We all remember our first right? To me, in medicine this phrase always refers to the first time you see a patient die. Since my first – back when I was starting my 2nd year of of medical school – I’ve had a lot of patients I was caring for die. One particularly horrible day in the ICU, I had 4 patients die on me within about 6 hours. I’ve still yet to “kill” a patient with a mistake, though I can think of one instance that a poor decision likely caused a patient to die in the morning, instead of the evening. I’ve managed to keep patients alive today, only to suffer more, and die tomorrow. I’ve had patients with severe disease I’ve graciously allowed a comfortable death today, instead of suffering to die tomorrow. I’ve had patients speak their last words to me. I’ve had families send me thank you cards, weeks after their love one passed. Death is a part of medicine. It’s a part I’m not truly comfortable with, even as it gets easier to deal with. As the number of patients I’ve seen die over the years increases, I don’t remember each one as vividly. I will always remember my first, though.
I had just finished my first year of medical school and was excited to have been selected for a summer shadowing program. I would spent 5 weeks at 5 different rural medical locations to see how primary care could be practiced in more remote areas. Most of the locations were clinics or family practice offices in underserved areas. However, much to my excitement, I was to spend one week in the emergency room at a very small access hospital. This was literally a 5 bay ER, with 1 bay used for storage. It was the definition of rural medicine, basically not more than a stabilization step before transfer to a bigger medical center. Most of my week was seeing coughs/colds, rashes, a couple lacerations, a broken bone or two, and the only “major” case was GI bleed that did need a unit of blood before transfer. The ER was covered bya mix of local family medicine docs and a ER physician locum tennums group. Only one doc would be covering at a time.
On my last day of that rotation, that quiet ER would become anything but. The solo doc on that day was a retired family practitioner just covering a few shifts here and their. It was mid-afternoon and very warm out. A call came in on the radio – local farmer, collapsed while bailing hay – coming in minimally responsive, diaphoretic, with BP of 90/40. A tenseness fell over the small unit. Nurses began setting up the biggest of the ER bays. Respiratory was called down. The doc began to pace as we awaited the emergency medical team.
In a hurry the doors of the ER burst open. The EMT immediately stated the patient had lost consciousness in the last minute and he did not believe he had a pulse any longer. Another EMT had started to bag mask ventilate the patient. I stood out of the way as they quickly wheeled the patient into the ER bay. One nurse confirmed that she couldn’t find a pulse – though some electrical activity was present on the monitor. “It’s PEA – Start chest compressions!” the physician stated. Like a synchronized team, one nurse started chest compressions, while the respiratory therapist took over the airway. Another nurse started readying the code drugs. “Give him epi” the physician stated as he paced back and forth at the foot of the bed.
I was overwhelmed by the moment. Just standing back, taking in the scene. It is a scene I’ve seen many times since, but in that moment was surreal. The providers, calm but clearly anxious, each doing their assigned job. The patient, who was still in his cowboy boots and jeans, looked as if he had maybe never been alive. The skin color wasn’t right, a shade of grey that just seemed lifeless. The physician, with a look on his face that said he’d seen it all before, just shook his head to imply he was too old to be seeing it again.
Two minutes went by in what seemed a short eternity. “Rhythm check!” Now the patient was asystole on the monitor. “Resume compressions! And another round of epi!” Multiple rounds would follow without any pulse returning. At one point the respiratory therapist intubated the patient. Eventually, the wife appeared outside the bay – “If he’s gone, please just let him go” I could hear her sob. The physician briefly informed her of what we were doing and decided with the wife we were to stop rescuitation efforts. The whole process was maybe 15 minutes. I never touched the patient.
As quiet as it had been before this patient arrived, it was equally quiet now. One by one, the nurses and personnel shuffled out of the ER bay and allowed family to come in. On my way out I brushed into the wife and daughter and only could mutter “I’m sorry.”
It would turn out, I had a connection to the patient. Though I had never met him, he was the older brother of a very close family friend. They would put the connection together when they called to tell my family the news and also found out I had been in the ER that day. I even went to the funeral and again had to see the same somber faces I had confronted that day. “I’m so glad you were there, thank you for what you’re doing” – the wife told me. I had never touched the patient. I only muttered again I was sorry, and that I’d never forget the experience. To her though, it didn’t matter. For some reason, I still cannot explain, she was comforted by the idea of someone even distantly familiar being with her husband at the end. But as I think about it, I too would have been comforted by a similar connection.
Death is a part of medicine and it’s a part of the training. You will have many in your career. Take something from each and carry that on. Each patient that’s died under my care – a part of them lives on with me. Something they taught me or an experience I can learn from. I thank them for that, and even though I don’t remember each as vividly at this point, I know I’ll always remember this first one.
Do you remember your first encounter with death in medicine? Tell your own story in the comments or consider contributing your own experience to #LifeofaMedStudent!
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