I’m told every doctor has their list of unsolved patient mysteries. Those patients where something terribly awful or something miraculous happens for which you lay awake at night trying to understand. The nature of doctors is to want solve problems and figure out medical mysteries in sleuth-like Sherlock Holmes fashion. It’s these unsolved mysteries that you remember as they perplex you for days, weeks, possibly years after.
For me, it happened so quickly and unexpectedly. I left the night before after a long family meeting to discuss the plan for blood transfusion overnight. The patient had been been fatigued and short of breath. She was cleared by cardiology, hematology, and nephrology. There was no pulmonary embolism and she had therapeutic INR. Chest x-ray was clear. She had never had a white count, positive cultures or any obvious signs of infection. It seemed like cut and dry symptomatic anemia.
I came to work that morning, checked in with the patient anxiously awaiting to see if her hemoglobin improved after her transfusion. I expected some awesome turn around. She said she felt exactly the same, maybe a little better. I thought to myself that perhaps she could go home later today or tomorrow in time to celebrate the new year. I examined her, wrote my note and moved on.
We had just sat down to review our patient load when I got the page, “Your patient is tachycardic and rigoring. Please evaluate.” We rushed over as a team and found our patient without complaints, just said she felt cold. That page quickly progressed to rapid response then stroke code. Our heads were spinning with all the possible differentials.
The family arrived in the middle of the stroke code. With the rapid response team and stroke team helping the patient, I quickly directed the family to a nearby waiting room. Within minutes, a code blue was called overhead. I tried my best to comfort the family as best I could. They looked towards me expecting some sort of a miracle and nothing I could say offered the comfort or solace they sought. They seemed to know that she was dying even before I could accept it.
I left the hospital that night and the moment I got in the car, I wept. I felt terrible. I wondered if I had missed something. Over the course of a couple days I ran through scenarios in my head, reviewed labs and every possible differential to try to figure out what I should have done. In the days that followed, I sat down with the rapid response team and was reassured that we had done everything right and sometimes people just die. No explanation, nothing we could have prevented. We offered the autopsy but the family declined, asking us, “What else would this tell us besides that she’s dead?” Was it closure we wanted for the family or for ourselves?
We are used to things being cut and dry. Simple explanations based on science. Someone presents with painful urination and the urinalysis shows leukocyte esterase and nitrates. You are automatically reassured that it is a UTI and you can treat it. Problem solved. You come to rely on hard fast truths and algorithms of “if this, then that.” When things just happen, partly it is the shock, but mainly it is in not knowing where things went wrong. It is hard to accept that sometimes people just die with no explanation. It goes against everything we learned in school, and you are left mulling over details.
As physicians, we walk a very fine line between compassion and detachment to stay effective. It can be psychologically taxing at first to find that fine line between caring about a patient’s well-being and health, then finding the eject button if nothing works in the end despite every effort. It is through these rough days that you hope you at least learned something and can continue to improve for your next patient. I am halfway through intern year now and while I have learned so much in these past 6 months, there is so much left to learn and so much left to shock me.
Christine A. Garcia is an internal medicine resident who blogs at Christine Chronicles and Beyond the Classroom.
