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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

Sudden death after infarction in ages 40-60 in male patients that seem "healthy" and haevn't got any disease history is not a surprise. But it is very traumatic for the medic who treats such patients and for the relatives of the patient. They always say "he was so healthy". Dear dr. Ali, when you have again male patients from 40 to 60 years, you must be very, very carefull by their evaluation and always must expect the worst things, that could happen.

Posted by: mz | Oct 25, 2006 1:08:20 PM

Hi- I came across your blog when I was researching healthcare law. I am currently a law student in Pennsylvania. It was refreshing to read your experiences. I am sorry about your recent experience with your first patient expiration, you did your best, and these are the types of things that come with the job. Good luck!

Setareh

Posted by: Setareh Deljo-Zargarani | Oct 25, 2006 1:30:48 PM

Dear Dr. Ali,
Please, never lose that empathy, and compassion. And, yes, a full code is quite traumatic, but something that needs to be done. Maybe not so much for the patient, but for those left behind. The family, in the midst of their grief, can be at peace knowing that everything possible was done. I have seen good codes, and bad codes. What is a bad code? Not really caring, half-heartedly going throught the motions.
1997, my 5 year old daughter suddenly had bradycardia. She was normally on oxygen. Worst CPR I have ever seen. She was bagged at room air, received 2 finger chest compression, and I watched the staff looking up meds in a book, while trying to figure out what to give her. With such feeble attempts to save her life, she died. And, no, after all these years, I am not at peace, as I do not feel that everyhting was done. Nor did any staff reach out to me in my grief, not a single word of comfort.
Fast forward to 09/05. My 2 year old daughter presented as having a bowel obstruction. I took her to the ER, where they told me that they thought she had an ileus. THOUGHT being the key word. Well, she was admitted for observation, while I desperately tried to get help for my child. The next night, she presented as a child who was failing, and I screamed, ranted , and raved, insisting that she be moved to the PICU. Well, right after beinf transferred, she coded. It was too late. Her bowels had already ruptured, and one third of her intestines had necrotised. The staff were tripping over their feet, trying to help. It was a major, 'ooops'.
Anyway, she survived that incident, but struggled for several months before she finally died. I caught her right when she went down, and performed CPR until the paramedics arrived. On the way to the hospital, she was intubated, and a full code was in effect. Later at the hospital, the code continued for another 45 minutes, before she was pronounced. My baby was only 2 1/2 years old, and of course I would have liked them to continue the code longer. But, the attending was a very nice young man, who told me that it was time to stop, as she was definitely gone.
Why am I telling you all this? I represent all the family members left behind, and I can definitely tell you that, yes, it makes a difference when we know that everything possible was done. And, Dr. Ali, a little compassion does go a long way. Do not lose that, please. Your humanity is what will make you a better doctor.
Good luck, and God bless you

Posted by: Sarah | Oct 25, 2006 1:34:53 PM

Dear Sarah, who posted a comment to this article earlier on today. I can't even begin to imagine what you have been through, losing two children like that. It made me so sad to read your story, and I really hope that you can find happiness and peace again, I really do. I wish you all the best.

Dear Dr Ali, I think that the compassion you felt for your patient and your unrelenting efforts to save him are what being a doctor, nurse, midwife, health care professional, or simply a human being are all about. You did the best you could, and that's all you can do. I completely agree with one of the comments left by someone, that said that the manner in which the bad news is given to relatives and loved ones is extremely important, because it's the ones who are left behind who suffer.

Posted by: jennifer | Oct 25, 2006 3:27:38 PM

It's hard when your first patient dies, that odd sensation that everything you did was meaningless, and useless; that it doesn't matter how much you know about medicine, you can't bring him back. It happened to me 5 years ago and sure I can't remember the name of my patient or many other thing about him; I just remember he was a little kid. The worst thing is that after the first comes the second, and the third, and the next. Eventually you stop counting how many people you have seen die or how many patient that you had the chance to care for die. Thanks to you now I remember what is the point of all the effort, of all the long nignts and days.
Keep going, good doctors are above everithing human beings and theres nothing more human than feeling bad after that experience. Never give up!!!

