August 15, 2014

what if?

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     "How are you feeling this morning Mrs. Smith?"  It was my first day on the ICU ward and as with any first day of a rotation, I tend to keep things low key until I get a feel for the way the team functions.  In this case that means the respiratory therapists, the nurses, the new interns who just started practicing being a doctor for a week now, upper level residents, a fellow, and an attending.  It's a large milieu to insert a med student into.
     "You tell me doc," she responded as she was currently passing foamy diarrhea while the nurses cleaned her up.  The nurse looked at me and with her eyes and asked, "you ever seen anything like this before?"  I must confess I had not.  But I did my physical exam and when rounds came I presented the history and the pertinent physical findings, especially a distended abdomen which had not been noted in the chart.  In my plan, though, I stopped short of recommending an abdominal CT.  I thought she definitely needed one but I didn't speak up.  I've been so bruised and battered and broken these last years, I didn't feel like rocking a boat on the very first day.
     I came in the next morning at 0:dark 30.  My patient's room was empty.  Maybe she got transferred and so I picked up another patient.  It wasn't until rounds that I learned that  overnight Mrs. Smith had coded multiple times and died, likely of a gastrointestinal infarct.  An autopsy was scheduled.  My heart sank.  After rounds I went up to the attending and asked why she never received an abdominal CT.  No one knew that she had a distended abdomen.  I said it at rounds.  Loud and clear.  My voice projects as I am no wallflower.  But I never said, "she NEEDS a CT."  Tell anyone this story and clearly it is not the fault of a med student.  There was an intern, an upper level resident, a fellow, and an attending.  And even if she had the CT done, it does not mean she would have survived.  The patient was in the ICU for multiple reasons and when multiple things start to head south, there's not a lot we can do.  But the question, "what if?" hangs in my mind, especially given my past experiences.  I do not allow myself to miss things despite rationally knowing that's impossible.  No one can bat a thousand.  But still, what if?  Would Mrs. Smith still be alive?

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