I remember the first time somebody asked me, ‘Have you ever killed a patient?’ It’s kind of a strange question. I’m not sure what they expected. If they expected, ‘No,’ then they probably wouldn’t have asked the question. If they expected, ‘Yes,’ then do they expect you to go into detail? Stranger still, I’ve been asked this question numerous times.
I remember feeling like I killed a patient for the first time. I was in residency and I sat on a guy (meaning I drug my feet instead of treating him more aggressively early on, not that I literally sat on him).
He was 50-something, young by American Emergency Room standards. Hepatitis due to a history of drug use. His disease kept progressing. He got ascites (fluid in his belly seeping out of his vessels due to his liver not making enough protein). He got a little off in the head (presumably from toxins that his non-functioning liver could no longer clear out of his system). And he came to me because his lungs seemed to be failing too. Oh, and he was hypotensive.
I should have treated him early on. Treated his liver failure. Treated his lungs. Treated his hypotension. Treated him. But I didn’t. I sat on him. It wasn’t convenient. The nurses didn’t get the things done that I had ordered and I didn’t push the issue with them. He wasn’t necessarily a pleasant gentleman, and that made him even easier to not treat. And he was in a room far from where I was sitting.
I eventually decided that I had sat on him too long and went to see him. He was more confused and more hypotensive. I moved him to a room closer to myself and the nurses and put oxygen on him and put a giant catheter into his internal jugular vein in his neck. By the time I was done, he was becoming combative from his confusion, becoming alert intermittently only to be contrary. The poor man wasn’t getting enough oxygen to his already-confused brain.
His daughters arrived and I explained the gravity of the situation, that he had many chronic illnesses which would just continue to get worse and that he was now confused and breathing poorly. I explained that we would intubate him, putting a breathing tube into his throat and lungs and then connect him to a machine that would breathe for him. I explained that we would sedate him heavily so he wasn’t uncomfortable from the breathing tube. I told them that there was no guarantee that he would get better.
I intubated him and admitted him to the Intensive Care Unit.
I looked up his records on the computer the next day and he had died.
If I had treated him earlier, I told myself, I could have prevented his death.
It wasn’t the last time. There was the patient who came back the day after I saw him. But when he came back, he was in full-blown cardiac arrest, neither breathing nor having a heartbeat. And when I had seen him the day before, it was the second time he had come to the ER that day. He later recovered his heartbeat but, brain-dead, never breathed on his own. He died in the ICU a few days later.
When I met him for the first time, he immediately started apologizing and asking to go home. He had been released from a hospital in Boston earlier in the day, a few days after having tracheal surgery. He breathed through a hole in his neck and held a battery-operated gizmo up to his throat to make the robotic sounds when he talked.
As soon as he got home from being discharged, he fell asleep on his couch. He woke up short of breath and called an ambulance. The ambulance arrived and suctioned his stoma (the hole in his neck) and he immediately felt better. He didn’t want to come in, but the ambulance made him. He proved in the ER that he could suction his own stoma and promised to stay by his humidifier.
When I saw him, he had fallen asleep again and woke up again feeling short of breath. Again, he called the ambulance, again they came, again they suctioned him out and again he felt better. Again, he didn’t want to come in, but again, the paramedics insisted.
I decided to do a bit more for the second visit in a day. I got an x-ray and an EKG. They both looked normal and were officially read as normal. I discharged him. Just before he left, his brother and sister arrived and demanded his admission to the hospital. I explained why I thought it wasn’t necessary, but their presence worked up the patient enough that I called the hospital in Boston.
Our surgeons and medical teams didn’t want to admit a patient just operated on in Boston, I knew already. I didn’t need to ask them that. The hospital in Boston said that they had already kept him more days than they planned, because every time the brother and sister came around, the patient became nervous about going home. The hospital in Boston didn’t want him back, but agreed to see him in the office the next day.
The patient went home.
The next day, he awoke with trouble breathing. An ambulance was called. They found a pneumothorax (absent breath sounds on one side of the chest due to a collapsed lung), shoved a needle into his chest (thus puncturing the lung if it wasn’t collapsed already) and started CPR. Since they put a needle in his chest, we’ll never know if that was really his problem, but with a radiology review afterward, we still feel that there was no pneumothorax visible on the x-ray the day before.
A week later, the family filed a complaint. The hospital did something very unusual, and I believe the first time they allowed this to happen. Another doctor, our nursing supervisor and I sat down with the family without any lawyers to discuss what happened. We brought the chart.
It began immediately.
‘Did you think of a pulmonary embolism?’ Somebody in the family had a medical background and armed the family with questions.
‘Yes, but neither the EKG nor his symptoms nor his vital signs nor the x-ray nor his physical exam gave us reason to look further.’
‘Why didn’t you find the pneumothorax on the x-ray?’
