Losing a Patient

Something I've been meaning to share for a while, and a school assignment finally made me put it down in words.

The weekend before my first month of surgery, I got into a terrible fight with my family. We were celebrating my dad’s 69^th birthday, and as usual, my parents and my brother started spouting their opinions about my future medical career. I told them that surgery was simply, just not going to be my thing. I had no interest in the specialty and just wanted to make it through the next two months relatively unscathed. They insisted that I shouldn’t write it off, that I would make a great surgeon since I have small hands, that it would be a better specialty option than anything else I had in mind. When corned, I become defensive, and amidst our steaks that evening I lashed out at my family. I told them to mind their own business. I was going to hate surgery and there was nothing they could do about it.

As these things usually go, I would later eat my own words. I ended up really liking the rotation and even contemplating a general surgery residency. Although I’ve now decided to pursue another path I have to admit that I learned a lot on that rotation. I grew as a medical student and as a person. I interacted with a lot of patients that I will never forget. And this is the story of one of those patients, a man named Russ.

In reality Russ wasn’t really my patient. He was assigned to one of the trauma surgeons and the surgery residents put in all his orders, but I followed his progress my entire month on the SICU (surgical intensive care unit) so let’s just call him my patient. Russ’ story is one of those bad-luck stories that reminds you of how fragile and cruel life can be.

Russ was a perfectly healthy 72-year-old man who was out walking his dog one weekend afternoon when he was hit by a car. The car drove off and Russ was left with a broken pelvis, broken left femur, ruptured left iliac vein and crushed bladder. The first time I saw Russ he was on his hospital bed, intubated and sedated. He had metal scaffolding screwed into his pelvis to help stabilize it during the healing process. His entire left leg was covered in a wound-vac (pretty much fancy Saran wrap that helps protect exposed tissues). His limbs were swollen, yellow, covered in little scabs. His lips were cracked and bloody.

During my first week on the SICU I went about my duties, collecting Russ’ vitals, listening to his heart, feeling his pulses, peeking under the sheets and checking his wounds for any overt signs of infection. Every morning when I walked into the room around 5:30, I would say, “Good morning Russ. It’s me, Kat, I’m just here to see how you’re doing”. I did this for about a week without any response. My greeting went unanswered, and I was able to poke and prod without any objections from my patient. On September 10^th, the day before my birthday, I walked into the room as usual and said hello. Russ opened his eyes and turned his head to look at me. I jumped. I ran over to Russ’ bedside, my eyes quickly getting misty. He looked at me and I asked, “Do you know where you are?” He shook his head no ever so slightly and I started telling him about what had happened. Whether he truly understood me I don’t really know, but he was awake and communicating, and I was pretty much over the moon. As I drove home that day I truly felt like Russ’ awakening was an early birthday present, and I was really optimistic about his recovery.

I wish this were otherwise, but Russ did not continue to make much progress. Although he was awake and alert, he constantly fought the intubation tube down his throat. He struggled so much that he had to be sedated, since he wasn’t strong enough to breathe on his own yet. Over the next week or so Russ had to face a string of different challenges on almost a daily basis.

The ICU is such a scary place because it tends to be home to “super bugs” that infect the patients trapped, and often strapped, to their hospital beds. Russ had one line infection after another. I remember during my first week of the rotation, I expressed some distress at morning report that Russ’ white count was elevated. I was a little upset when the residents didn’t seem to pay much attention to it, but I quickly learned, the only reason they didn’t look surprised is because they knew he would eventually get an infection.

Russ also required a lot of trips down to the OR with the orthopedic and plastic surgery teams. Ortho was trying to fix his femur, but this was complicated by the fact that he had almost no skin left on that leg. Plus it was swollen to four times its normal size. Anesthesia would wheel Russ down to the OR almost every other day. When he came back he was always doing poorly. The surgeries to repair him would literally almost kill him – after the OR his blood pressure would be extremely low from all the blood loss he had sustained. We would pump him full of pressors (to get his BP up) and lactate ringer (to keep fluid in his arterial system). Needless to say, I did learn a lot about fluid resuscitation from Russ. Somehow, we managed to bring him back to life each time, but overall it was a terrifying cycle.

