Handle With Care

The nearly fifteen years since I graduated from medical school have been a constant learning curve, none more so than my year of internship when the problem was predominantly one of inexperience. The transition from being a confident young medical student, secure in the shadow of a constant supervisor, to being an independent intern was exhilarating but challenging. I lost quite a few patients that year.

One memorable patient was a very old man from a nursing home who came in with a decline in his already poor functional state as reported by his careers. The trouble was he could not provide any meaningful history, which may have been accentuated by his having a degree of dementia. I recall examining him but not exactly what I found. It was nothing that alarmed me, although I daresay the examination could not have been comprehensive given the elderly man’s limitations with movement in the narrow bed.

Unable to make a bedside diagnosis, I took some blood tests hoping that they might point to a cause of his presentation. It was frustrating to not have a clear diagnosis but because the patient was so completely subject to our will and didn’t complain at all, figuring out his problem didn’t seem to be an urgent priority. All in good time, I told myself. The nurse then drew the curtains around him to afford him some rest.

When I went to check on him shortly thereafter, he had died. Needless to say, a death on my very first shift turned me pale with fear. When someone suggested that the cause of death may have been a ruptured aneurysm, I was petrified. I visualized my career as having ended right there until a kindly consultant advised, ‘These things happen from time to time, he died quickly.’ His words had the opposite effect of making me feel worse.

Someone had to call his family and the task fell to me. ‘I am sorry to tell you your father just passed away’, I advised the daughter, with a tremor in my voice. ‘We were expecting it, thank you for doing your best.’ ‘But that’s it, I didn’t do my best’, I wanted to shout, but burdened by her generosity and feeling terrible about the death, I didn’t say anything else. There were no curly questions, in fact, no questions at all. I filled out the death certificate and forgot about the case.

But the fact that I am writing about it some fifteen years later shows that in fact, the event has never really left my mind. And this is why. The poor man may well have harboured a ruptured aortic aneurysm in which case his death was a foregone conclusion. I could scarcely have changed that outcome but what was in my capacity was to read his expression and manage his discomfort. In retrospect, he had looked pale and discomfited, but because he was unable to articulate his symptoms, I didn’t have the patience to read any more into his expression. As a newly minted intern, I thought I had the right to expect a clear history and a meaningful examination from a patient in order to reach a diagnosis and provide treatment. And I thought that if the patient couldn’t keep up his side of the bargain, I was justified in not trying harder either. With the benefit of maturity and experience I realize that I missed the opportunity to respond to many non-verbal cues that day. I also wish that I had had the courage to speak openly to the family and tell them that I might have missed a diagnosis. The fact that they didn’t ask was a godsend at the time but now seems like a poor excuse to have avoided a more honest disclosure. I imagine that they still talk about their father’s death as a mystery – ‘He went to hospital and just died.’

But by far, the patient whose memory still pains me was a relatively young man in his fifties whom I was called to see one weekend on the surgical ward. The charge nurse reported he was bleeding and needed my attention. Imagining from her tone that he was having a nose bleed or some sort of a ‘correctable’ bleed, I attended the scene. He was in a single room directly opposite the nurses’ station. The curtains were open so that passers-by could see through the window. The man sat in a chair by the window holding his abdomen. ‘Hi, I am the intern’, I greeted him. ‘I hear you are bleeding.’

‘Yes’, he replied, without any obvious emotion.

Looking around, I saw no blood, so I was forced to ask, ‘Where are you bleeding from?’

It was only then that I noticed his hands folded across his abdomen. He lifted the thin gown to reveal a blood-soaked bandage. As he took away his hands, it took all my self control to not jump back in shock. The patient had a gaping hole in his abdomen through which bowel loops were pushing out, some of which were steadily oozing blood. The bandage was soaking wet.

‘What happened?’ I asked, concerned that this was a problem well beyond my expertise.