Posted by: Luis | Oct 25, 2006 3:37:36 PM

dear ali.
ur title cought my attention, & i'm sorry for what u've been through, since this is ur first patient that had died in ur hands i'm sure u'll remmember this moment. i'm a radiographer student, & i hope i never encounter a situation like this, ever...
keep up the good work..
chaw

Posted by: mona | Oct 25, 2006 3:43:49 PM

Hi everyone. My two cents here. I do not think it is proper to call this death a "kill". Certainly neither Ali nor his resident, nor the attending were instrumental in this man's demise. They were working hard to keep him alive.

For me, the worst part was wondering if I had done everything I could have and should have done for my patient. Was there something I missed? Was there something more I should have done? After you are able to answer these questions, especially if the answer is "no, we did everything we could", or even better, "I did everything I could", then you find a measure of peace.

Also, I want to thank Simon Davey, for his insightful comments and the poem. It is beautiful!

Thanks for the opportunity.

Posted by: Rebe | Oct 25, 2006 4:01:38 PM

After working several years as a Medical Assistant while I went to school, I finally moved into the profession I was born to work in. I've never regretted those years as the lowest rung on the medical professional totem pole. I learned more as an assistant in Emergency Medicine than I could ever have learned in school. The training I received in that position over the years gave me clarity and focus, and saved my butt on more than one occasion...

...until the first patient who died under my hands.

You see, it's easy to remain calm and focused when you are only a cog in the life-saving team wheel during a code. You have a particular job to do, have someone else giving the orders, and have a series of steps to perform for which you are regularly trained and tested. It just isn't the same when you are the head of the team, and are the one giving the orders. No matter what happens, it seems that you either get the credit or the blame.

Most of the time, when things go bad, you just blame yourself.

I helped save many a life under orders as a Medical Assistant. I also watched as many other lives slipped away. The first patient who died while I gave the orders has never left me. Never will.

I don't brood on this experience negatively, blaming myself for something I perhaps should have done, or could have done, or would have done if I'd just been clear-headed enough to think of that thing or under less stress. It doesn't do any good to do so.

The first patient who dies on your watch is only the first in a long line of learning experiences that you, as a practicing physician, MUST go through to become a good doctor.

Remember the experience, but let it go.

Posted by: A | Oct 25, 2006 7:54:56 PM

Dear Ali,
I have been in the health field for over 23 years. I work as a nurse intensivist and as an educator for BSN nursing students. I have experienced the loss of many patients, and the pain never goes away. I would like to share the loss of MY FIRST ONE. Last Christmas Eve 2005 while at work, I received a phone call from my son's fiance stating he had collasped and she had to call an ambulance and I needed to come to the hospital. A million things went through my mind while driving home,the year before 2004 he had had a pneumothorax, and I thought oh well, he has had another pnuemo. I worked 90 miles away from home. I did not know that earlier that day, he had gone to a local clinic with chest pain, diaphoresis, shortness of breath. THe clinic did one EKG, one set of cardiac enzymes gave him a GI cocktail and diagnosed him with pleuritic pain, gave him a Rx for Vicodan and sent him home. When I got the phone call, from his fiance,I left work, drove over 90 miles home to the hospital and when I arrived at the ER, I thought O.K. he probably has a pneumo, but someone walked up to me and said I need to take you to the quiet room. I was taken to the quiet room. I was told my son died of a massive MI. I lost my son who was only 31, with no history of Heart disease, who was healthy who rode his bike everywhere, even on the weekends from Russellville to Little Rock, bike marathons, was a college student who loved life. I am so thankful that your patient was so blessed to have had a chance to be saved. You should feel peace that you were able to provide that standard of care. I will never have that peace, my son never had a chance, he was sent home with clasic MI symptoms.

Posted by: Margaret A. Moore | Oct 25, 2006 9:21:10 PM

I'm still a med student, & I get terrified when I think that there will come a day when I face such a situation...

Posted by: A.M | Oct 26, 2006 1:26:05 AM

It is so strange that in our western society we do not accept death as an option. In fact we almost believe in our hearts that we should be able to keep everyone alive and to have someone die is our failure to carry out, the sometimes, impossible dream.

Our oath contains the phrase "first do no harm". In our desparate need to save someones life, we do not think of those words which top the list of dos and don'ts.

One day you will find that inner peace which will free you of the need to scrutinise your every action and realise that you can still have enormous empathy and compassion whilst staying detached.

Be true to yourself and realise that there is a much bigger player deciding whether we live or die. It is the people greiving their loss that need you the most.

