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The First Patient Death Leaves Its Mark

Alitabatabaeyhat72x721_1Ali Tabatabaey -- "My patient is dead." Cold, frank, real; that’s how it hit me when I realized there was no use continuing, and that the electrical impulses on the monitor were nothing but a mere manifestation of EMD. His mydriatic eyes said it all: "I am dead and I’m not waking up this time."

It is almost 15 minutes since he stopped breathing for the fourth time, and no heart sounds exist despite my aggressive cardiac massage. "Time of death -- 3:33 p.m., record a flat strip for his file please," the resident announced to the CPR team.

I have seen patients die before, but not under my very own hands. He was only 48. He didn’t smoke, he didn’t have diabetes, no hyperlipidemia, and no hypertension. What he did have was an inferior MI with extensive anterior ST segment depression on his ECG.

From the moment she scanned the ECG, the staff cardiologist saw it coming. She ran around the CCU asking the CPR team to be ready, ordering serial ECGs and performing bedside echocardiography. All that time I was wondering why -- this wasn’t our first MI here, and the patient wasn’t in obvious distress; he lay in his bed, quietly complaining of the pain, and his lungs were all clear. I had never seen any staff act like this, not even her. Three and a half hours later, I know why.

Just a few hours ago, I was asking him about his substernal chest pain, his sweaty forehead, and his cold feet, while he answered calmly, trying not to complain about the pain. Now, I’m pressing down my stethoscope on his chest and concentrating as hard as I can, begging for a reply from his heart to all the Atropines, Epinephrines, and cardiac massaging we had offered it. I guess it just doesn’t want to beat anymore. It’s too tired; it’s too hurt.

The resident gave his family the news. Shocked might be the only way to describe them. "But how?" … "He was OK -- he walked in here this morning!" … "He was so young." … "He didn’t touch a cigarette in his life." … and a lot of other "he"s and "why"s.

Damn! Why is this awkward feeling building up inside me? Damn, damn, damn! I knew this was coming the day I entered this profession. Yet, this is the first "expired" patient with my name on his file, and I guess he is just leaving his mark.

I can still hear the staff shouting, "His rate dropped…," and see them running from the central station to his bed. I can still sense his filliform pulse under my fingers as I tapped it for an ABG. I can still see his tired eyes rolling back, and his worn-out hands clenching. I can still feel the crack of his ribs beneath my palms just before he survived the first CPR attempts. But two hours later, he didn’t survive the fourth.

3:37 p.m. The ventilator’s been turned off, the monitor is almost flat, pulse rate zero, all infusions stopped … and I still can’t hear a damn thing beating in his chest. So, I give up, too.

As I stand back and watch his eyes being closed by the head nurse, I know that I will never forget this 48-year-old bicycle repair guy, with dirty cracked hands, no insurance coverage, and a couple of broken ribs, courtesy of me.

May he forgive me, and may he rest in peace.

October 19, 2006 | Permalink

Comments

dear colleague!
I really understand the way you feel & I'm really sorry.my experience of first patient death was worse.
In our university we have shifts as soon as we enter the hospital as stagers.(the students of the 5th year),& in my 2nd shift,when i had entered the hospital just for 7 days,I received an immatiated 7 day old female neonate in respiratory arrest for helping in CPR process.& i can't forget the minute that her parents wanted me to finish amboing her after 2 hours of trying.I couldn't stop my tears.The impact of this death was really great on me & made me think about the philosophy of life and death for the following week.

Posted by: Sahar | Oct 19, 2006 2:03:22 PM

Hard time eh..:-(

Sorry Ali

but I think this is inevitable, all of us have to go through this at some stage of our life,sooner or later. You cant do much about it. No one can. I guess we just have to give ourselves a bit of time to cope up with it...

Posted by: Umme Habiba | Oct 21, 2006 12:05:00 PM

They all leave a mark, Ali.

It's what keeps us human.

Sometimes it is like waging a tug-of-war with God/Allah and sometimes we are allowed to win and sometimes we lose.

