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February 2005
Internal med rotation: Death pays
a visit
One
of the first patients I admitted during my internal medicine
rotation was a Korean man in his mid eighties. He suffered
a left MCA stroke leaving him paralyzed on the right and
aphasic. Before he was found unconscious and incontinent
in his apartment, Mr Soh was a healthy senior, swimming
laps several times a week. Now he was lying limp in a
hospital bed, gasping as if he had wet sponges for lungs.
His worried family made sure there was someone by his
side at all times.
Over the next two weeks, I came
to realize that there wasn't a lot medicine could do
for stroke patients like Mr Soh. We gave him furosemide
when his lungs became too crackly. We loaded him with
antibiotics to stave off pneumonia. And we waited —
waited for the brain swelling to go down to see what
we were left with.
His condition gradually improved.
Although his lungs never cleared completely, they started
drying up. His oxygen sats increased and he actually
became responsive, moving his right arm while I listened
to his chest. His increased mobility also meant that
he began pulling at wires and eventually his NG tube
came out. I decided to put in a PEG tube. That's when
he took a turn for the worse.
Mr Soh returned from surgery more
dyspneic than I had ever seen him before. He must have
aspirated, but chest physio and suctioning didn't help.
"Yesterday he was awake and responding to me," said
Mr Soh's daughter, looking to me for an explanation.
I had no words of comfort for her.
A
DEATH IN THE FAMILY
On my last day before a long awaited holiday, I arrived
at the hospital early. I found Mr Soh lying peacefully
in bed, his breathing no longer laboured. Strange, I
thought. Was there a miraculous improvement overnight?
The oxygen flow was still on 10 litres, but sure enough,
none of it was entering his lungs. There was no heart
beat on auscultation.
"I guess this room is done?" said
a busy nurse. I said that it was, a little bewildered.
"Are you going to pronounce him?" she asked. I answered
yes, but the truth was I had no idea how.
I was relieved to learn that Mr
Soh became do-not-resuscitate (DNR) just the day before.
The nurse gave me a bunch of forms and I filled out
Mr Soh's final progress note. Dr Bell wasn't at the
hospital yet so it was my job to inform the family.
I called Mr Soh's daughter. "I'm very sorry to tell
you this, but your father died this morning," I said
quietly. "Oh God, I'll be there right away," she whispered.
LEARNING
TO BE HELPLESS
I can't help feeling that I might have had a hand in
Mr Soh's death. After all, he seemed to be recovering
until I suggested we put a PEG tube in. While it's true
that Dr Bell had warned the family in advance that the
prognosis was not good, given his progress last week
I believed he'd leave the hospital alive. "I really
thought he'd make it," I told my preceptor. Dr Bell
had no words of comfort for me.
I told myself that was my first
death of many to come. But I'm having a hard time coming
to terms with feeling helpless. Every time I think about
Mr Soh's ragged breathing, I wish there was more I could
do — maybe suction his lungs, tell him to give
us a good cough. But all any of us could do was order
an x-ray, or maybe some more medications. I had an escape
though.
Probably somewhere else in the
hospital, another patient also died, another intern
having to break bad news. I imagined a classmate in
maternity, delivering a baby. For that family, today
would mark a new beginning for life. For me this day
will always be the day my first patient died, despite
my best efforts. (Names of doctors and patients have
been changed.)
Next
month: Home alone — and on call
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