Posted by: Sandy | Oct 26, 2006 3:50:52 AM

my first patient that died was my 14yr old son and that was b4 i became a cna he died in my arms 3/11/05 the night of my bday. as a cna working in a nursing home ive had 2 deaths since then i think going through what i did with my son made me stronger and prepared me for my future it also made me realize that death is a part of life an can be just as beautiful

Posted by: theresa | Oct 26, 2006 5:59:07 AM

Dear Ali
Your note was impressive and i can understand your feeling. Just remember the most of patients who come with bad conditions to your centere but by efforts of you and other medical sttaff their situation will improve dramaticaly. We should consider the events like that a lesson for treatment of other patients. yes i prefer to look at the full half of glass and finally i believed that there are things which are not in our teritory of power or knowledge.

Go on ...

Posted by: Behnam | Oct 26, 2006 6:12:16 AM

I can relate...I lost my first patient 2 weeks ago. I was just in the room 5 minutes earlier, and the patient was trached on a ventilator. He was still conscious and responding to when I said I will be back to check his ventilator. I steped out to answer whoever paged me out. I went back in the room and the patient was low pressuring, and I checked everything on the vent. I noticed he was turning cyanotic and the pulse ox was reading nothing...I yelled for the RN and next thing you know everyone is in the room. The patient was a DNR, so I had to bag until the EKG showed no cardiac activity. I was just in shock kind of...fresh out of school on my first job, and is one thing when u are called to a code to assist or expect to do something...but something else when u walk in the room and are the one to find them already gone to a better place. Your first time is always the worst!!!

Posted by: Stacey | Oct 26, 2006 7:42:35 AM

it was interesting to read this article and responses as i am a student nurse. I have not witnessed anything like this as yet but hope I can give the same support as was given by dr Ali.

Posted by: mags | Oct 26, 2006 7:58:39 AM

im a 3rd year physiotherapy student, just had my 1st posting at a SICU. altho i never had the chance to witness coding in process, it was hard to see my first pt go. he was only 33, married, with a young kid. fell frm a ht of 1.5m, fractured the base of his skull. treated him everyday for 1.5 weeks. didnt really know how to handle it emotionally and professionally when i reported for work one morning to find out that they were going to let him go. but i guess its a journey we'd have to carry on despite the odds. very encouraged to know that im not the only one struggling with keeping up.

Posted by: grace | Oct 26, 2006 11:02:09 AM

wish u all the best for future your level of care for your pt is really one thing which will make you stronge enough that not to forget what has happened to your first patient but it had already tought you one lesson that experience of paramedic staff is as good as your present knowledge which help you to acess patients henceforth.hope you will become a good phisician.
bye

Posted by: mahesh | Oct 26, 2006 12:36:11 PM

As a nurse and wife of a 33y/o man that recently experienced a heart attack, thank you.
May God (or whomever you believe in as a greater power) grant you the serenity to accept the things you can not change, the courage to change the things you can, and the wisdom to know the difference.
Peace be with you.

Posted by: Roxanne | Oct 26, 2006 2:59:00 PM

Dear Dr its my first time to write to someone here and its my goodluck to read ur article , it was really impressive by the way i have been witness to many stories like yours as i am head nurse for an intensive care unit for post opertive cardiac surgeries . But i still remember first death between my own hands while i was student ,and it leave mark really . i can tell u we are experiencing pain more than another professions and its good u became more human with more pain in ur life so cheer up dear its good not bad to feel like that towrd ur patients u so normal human ...good luck

Posted by: dawlat | Oct 26, 2006 3:32:42 PM

Well,it happens at times,it does! am a med student and more than once i have seen it happen,not to me but to other clinicians.so i know that i does happen.more important however i think is that we shud feel it but then we shudnt grieve about it for so long.
sometimes we are the cause,in most cases we are not, but the end point is that the patient is gone,and i believe a word or two to the family,just to encourage them and make them understand that we also feel the same(even if we dont) does wonders to their broken spirits.they badly always need that,lets never deny them the chance, i really think!

Posted by: anthony | Oct 27, 2006 2:59:49 AM

though currently i am a clinical microbiologist i remember the day when i was about to kill a young child of 2 yrs old inadvertently by rapidly infusing Kcl for rehydration instead of slow infusion during my internship in pediatrics. Fortunately with the help of my registrar and the incharge nurse we were able to revive him and was sent home happily with the mother who always feared me then touching her baby. Deaths happen in every clinicians life if not at the begining or atleast in the middle of your career. This experience will bring in confidence in handling patients and their relatives when needed.

i wish you a bright career.