When it stops bothering you, that's when to start worrying.

Posted by: Kim | Oct 22, 2006 5:13:47 AM

We all get into this profession knowing it's going to happen, but when it does it still sucks. My sympathies. We never forget the first person we kill, and it hits us hard, but we have to keep plugging. If we didn't, there'd be no doctors left. Like Kim said, it's only time to worry when we stop caring.

Isn't there a saying out there, "you're not truly a doctor till you've killed someone"? Sounds morbid, but once you realise the emotional cost of losing a patient, you work harder the next time around. And you feel the humanity of the patients under your care. Something like that.

Keep it up!

Posted by: The Angry Medic | Oct 23, 2006 9:37:40 AM

you know dr.Ali,this is how life goes...i also remember the first patient i was following her case and died.she had familial adenomatous polyps and came to ER with persistent intestinal obstruction which necessitated emergency resection ,Hartman's procedure and proximal colostomy...(although i have seen many patients before sincei started to enter the wards in the fourth year of medicine), but now in 6th year (final) i saw her since she came to the hospital, followed her case, attended and participated in her operation and which was from 6 p.m. till somewhat 12 midnight..in less than 24 hours my doctor told me the bad news of her death...
yet when i look back i see that Allah has chosen to end these patients' pain and mesery and to also send us a message that life can end at any moment without any alert

Posted by: Rahmah | Oct 23, 2006 11:28:48 AM

Damn.

My first patient death is coming soon, it's only a matter of when.

Getting a little wet at the eyes reading your story makes me dread when mine inevitably unfolds.

Posted by: Vitum Medicinus | Oct 24, 2006 1:18:00 AM

From experiencing the first death to 100 deaths later. the feeling never changes. probably one of the hardest things to deal with as a dr. you can only do your best. but in the end, we are born and from that moment, we begin to move to the time of our death...untimely or not.

we are only human and can only do so much within our capacities to help others. just do your best...and know that without your efforts, the patient does not have a chance.

Posted by: lisa p | Oct 24, 2006 6:30:28 AM

Please tell me that you took this guy to the cath lab as soon an he presented... It would truly be a sad story if you let him sit on an MI all day until he coded.

Posted by: Treponema | Oct 24, 2006 2:45:14 PM

I just had my first patient death in the SICU- and he coded while i was placing my first subclavian line. My first thought was that I perfed his aorta or lung or something horrible. I couldn't stop crying and hid in the bathroom for about 30 minutes. It was horrible. Turns out he aspirated and that's what killed him, not my line. it was terrible experience seeing someone's heart stop beating right there in front of you. But apparently it happens to everyone at some point, and apparently it's also part of the learning process. I just hope that the next time it happens, I will be able to help with the code and not just stand there in disbelief as people start acting around me, like i did this time. That's also part of learning- what went wrong and how can we improve the next time. None of us are perfect and we just have to learn to be the best we can be for our patients. Good luck with your coping process, you'll make it.

Posted by: kathryn | Oct 24, 2006 2:51:47 PM

Sorry for the loss of the man that went away. You need to remember that God gives and he takes away. It his choice if the patient lives or dies not yours. You can help the process or you can ignore it. The bottom line is the patient went home to our father up in heaven and there should never be a sadness but a joy knowing that some day we all will be with him. HOME.


Posted by: Mary | Oct 24, 2006 2:55:24 PM

So Very sorry to hear what you experienced. Heart wrenching for all involved! I am currently writing a paper on death anxiety and how it affects MD's and Nursing staff. What interventions do you partake in to aid in self care?

Thanks in advance for your thoughts and feelings!

Posted by: libbyking | Oct 24, 2006 3:13:25 PM

I think that we all do the best we can, and that it serves us well to remember that life is precious, and sometimes, the best we can do is not enough. Death and birth are so close together..... just a breath away from each other. Peace.

