The patient in front of me is trying to die. Elderly and frail, he is lying in bed. His ribs outlined under the skin that should be smooth. His temples are concave where they should be flat. Both are an outward display of internal damage from his lung cancer. More striking than his cachexia are the strained muscles in his neck and his pursed-lip breathing. He is working hard for each breath, drowning in the air around him. From his cancer or pneumonia or more likely both. It is my first night on call as a senior resident in the ICU.
It’s early in my second year of residency at the University of Chicago, where I am splitting my time between internal medicine and pediatrics. The ICU is outside my comfort zone, with its rapid pace, large volume of data to process and the complexities of multiple failing organ systems to manage. I am both intimidated and inspired by those who seem to recognize patterns, synthesize information and anticipate problems with ease. I want to be like them. I want to face my fears head on. I have chosen to be here, to prove to myself that I can do this. I am capable of caring for the sickest of the sick. And now, in the middle of the night, without a supporting daytime cast of residents and attendings, I am anxious for my first test. And it happens to be the man in front of me struggling to breathe.
I want to be here. I want to be a critical care physician. I know what to do.
ABC. Airway, Breathing, Circulation. He has “A” (an airway). He needs “B” (breathing). His “C” (circulation) is fine, his blood pressure for the moment is good. The team, two interns and me, prepare to intubate, place a tube into his lungs to help him breathe. I have been reading for months about managing patients on a ventilator. The perils and the pitfalls. I have reviewed chapters in books written by my attendings, who I will report to in the morning. I am ready.
Anesthesia comes and places the tube. I run fluids to prevent low blood pressure. I start medicine to sedate and calm my patient. I call out ventilator settings to help breathe for and give oxygen to my patient.
It all goes wrong.
His blood pressure drops dangerously low. He is thrashing around in bed, working even harder than before. Alarms on the ventilator are beeping. His oxygen levels are now critically low. He needs more sedation to calm him, but that will make his already low blood pressure worse. He needs medicine to help support his failing circulation, but it requires a special IV, a central line in his neck or groin. I have placed a few, but not in critical situations, much less in a patient moving all over the bed. I try different settings on the ventilator: Settings for pneumonia, with high oxygen and more pressure and settings for COPD, with quicker but smaller breaths — all to no avail. He is not following the books I have read nor any pattern I recognize. He has gone from bad to worse and is now close to death.
I breathe. All eyes are on me. The nurses, the respiratory therapist, the interns are all looking to me, the senior resident, to take charge and help this patient. But the puzzle of my patient’s physiology is beyond my recognition.
“Call a code.”
The nurses look puzzled, “But he is not coding. His heart hasn’t arrested!”
“He’s about to. Call it. I need more people here. I need help.”
“DR CART … ICU. DR CART … ICU,” echoes overhead, alerting all those on call, scattered throughout the hospital, that there is a code or arrest. They are to stop what they are doing to come to assist when that hospital-wide alarm is sent out. But when they enter the ICU, breathless from their sprint, they do not find a patient without a pulse, but instead, a senior resident who is failing in his responsibility to help his patient. I feel shame. Inadequate. An imposter. Worst of all, I am a danger to my patient.
There is now a larger group of residents, some more senior, others the same level of training as me. I quickly explain the situation. After a few questions, two of them look at each other with recognition of the pattern that has eluded me. Acute right heart failure prompted by positive pressure from the ventilator. The right ventricle is struggling to pump blood to the lungs. Usually, our focus is on the left ventricle pumping blood to the body. It’s difficult to treat when recognized, impossible if not appreciated. One resident deftly places a line in his neck. The other goes to work on the ventilator, modifying the settings. Thirty minutes later, my patient is stable at least for the next few hours, through no help of my own. The three of us debrief a bit and talk about a game plan moving forward, before I call and update the attending at home. They go back to their patients, leaving me alone with my team and my thoughts.
The patients in the ICU make it through the rest of the night unscathed, unlike my psyche. I am humbled by what I need to learn and shaken by how my deficiencies almost led to a death. My patient’s life now on a more stable course, I find my own career path in jeopardy.
With a bit more time separating me from the event, I start to process the evening. My colleagues who came to my rescue did not judge me. They came to help a co-resident and patient in need. The shame or judgement I felt was my own, and my own to bear. Today, I appreciate even more the culture and learning environment at the University of Chicago; where cooperation trumps ego and pride. In an environment that encourages resident autonomy, asking for help is not a sign of weakness. What could have led to an abandonment of a life goal, instead, became a building block for future learning.
It has been seventeen years since my first night as a senior resident in the ICU. Twelve of those have been as an adult pulmonary and critical doctor working with a group of physicians that practice with the same philosophy. That recognizing one’s limits is an important part of being a doctor. There is no sin in having deficits. But there is, in failing to acknowledge and learn from them. I learned more that night than the pattern of acute right heart failure. I took a big step to being a lifelong learner.
Jeremy Topin is a critical care physician who blogs at Balance. He can be reached on Twitter @jtopin1.
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