And so the morning routine begins, checking morning labs. I turn on the computer, login to the medical record system, and up pop a bunch of lab results for my favorite patient–he’d been transfered off my service to the surgeons, but I liked to keep an eye on him and his labs (I’m very protective), and I had forgotten how to turn off his lab notifications, anyway. I had just seen him the day before when I stopped by to say hello just briefly.
He has abnormal labs every day. A high blood sugar from his diabetes, a moderately low sodium, an elevated creatinine from his chronic kidney disease. I skim them again today. That’s weird. A critical result?
I double-click the chemistry panel. It’s probably just a high potassium before his dialysis.
CO2 9 L
RESULT RE-CHECKED AND REPORTED TO NURSE.
My heart skips a beat. What the hell? 9? That’s too low. Wait, CO2, that’s not pCO2. That’s bicarb. Bicarb is supposed to be 24. Oh shit. What the hell is going on?
I move the mouse over to the Notes tab of the system to get more information. I’m overwhelmed with the slew of the last 100 notes written on the patient. The most recent one is selected automatically.
Pupils fixed and unresponsive.
No! What the fuck. Wait, does that mean coma? What the hell does that mean? My eyes somehow skip ahead to the last line of the short note, as if they’ve already read the conclusion before my consciousness has.
Patient pronounced dead at 9:40pm.
I go back to read the lines again. Pupils unresponsive. No sign of breathing. No pulse or heart beat. This can’t be happening. Tears wet my eyes. I read through the last 5 notes. ICU transfer accept note. Pt found unresponsive, E-team notified. Patient intubated, blood pressure stable on pressors. Family arrived. Discussed patient’s status, and care was withdrawn. Pt extubated, put on comfort care.
I’m just stunned. That’s not how things go, I tell myself. You don’t go from smiling and with it and happy and you don’t just go see your favorite patient one day for 20 seconds, run off to do your work, and read that he’s dead the day you come back. You don’t die that way in a hospital. You die a long, protracted course in the ICU, where we throw everything but the kitchen sink at you. And you get better. And you get worse. And then you get better again, and then you get really sick. You don’t just fucking die like this.
I went up to the ICU to talk to the intern about what happened. Luckily I knew him, and luckily he’s a very outdoorsy, in touch with his feelings kind of guy, so I wouldn’t feel stupid to ask him what happened, and how the patient died, and if he was comfortable, and if his family got to see him before he passed, and what we tried to do to save him. He explained everything to me, and my mouth kind of did that little involuntary frown thing it always does when I feel just really sad and like I want to just lose it but I have to fight back the tears. He could tell I was upset. But it was okay to be upset.
So I walk back to the team room to finish my work on both my patients who are cranky and crotchety and tell one intern about it, and there’s not much reaction. The patient wasn’t his. I understand. I assume there will be a larger showing of grief with the other intern–the one seeing the patient with me. She finds out, and there’s a minute of a surprise, and sigh, and a discussion of what happened. But then it’s business as usual.
Both are incredibly caring people and will be wonderful, compassionate physicians, but more than anything I fear–no, I know–that this will become me. That I’ll have so many patients die on me that often their deaths will be only a minute of my time. Now maybe I’m wrong, maybe they grieve privately, on the inside, like I am. Or maybe not.
I guess I’m mainly so torn up about this patient because he was mine. And maybe it’s some sort of screwed up egotism. Or just that his death was so unexpected. Or that I spent so much time fighting for him, worrying about him, and trying to make sure he got his surgery and his studies as soon as possible. Or that I feel guilty for only giving him a casual Hello, how are you today as our final words. Maybe that’s all our relationship was to him to begin with.
But I think, most of all, I was upset was because he treated me like his doctor. I was the first one to greet him every morning. I was the one that helped him put in his hearing aids and change their batteries, getting his ear wax all over my hands time and time again. I was the one that always complimented him on the really great deep breaths he’d always take so I could listen to his lungs. And no matter how often I corrected him, he always called me Dr. Walker. He was the one that woke up one day, confused from getting too much medication, and didn’t understand he was in a hospital. He cursed at me, and I told him we were all here to help take care of him, and he groggily but immediately said he wanted a second opinion, as if I was his first.
After he was transfered over to the surgeons for his operation, I visited him every day, and he told me how much me missed my morning exam, and how much he loved hearing me encourage his deep breaths. He had gotten in the habit of mimicking me, without his hearing aids, to the point that he was practically yelling to the entire floor.
“Wonderful, just wonderful, Dr. Walker,” he used to say.