Posted by: Kathleen Bruce | Oct 24, 2006 3:44:27 PM

The other day you sent an article which you titled, "interesting"....now it's my turn. dad xoxo

Posted by: Wen | Oct 24, 2006 4:15:03 PM

It is never easy when one of your patient dies; but I think we also need to learn when to give up. There you have a 48 YOA with a pretty bad MI that coded how many times? 4? What do you think would've been the outcome if you wouldve being able to bring him back once more and he just didnt die? How do you think the patients quality of life wouldve been? How many neurons do you think died during these four cardiac arrests? How functional was he going to be? What if it was your father, brother or best friend? A couple of weeks ago we recieved this 68 year old with Stage IV Ovarian CA. She had it all, the mets, the ascites, the pleural effusions; you name it, she had it. She coded 5 times in one night and 5 time we brought her back. She had the ribs broken and we knew that the damage to her brain, heart and other end-organs was major and irreversible due to the hipoxia (Manual compressions are NEVER as good as a true heart contraction) but we had to keep running codes because her family members did not want to let her go. So I am sure all of you have seen this kind of patients. Intubated and getting pressure ulcers, aspiration pneumonias, sepsis etc just bc their kids cant let go and it is important to help those family members to cope with the reality that there is nothing more to do. One more thing, the entire obgyn, er and internal med teams were in that room during those codes and during the 6th and last code, we gave up after 10 minutes of efforts. All of us walked out of the room one by one and the only person that stopped and gave some support to that daughter who was emotionally destroyed was me, an MS IV.

Posted by: JP | Oct 24, 2006 4:19:19 PM

Sorry, for the way that made you feel.. i feel the same way when we have poeple pass where i work too. i care for these people daily and it hurts so bad when they go but that is part of the nature. we can't explain god's plan. he has a plan for all of us. i believe everything happens for a reason.. god may have taken that man to show you this is part of life to see how strong you are,, well i hope things get better for you...

Posted by: Lisa | Oct 24, 2006 4:21:10 PM

Death is never an easy experience for someone with compassion in their heart. Don't ever lose your empathy for others for if you do it is time to change professions. I know this won't make you feel any better but your feelings are normal. It's how you learn to cope that will get you through each experience.

Posted by: Alison | Oct 24, 2006 6:26:58 PM

Our profession is truly torture on our souls... but remember for each of these tear drops that scar your heart you will have victory that gives you wings. Always look a little harder and listen a little longer. Advocate for your patients and hear what your nurses are saying. You will move on, but you will always remember. That is the humanity of medicine. Peace. Donna, R.N.

Posted by: Donna | Oct 24, 2006 7:30:47 PM

Just keep your head up.. and keep doing great things for humanity as a whole.. sometimes you win the race and some time you don't. when you don't win you learn from it. your heart is in the right place, even though we become a little harder on the inside the longer we practice in this profession, we must never forget that the person we are working on is some one's friend, mother, father, husband, wife.....emotions are a great way to show compassion for all of man kind.. don't let it get you down.

Posted by: Serena | Oct 24, 2006 8:28:53 PM

Ali, So sorry for the loss. I don't know why, but for some reason there are certain passings that I think effect us more than others - that is not to say that any one life is more important than the next. However, this brings a thought to my mind - advance directive. 4 codes in 24 hrs and JP 5 codes on one human being? What a brutal way to end a life. LMM

Posted by: Lynda | Oct 24, 2006 9:13:57 PM

I'm glad to have read this article today. I've been cycling through what must be some sort of health professionals' stages of grief over this past week and wondering if I am really cut out for this field. My current rotation includes a lot of time in a spinal cord rehab center, where many of the patients are 22 year-olds with control of only one limb as a result of some unfortunate risk-taking or innocent bystanderism. As a mother, as a clinician, as a person who's made more than her share of risky decisions, I'm finding it emotionally overwhelming.