‘The radiologists still don’t feel that there’s any pneumothorax visible on the x-ray.’
‘We think your pathologists who did the autopsy are just covering for you. We want an independent autopsy.’
‘Okay, just let us know how to help arrange that for you, if you want our help.’
Then it became personal.
‘I hope you think of my brother when you go home to your family tonight. I hope you think about the fact that you still have family while you took away my brother.’
‘Would you do anything different?’
It went on and on.
They were angry. Very angry. And I listened. I nodded. I told them that if I knew he had a pneumothorax, which we’ll never know, I would not have discharged him. I told them that if I knew he would die, I would not have discharged him. But with the information we had...
And I realized something. I hadn’t thought of him that night. I only thought of him again the next day when I heard he came back in cardiac arrest.
It seems that somewhere between work and home, during those three years of residency, I learned to leave work at work. In ten minutes of driving, I had the ability to forget about all the patients I saw. My wife complained (not complained, marveled really) that I never talked about work. My mother was frustrated that I never talked about the patients I see. I would just say, ‘You know, I can’t discuss it because of patient privacy rights.’ The truth was, I couldn’t remember a one of my patients by the time I reached my driveway. And somewhere between leaving home and arriving through the sliding glass doors at work, I would remember them all.
To a stranger, it might seem that I didn’t like my job. I loved my job. My wife knew that. I loved that I didn’t need to remember people. I loved the new slate with the next patient. I loved everything about my job. And it seemed that forgetting was a survival mechanism.
How can I go home and be completely emotionally with my wife and son when I’m still thinking about patients I saw in the ER? I was blessed to be able to forget.
But now, here, in the quiet of Tchad, where we often have no electricity, meaning no fans, no TVs, no radios, no artificial noise, not to mention no windows, here I can lie in my bed at night and hear my patients in the pediatric ward crying, a three-quarter pitching wedge away. Here, I know that a nurse is going to knock on the door at any moment to ask me to come see a patient at the hospital. There is no ten-minutes in the car to prepare my mind in the morning and purge my mind at night. The hospital is always with me. My patients are always with me. There is no forgetting.
Worst of all is little Zeke. Maybe we should have started his antibiotics earlier. Maybe I should have tried his femoral line or jugular line earlier, when he had better veins. Maybe I overdosed his fluids. Maybe I overdosed his quinine. Maybe I overdosed his gentamicin. Right now, I’m too afraid to find out.
So now what happens when the patients die?
A nurse came to me crying this morning. She was sure that she had killed a patient. A one-year-old came in the middle of the night with anemia and a hemoglobin of two (you and I are probably in the teens). Here, a child with a hemoglobin of two and no bleeding is virtually always malaria. (The little parasites mess up the blood cells, which then get all chewed up by the spleen, so there aren’t as many red blood cells to go around.) She started with intravenous quinine and a blood transfusion. She was doing everything right. The kid started out with gurgling respirations, which can accompany both the anemia and the malaria. The nurse went to take a nap. She awoke several times to hearing the gurgling respirations. They didn’t seem to be any better.
Early in the morning, another nurse woke her up and told her to stop the transfusion. She didn’t understand why. The family insisted to have the whole IV removed. She removed it. Shortly thereafter, the baby died in her arms, the first time she’s held somebody as they die. The other nurse explained to her that he felt the child died from a transfusion reaction and that if she had stopped the transfusion earlier and given Lasix and Dexamethasone that she could have prevented the death.
Is it true? I have no idea if she could have prevented the death.
But that’s what she was looking for, the reassurance that the death couldn’t have been prevented, that the child would have died no matter what.
Did I give her that reassurance? No, but I probably should have, for her sake.
But the simple truth is that we’ll never know.
I could reassure her of one thing, however. Even if she didn’t kill this patient, she will kill a patient. If you work long enough as a doctor (or in Tchad as a nurse, who functions oftentimes as a doctor), you will kill a patient.
In my three experiences above, who knows? Maybe I couldn’t have prevented their deaths. But there are many others that come to mind. Even more frightening are the ones that don’t come to mind. The cases where I killed the patient and I have no idea that I did it.
So what do we do? Do we give up?
Or maybe we ask God for guidance daily. We ask for intelligence. We ask for wisdom. We ask for patience. We ask for stamina. We ask for compassion.
We also ask for mistakes. Mistakes that can be remedied. Mistakes that can be learned from, so that we can prevent the mistakes which cause any permanent harm.
We ask for forgiveness. Forgiveness for the times that we came up short, perhaps from being lazy, perhaps from being uneducated.
But most of all, we ask for opportunities. We’re here to bring Jesus to a world in need. Without patients, we won’t have those opportunities.
I accept the opportunities of having patients continue to die in my arms if that’s what it takes to have the opportunities to show them Jesus.
God, give me the ability to save more lives than I lose.
And may I never be responsible for losing a soul.
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