronary arteries but he did not want to pursue any treatment. He also didn’t want to have any procedures for the blood in his urine, and it continued, although mild for several days. I knew that Mr. F would eventually come back to our service, so I visited him everyday in the MICU. I met him and his family, and we talked about where he grew up and how he ended up in Houston. I was happy for him when I learned that he would come back to our team for a few  days and then be discharged to a nursing home where he could be cared for.

On the day before he was to leave the hospital, our team went into his room and he was peeing clots into his Foley catheter. He seemed extremely uncomfortable and we did our best to console him. When my team walked out, I told my residents I was going to stay behind. I adjusted his bed, poured him some water and placed the cup against his dry, quivering lips.

He looked up at me the way a child looks at a parent and asked, “Is this what death feels like? This has gotta be death.” It sent a chill down my spine. I quickly responded, “C’mon Mr. F, don’t talk like that. We’re going to get you better and get you out of here.” I stuck around for a few more minutes but then left for Grand Rounds, telling Mr. F I’d see him in the morning. He didn’t respond.

The next day I went about my pre-round routine. I walked into Mr. F’s room. But he wasn’t there. It was another patient. My heart leapt. I figured he had made it out of the hospital and been transferred to the nursing home. I felt proud that we were able to get him out.

I went back to the team room and sat there before anyone else had showed up, checking labs and making sure I was ready with all of my other patients. I didn’t even bother going through Mr. F’s note. That’s when my upper level walked in and calmly said “Hey Anup, I’m sorry about Mr F.”

My stomach sank like a rock.

I scrambled to open Mr. F’s note. There it was. Apparently he never stopped bleeding. He became extremely unstable after I left, his hemoglobin dropped down to 4 (normally it is around 13-18 and drops when a patient loses blood). He had a Do Not Resuscitate order. Just before midnight he passed away. I couldn’t believe it.

The first time my patient died, I was left in a fog the rest of the day. As a medical student, you don’t have any true responsibility to your patients other than making sure you’re there to talk to them. As my team went about its business as usual (because they had no choice with 19 other patients on the service), I kept dwelling on the fact that I didn’t come back after Grand Rounds to see Mr. F. It’s not as though I could have done anything, but the poor man died alone in his hospital bed with only a couple of unfamiliar night nurses and doctors at his side. At least I knew him. At least I could have given him a familiar face. Perhaps my teammates felt the same way – they just couldn’t show it.

The first time my patient died was one of my most memorable moments in medicine, and I can’t imagine feeling any different or desensitized if it happened again. We are entrusted to care for our patients, and even if there is nothing we could do, we can’t help but feel obligated to keep our patients alive and healthy.

The first time my patient died will not be the last. Patients will die. My career will go on. But this unwavering sense of responsibility and duty to my patients is what will transform my career from “just a job” to a profession where I can truly make a difference.

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