Through all this running about, I got to know Russ’ wife and daughter. This may sound horrible, but the first time I met Russ’ wife I really wanted to ask her what had happened to his dog, but I restrained myself. You see I adopted a dog when I started medical school, and he is pretty much the center of my world. When I heard Russ’ story I knew that if I were in his shoes, when I woke up, I would want to know if my dog was alright. Somehow the topic came up and it turned out that Russ’ dog was perfectly fine. Probably the utilitarian thing to say is that it would have been better if Russ was okay and instead the dog had died in the accident. But, that’s not how things went and you can’t turn back time.

I tried to update Russ’ wife and daughter as best as I could. Sometimes things were just too fast paced in the SICU or I didn’t completely understand what was going on. When they were visiting him we would all talk to Russ together. They told him about the friends and family members that were thinking about him. Russ’ wife told me that their church had been really supportive and was helping her out by cooking meals and finishing chores. They showed him videos of his dog and told me how if they said Russ’ name in front of the dog, she would cry and start whimpering, wondering where he was.

That first month went by pretty quickly, and it was time to change services. As I started my second month of surgery with another team, I was disappointed that Russ had not made much progress. His biggest problem was his left leg – to put it simply, the leg was trashed and they were thinking about amputating it. I tried to stop by Russ’ room when I could. Even though he was technically awake he was still pretty out of it, and I just wanted to check in with his wife or daughter.

About two weeks into that second month, I asked a fellow student who was now taking care of Russ, how he was doing. She told me that he had started bleeding from his rectum and that the team was trying to figure out what was going on. When I saw my old SICU resident later that day, I joked and said, “I heard Russ is doing GREAT!” because actually, bad news regarding his progress was not all that surprising.

About a day or two later, I had some free time and decided to visit Russ in the afternoon. I got up to the SICU, walked to his room, and he was gone. There was an unfamiliar woman in his place. At that moment I knew what had happened, but I was in shock and didn’t fully process what his absence meant. I stood there for a second when a fellow student sitting at the nurse’s station asked what I was looking for.
          I replied, “I came to check on my old patient but he’s not here anymore.”
          “Oh, that guy? He’s dead.”

I walked out of the SICU and took the elevator down to the first floor. When the doors opened I ran straight into my SICU attending, a young trauma surgeon that had been hired the previous year. He must have seen the look on my face because he said, “I know.” We exchanged a sad glance, but we couldn’t really talk about Russ since there were other patients around, and after a few seconds we were both on our way. I found out later what had happened. Once the bleeding started, the SICU staff called for a GI (gastrointestinal) consult. GI didn’t arrive until nine-hours later. They diagnosed a bleeding rectal ulcer but it was too late. Russ was really crashing this time. His family decided to withdraw care and he died a few hours later.

I took everything pretty hard. At first I was really angry. Why did it take nine hours for someone from GI to see Russ? Maybe if they had seen him sooner he wouldn’t have lost so much blood. I thought about how his case had been regarded by the surgery attendings and residents. What mistakes had we made in his care the past month? I also felt guilty that I hadn’t seen Russ or his family one more time before he passed. I wish I could have said goodbye or expressed my condolences.

Although some people do recover from terrible injuries, in retrospect, Russ probably started his whole SICU journey with only a slim chance of getting better. In the end it was Russ’ family who decided to withdraw care. I think they knew how much he loved life and understood that he wouldn’t want to perpetually be in a state where he was barely hanging on. I never had a conversation with Russ or his family about his end-of-life wishes, but maybe it would have helped me as a student to have done so. I know how important this will be for my future interactions with patients. Maybe it never came up because we didn’t want to consider that possibility – at least in the beginning. Whether Russ was aware of it or not, he suffered. He was not going to be able to return to his old life before the accident, and I think his family made the right choice for him.

I know that Russ is a patient who will stay with me throughout my entire career. What happened to him was unfair and tragic. This is going to sound cliché, but for me, his story really is a reminder that you never know what is going to happen in life. We should try to appreciate our blessings as much as we can, even when our worlds are falling apart. This experience also taught me the value of compassion and actually being present in a moment. Taking that extra minute to talk to a patient or family member can make a big difference in someone’s day-to-day life. You may not be able to control all the end outcomes, but you do have control over the way to treat and respect others. I wish that I could have seen Russ walk out of the hospital and back into the arms of his wife, his children, and his dog. It didn’t happen, but I am grateful to have met him and participated in his care. I hope he is at peace, in whatever place that may be.