A.Kumar, MD

Posted by: A.Kumar | Oct 27, 2006 8:14:46 AM

Being in a third world country where there is unequal ratio of patients to hospital staff, our school had this inspired idea of letting 3rd yr medical students help out the junior interns (4th yr medstudents).

On the second friday of our duty, we were assigned to the pediatric service ward of our government hospital. To my surprise, there were only a handful of nurses and two junior interns manning the 80-bed pedia ward. Not to mention the corridor was also occupied with patients on their own folding beds. You see, it was Dengue Season at that time and the ward was definitely overflowing to capacity. Here, all the work is done by the junior interns -- from taking the history & PE, IV insertion and monitoring the patients, almost everything except answering the phone at the nurses' station and sorting out the prescriptions. Yes, junior interns do the work of the nurses here, mostly.

Anyway, I would like to tell you my first death experience with a patient. I've had three so far. The first one I'm about to tell you. The second was another premie. The third a 44-yr old with multiple stab wounds. As soon as the junior interns saw us, they were very much thankful that we were there to help them get the VS of those kids suspected of having Dengue. But, unfortunately for me, I was assigned to bag a baby. (Bear in mind that this is a service ward, the patients here couldn't afford to have their ventilators..) So there I was bagging the poor kid.

I didn't know his history at first. When I asked his family, I learned that he was premature and he had neonatal septicemia. He was on a make-shift bili light. His skin looked so dark. He was so thin. And would you believe that ants were crawling over him! The injustice of it all. I couldn't help but remark on it. The parents only shrugged their shoulders and said, "We are so tired." They've been there for a week. The baby survived the 2 CPRs last night. He was now on DNR.

Four hours later, I couldn't even hear any heartbeat at all. I called our junior interns who then requested for an ECG. With a shake of his head, the JI jotted down the time of death at 10:45 pm.

The mother was openly crying. The father comforting her. I was in shock. I couldn't shed a tear. I couldn't do anything at all. I offered them what I could -- I prayed with them for their baby's soul to rest. They haven't even named him for goodness' sake!

Yes, I know how hard it is to lose a patient. It still hurts eventhough it has been 3 months since that day.

But as they say, "Acceptance is the first step to inner calm." I've had my share of hospital death experiences. They're all difficult to forget. Yet, I'm learning to accept that death is a fact of life. And there is nothing I can do to stop death from taking the life of a patient...

Grow strong Doc Ali.. Keep the faith.

Posted by: chunchun | Oct 27, 2006 9:56:00 AM

Hey Doc Chun Chun,

Where are you from?

Posted by: ?? | Oct 28, 2006 2:55:31 AM

I read your articles and although I am only a medical student I think I can relate. When we started dissection all my friends used to ask me how I could possibly look, let alone touch, a dead person. But I never saw it like that. It just did not seem real. When however in my first year of clinicals we went on nights, we received a bleep for a cardiac arrest pt. We thought it would be ER exciting and all but it was soooo the opposite. When I saw the man being wheeled in, I just froze. He just looked dead to me. Much more dead and much more real than anything I had seen before. Yet, the doctors stood patiently and did everything they could. They tried persistently for a to resuscitate him and they did everything they could. It was with that patient that I learnt that no matter what, no matter how it looks, it is not over until you have tried EVERYTHING.

Posted by: db | Oct 30, 2006 2:38:26 PM

Ali,

This was my first time at this site and I truly enjoyed your notes. I felt that I was in the Emergency Room as I was reading your note. Being a first year medical student, I still haven't had much clinical exposure and I surely haven't seen any lives lost at the hands of a physician or other health care professional. Learning to deal with death and dying is not always simple. Dr. Elizabeth Kubler Ross's "On Death and Dying" helped me cope with my experiences with deaths in the family and in my social life. Although I didn't lose a patient, I could somehow relate off of an indirect tangent. Losing a patient may not always be easy. I could image how emotionally attached one may become to their patients and how the tide of medicine may turn in such a manner that cannot be predicted or explained at times. Look forward to reading more.

Posted by: Keval | Nov 4, 2006 2:55:17 PM

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