As a practicing physician, I have a few scary doctor stories…moments in my career than have left an indelible impression upon me. Occasionally I like to share with you from my own experiences about the harrowing sagas of the humanity I have witnessed. I think as leaders, remembering and recounting these stories gives us perspective on life and living. This is one of them. Few events that happened to me during residency have stuck with me as much as this one.
In the early 2000?s, a federal law was passed dictating that residents could not be scheduled to work more than 30 hours per shift. I know, unbelievable. Before that law, it was open-ended. You just had to be awake, alert, and handle life and death situations at some points during those shifts.
I was lucky to have started residency in 2003. The 30-hour shifts usually began at 7 am one day and ended at 12 pm the next. We had a shift like that every 4 to 5 days. In between we worked normal hours. During this long shift, we cherished a 30-minute nap at night. Occasionally we got to sleep for 2 hours if things were quiet. Rarely, I got to sleep 3 hours and that was for me considered almost a full night of sleep.
A Night in ICU
One of our rotations as second year family practice residents was ICU. This was amazing because most family medicine residencies did not give their residents so much responsibility as ours did at John Peter Smith Hospital in Fort Worth, Texas. We were practically the only doctors in the hospital who admitted patients to the ICU. Further, we were also called for codes (when patients stopped breathing, or hearts stopped pumping or went into a catastrophic rhythm) or emergencies in the ICU. While a full attending physician was on call, they were at home. So it was really up to me. Stressful? No. Terrifying.
People in ICU are very sick. And even though I was only responsible for their care from 7 pm to 6 am, that was a long time. Many things could go wrong during that time, and many things did.
On this particular night during my ICU rotation, it was about 2 am and I had just laid my head down to sleep in our ?call room? at the hospital. I had been awake since 6 am the previous day and would not go to the bed for another 5 hours. My pager beeped, which is by now a piercing sound that brought immediate tension to my brain. I sprang up and called the number. A nurse got on the phone and said that I needed to come assess this patient ASAP because he was vomiting blood.
The Step-Down Unit
This patient was in a ?step-down? unit. These units carried patients whose level of sickness was between those who needed the ICU and those stable patients who were on a regular floor. This unit was physically close to the ICU. It was designed like that because these patients were the most likely to get sick and have to go to the ICU.
I walked briskly toward the unit reviewing in my mind what I know about vomiting blood?hematemesis. These patients usually have liver failure, resulting in back up of blood and engorgement of blood vessels in their esophagus which sometimes burst and start bleeding. Most of them are either alcoholics or Hepatitis C patients. Occasionally, we saw patients with bleeding ulcers as well, however, ulcers do not usually bleed profusely. Since blood is a cathartic (ie: causes vomiting or diarrhea depending if it?s found in the stomach or rectum), when internal bleeding happens in the stomach, forceful vomiting occurs. Bloody, dramatic, and scary (not in a scary movie sense, but in the sense that someone may lose their life).
As I was walking there, I was sure this was going to be one of those situations. See nurses, especially those in a high acuity unit like the step-down unit were pretty sharp. Even though they made sure we residents did our jobs right, they also knew that we were overworked. ?So at night, they usually only called when they really needed help.
There were two patients in the room. This patient was the one farthest from the entry door. Between the two patients was a curtain. In this instance however, the curtain was retracted. As I entered the room, I clearly smelled the distinctive odor of blood and vomit. The patient was a man in his early 50?s, holding a pink tub, sitting up in the bed. He looked a bit dazed, almost too peaceful for having awoken to this ordeal.
I glanced at the tub in his lap. It was almost half-full of red blood?what we call ?frank blood??meaning this was not diluted blood. It was not vomiting with a little tinge of blood. It was blood. And there were splatters of it all over his bed. Not good.
When someone is bleeding this heavily, the first thing to do is to give them fluids, and to give them aggressively. The reason for this is that when a bleeding death occurs, it is usually a result of the blood pressure dropping severely to impede circulation to support vital organs. If you can get enough IV fluids in someone?s body, the blood pressure can be maintained, and hopefully if you are able to stop the source of bleeding, you can save their life. So in these situations, a large access into their venous system has to take place immediately and bags of IV fluids have to be pumped in.
We Must Act Fast
I knew I had to act fast. I was the only doctor there. The only doctor available in the entire hospital for such emergencies at night. I smiled at him and said ?Hi sir, I am Dr. Saade. I am here to take care of you.? I looked over his arm and realized that the standard IV access he had in his arm was not big enough to give him enough IV fluids to save his life.
I told his nurse we needed to wheel him to the ICU next door so I could put a central line in him. A central line is a large IV tube (wider tube) that goes directly into a big vein, usually the femoral vein in the upper thigh close to the groin, the jugular vein in the neck, or the subclavian vein in the chest. These have to be placed by a trained doctor. At our hospital, family medicine residents were trained to handle these procedures, and I could put one in within 2 minutes in an emergency. But I needed the patient in the ICU, because a more aggressive and highly trained team would be there to handle such an emergency.
So I quickly walked to the ICU next door and talked to the charge nurse. Nothing happened in the ICU, especially no new admission took place unless the charge nurse approved it. I told her the situation and she said without hesitation for me to bring the patient. I was happy about that, because many times I was rejected and told to try to do what I needed on the floor, and if not successful then I could call her.
I walked back with decided intention to help wheel the patient to the ICU. I entered the room. There were several nurses there. More blood in the tub. His head was slumped down, motionless. He was dead.
It hit me like a ton of bricks. I was just in his room not even 3 minutes before and he was very alive. He basically vomited blood to death.
Even for a resident who had seen lots of and blood and guts, this was gruesome. Ugly. Cruel. Horrific. Poor fellow, I thought. The bleeding was so severe and quick that it took his life before we could save him. I looked at the head nurse with a firm question of why is he not being coded?meaning CPR, etc. I knew the answer from their body language, but I wanted to hear it, ?He?s DNR. (Do Not Resuscitate)? designating that the patient did not want these type of measures.
It has been 8 years since that evening, but I clearly remember it. I had seen more grotesque scenes in my training. But I remember this evening most because of the smells, the fear, the gruesomeness. And the astounding quickness in which a life can be lost.?I sometimes share this story with people in my clinic who are heavy alcohol drinkers, especially young ones who think they are invincible. I tell them if they continue to drink, they are at risk of dying a gruesome death. Sometimes they listen.
So, I went to his chart and wrote a note?as all doctors must do to update a patient?s medical record. ?Called to beside for severe hematemesis. Went to ICU to get bed for patient to place central for IV fluids. Upon return to room, patient had expired. No resuscitation, patient is DNR.?
This was the close of this person?s life. I did not know anything else about him. What was his life about, I wondered.?It was then 2:30 am. I went back to the call room and collapsed into a deep sleep.
Stay In Touch With Your Humanity
I encourage you to recall and retell moments that have marked your journey?in life and in leadership. They will help you keep a healthy perspective on where you’ve come from as well as what others are facing under your leadership and guidance. It will keep you in touch with your humanity.
Your Friend,
For Further Reading:
Lessons from a Dying Patient
The Most Crucial Step of Growth
Comment