The first code I ever actually participated in was the first code I witnessed wherein the patient didn't make it. I had great preparation before and wonderful support afterward, but I remember standing in the cath lab bagging him, watching my colleague perform CPR while I mentally noted the absence of capillary refill on the man's chest. It occurred to me then that this man was dead - he was in a chair next to his bed an hour ago, talking with his family, and now he's gone and why are we still doing this? The resident running the code refused to call it for another fifteen minutes - it should have been called ten minutes before, even - and all I could think was "I'm sorry. We'll let you rest soon."

It's comforting to hear that my empathy is not uncommon. I watch the seasoned providers around me and wonder how they cope. I guess we just have to learn how to separate the outcome from our efforts.

Posted by: Spackle | Oct 24, 2006 9:22:49 PM

I'm glad you posted this up. It's a reminder that everyone goes through this kind of process one day or another, within the medical field.

Feel better soon!

Posted by: Thesanica | Oct 25, 2006 5:08:35 AM

My grandmother used to call dying her greatest and final adventure! She relayed a story to me how her mother had been in a coma for six days during the 40's. Granny could do nothing except sit with her and hold her hand. Just before she died she sat up in bed, arms outstretched smiled and said Charlie, the name of her husband and love, who died three years earlier. Then fell back dead. Granny was sad for her loss but not for her mom. She knew she was somewhere with her father.

Another friend who was in a severe auto accident told me she watched from a tree as paramedics worked on her body. She told me she had a choice to die or go back. She chose to go back. When the paramedics came in to check on her after she awoke, she somehow knew them and was able to tell them what each had been doing. She said she will never be afraid of dying again.

It is our duty to promote life. Yet all the great religions promise us there is much more. That our life, as we know it, is just a beginning. We need to remember the family members and that we can make a difference in their lives, helping them with their sorrow, with just a kind word or two.

Posted by: bdillon | Oct 25, 2006 7:01:08 AM

Totaly stresed situacion.
Our profession can kill as,our souls,made from us robots,sometimes.....but,we can save the life....that is the bigger satisfaction which gives only our profession.
But,bad things happens all the time...that is the fact...we must exept that.

Regards...

Posted by: milica | Oct 25, 2006 10:44:26 AM

As always, a good post, Ali.

Posted by: sara | Oct 25, 2006 11:47:31 AM

The thing that most disturbs me in this thread is that two of the posts say something along the lines of "..first time you kill the patient". None of us kill the patient. In this case he clearly had a bad heart. That's what killed him.

Ali no doubt followed the resus protocols and did an excellent job in doing so. Death is part of life. We all need to get used to it without losing our humanity. Not every patient death needs to affect you greatly - for some, it is the most wonderful release. For others, we have so little engagement in their lives and come into their medical care so tangentially that I think it is frankly patronising to suggest to the family that you "feel" their loss.

We're slowly turning into a society that seems to need to think it needs to say something all the time. We need to "express our condolence" pretend to be "deeply affected" when two hours later we're in a bar drinking beer and having a fantastic night. Real honesty about how we feel is disappearing because we're becoming so conditioned to say the right thing. The truth, when dealing with the dying is almost always the best policy.

We can and must treat the living with compassion and geninue care. And, if you believe in a God, the dead will be far happier than us here left on this imperfect planet.


Gone From My Sight

I am standing upon the seashore. A ship at my side
spreads her white sails to the morning breeze and
starts for the blue ocean. She is an object of beauty
and strength. I stand and watch her until at length
she hangs like a speck of white cloud just where
the sea and sky come to mingle with each other.

Then someone at my side says: "There, she is gone!"

"Gone where?"

Gone from my sight. That is all. She is just as large in
mast and hull and spar as she was when she left my side and
she is just as able to bear her load of living freight to her
destined port.

Her diminished size is in me, not in her. And just at the
moment when someone at my side says: "There, she is gone!"
there are other eyes watching her coming, and other voices
ready to take up the glad shout: "Here she comes!"

And that is dying

Henry Van Dyke.

Posted by: Simon Davey | Oct 25, 2006 12:34:51 PM

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