Morning Rounds: Sometimes the Hardest Lessons Are the Ones You Learn When Nothing Works
Thursday, April 21, 2016 3:39 PM
A few years ago, during my first shift at Miles Memorial Hospital (now the Miles Campus of LincolnHealth), a very sick patient arrived by ambulance at about two in the morning.
Mark Fourre, MD, is an emergency physician and Chief Medical Officer of LincolnHealth. He also serves on their Board of Trustees. Prior to joining Lincoln- Health, Dr. Fourre was an attending faculty physician at Maine Medical Center where he developed the Emergency Medicine Residency Program and served as Residency Director.
Up to that point in my career, I had worked in much larger and busier emergency departments, but I learned a couple of things that night. One was that small rural emergency departments see people with conditions every bit as serious as the much bigger urban departments where I had worked before. The second is about the lessons you learn when all of our science and technology isn’t enough.
When our patient arrived, he was pale and having a very difficult time breathing, but he was awake and able to tell us his story a few words at a time.
He was in his 60s and had smoked for many, many years but didn’t have any other ongoing medical issues. He had been coughing for several days, which wasn’t unusual because of his smoking, but he had also recently begun to cough up a large amount of green sputum (phlegm), which is often a sign of a lung infection.
A few hours before he arrived, he began to feel really terrible, short of breath, sweaty and weak. Initially he refused to go to the hospital, until finally his family called the ambulance against his wishes. His wife and his brother arrived shortly after he did and waited outside the trauma room, clearly anxious.
His blood pressure was low so we gave him two liters of intravenous fluids. We took an X-ray of his chest and sent off blood samples for tests.
The X-ray showed a large pneumonia, a life-threatening lung infection. The blood tests confirmed the infection had spread to his blood, which meant that it had spread throughout his entire body.
Sepsis (an infection that has spread to the bloodstream) is a medical condition that can make any emergency department team feel helpless. If it is caught early, intravenous fluids and antibiotics can often stop it. If not, the infection can cause a massive immune system response resulting in a sudden drop in blood pressure, multiple organ failure and death.
By the time our patient reached us, he was very sick and declining rapidly.
We immediately put him on very strong antibiotics but his breathing grew more and more labored. It wasn’t long before I had to put him on a breathing machine. Despite the fluids we were pumping into his body, his blood pressure continued to drop. Vasopressors, medications that cause blood vessels to constrict and blood pressure to rise, made only a temporary difference.
Three hours after he arrived, despite our best efforts, he died. I had to tell his wife and his brother that we were unable to save him.
That conversation is never easy, but that night it was particularly difficult.
When a patient arrives in the emergency department conscious and able to speak, it can be very difficult to explain to the family why you were not able to save them. It was also an especially tough loss because we had a chance to talk to the patient and we had gotten to know him. He was clearly afraid when he arrived and we were unable to prevent his fears from coming true.
Having been a physician for over twenty years at that point, I had spoken to families under similar circumstances, but the busyness of those other emergency departments had always served as a buffer. There had always been something to pull me away from the family and make me focus on the next case, the next patient, the next problem.
On that night, however, there were no pagers beeping to distract me or new cases demanding my attention. I had all the time in the world, and it felt like everything was happening in slow motion.
As I walked over to the family, I inwardly prepared myself for the worst.
It is very understandable under circumstances like these that family members become angry or upset or ask a lot of tough questions.
They could have heaped any amount of scorn or anger on me and I would not have offered a word of protest, but they did none of that. Instead, they seemed much more interested in taking care of me.
They had an innate politeness and a kindness that was truly humbling.
They said they had seen how concerned we were for their loved one and how hard we had worked to keep him alive. They wanted me to know they were grateful for everything we had done and they asked me to pass on their gratitude to the other members of the team.
I can’t tell you how much that meant to me. As doctors, we are trained to heal. We depend on our knowledge and technology. When all of that fails, there is an almost inevitable sense of failure and inadequacy.
The family had no way of understanding the technical aspects of the medicine we practiced that night, but they could see that we were deeply invested in saving their loved one. In the end, they could also see that we were grieving with them. All of that created a bond that was incredibly soothing when I was feeling pretty raw.
They also reminded me that sometimes the most important thing about being a doctor, just as it is in many relationships, is that we truly want to help, that we truly care. Even when nothing else works, sometimes that’s enough.