Wonderful, Just Wonderful, Dr. Walker
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 Discussed patient’s status, and care was withdrawn.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.
I had a similar experience at the VA last year. A patient I had worked up in the middle of the night – very sick, but actually doing quite well, then quickly went down the tubes overnight and transferred to the ICU. I checked his notes daily. I watched the discussions with his daughter go from “do everything” (his wishes on admission) to DNR. Then one day when I looked him up, a popup box told me “This patient was deceased on (yesterday’s date). Do you still want to access records?”
Different, because I knew he was headed in that direction, but still weird to learn it from the computer the next morning.
I’ve been reading and enjoying for a while, thanks.
Graham, I am sorry. :(
First of all, your residents *do* grieve, but not in the same way you do. They’ve experienced exactly what’ve you so greatly described here… it’s just hard to let oneself feel these things when there is so much else to do. And you’re right–you, too, will one day react just as they did–not because you are callous, but because life (of other patients) goes on….
And you WERE his doctor. The time that you spent with him while he was alive was priceless–both to you and to him.
You’ve always felt life deeply, Graham–it so much who you are. It serves you well to be able to express so concisely and yes, eloquently, through your blog. Words aloud are more difficult.
I’m quite surprised that you get the slamming shock of death from a screen. In my day it was entering a room and seeing a crisply made bed instead of the patient/friend I was expecting to see. EVen then, I always believed the pt had been transferred–never could quite go to the possibility of death as my first reaction. Thanks for letting me glimpse your depth through your words.
I am sure that there are many advantages to having all of a patient’s records available at the “click of a mouse,” but learning of a patient’s death from a computer screen is not one of them. I agree with the note by “mom.” When i was an intern and resident, I had to go to the ward to learn this, if I hadn’t already been called to see the patient because of his/her worsening condition.
After having been in practice for two to three years, I was attending a meeting at the hospital when I heard a ‘code” called from the orthopedic ward. In a minute or two I got a page in which I learned that the “code” was called on my patient. That was a shock but it is something that a physician faces in the course of his/her practice. The frequency depends on what specialty one has chosen. Although a caring physician should never become “accustomed” to the death of a patient, after one has experienced several of these events they become somewhat easier to accept. However, if a physician is in a specialty where deaths are not common, such as orthopedic surgery, it is always difficult to accept.
i totally understand what you mean. so many times this has happened to the patients i look after, but i guess i’m still not used to it. just recently, my friend’s grandfather, who had chronic liver disease and diabetes passed on. we (my friend and i) have been closely monitoring is health and visits to the hospital. one day we got a call. and that was it. someday we’ll learn to get through it. after all, it’s in our job description.
“but more than anything I fear—no, I know—that this will become me”
Maybe, maybe not. An oncologist was rounding in the unit yesterday, and he saw a nurse he hadn’t seen since Xmas Eve. I haven’t seen this onco much over the past few months, but when I have seen him, he hasn’t really seemed himself. Maybe a bit short, a little grouchy. Anyway, that was the night that a patient of his died, and he complimented the nurse on what an excellent job she did handling a difficult situation. The nurse got to talking about what happened and mentioned that for some reason, this particular patient was really weighing on her mind.
The oncologist seemed relieved to have a chance to talk about it, so they chatted for awhile about what happened, and then he said, “You know – I have been doing this for over 20 years, and being a cancer doctor have seen many of my patients die. For some reason, I have not been able to get this one patient off my mind and it’s really been bothering me. I’m so sad about how it turned out.”
I cannot remember the last doctor to admit to such feelings, and here was one who’s been around the block and is very much respected admitting to a nurse’s station full of people that he was very torn up about that one patient, who died almost 2 months ago.
Just thought I’d share that with you.
Hi. Dr. Walker, I can totally relate. It’s not always easy to separate your emotions from objectivity. But doctors are humans, too. Let me tell you my own story — The first patient assigned to me in my Medicine rotation was this 65 year old retired policeman. I had taken care of him for almost a month and then just one night, while I was not on-duty at the hospital, I got a text message from one of my fellow medical clerks that he had suffered an M.I. and that he had to be transferred to the ICU. Being the emotional person that I am, it was so hard for me to go inside the ICU everyday, having to face his dying body and most especially, having to talk to his very distressed daughters. I was there when he went into arrest and the residents gave him CPR — I watched, along with his 2 daughters, and I cried with them. I don’t know if it was wrong that I didn’t hold back my emotions (but I tried to, at first — I did), and I guess after that I felt a little embarassed that I was crying like I was one of his family — but I just felt so sad that day. He was revived several times, but only to go into arrest again — after a while I was starting to wish that he would just die so he wouldn’t suffer anymore. After several days in the ICU, he finally succumbed. It was his birthday. I still feel sad when I think of him. It wasn’t the first time that a patient of mine died. But I guess it was because I took care of him for so long that I felt close to him. I hope now, that wherever he is, somehow he’s resting in peace.
I think its a gift we can bring to our patients’ and our own lives, to be real and genuine. Sometimes you have to put the blinkers on, to get thru the day, but in the end you must deal with the emotions or they bust out in wierd directions. I truely enjoy most of my patients, have cried with them in the office, sat and listened to odd ramblings in the geri chair, and have gone to the visitation and funerals. Sometimes I have been privleged to be at the bedside at the time of death, and cried and comforted and connected with others in the room. Being authentic shows that you give a damn about someone else, enough not to lie to them. And, if you are really being yourself, you don’t have to remember which face you put on last time!
Thru training, it was a hell of a lot harder. Expectations, grades, evaluations, formation of personal ethics… I was lucky. In med school we had a Balint group, to talk things thru. In residency, we did, too, but more were over coffee in the cafeteria with favorite seniors and attindings.
In practice, I use hospice alot (and became the med director!), and talk with my folks/ patients about end of life when we can. Death is a transition in a family’s life and for me it is a privelege to be part of the family for that short while.