An “A” for Effort

We’ve all heard of getting an “A” for effort. At least it was an “A,” right?

But how meaningful is that grade if you still fail?

I remember a patient I shall refer to as David.

I didn’t know David very well at all. He was a patient in the Medical Intenstive Care Unit (MICU). He was not on my team. In fact, I didn’t really have a team. I was cross-covering the patients who were already admitted for a strech of 6 nights.

At the start of each shift, the primary team would hand me a list and “sign out” their patients to me. They would tell me about pertinent, active issues. They would also try and anticpate what could go wrong and let me know what to expect. Also, if there were any studies that were pending they would let me know if I had to check on the results.

David was one such patient. What I knew about him could be written down on just a portion of a full letter-sized paper. He had previously been diagnosed with cancer a little over a year ago. He had underwent treatment with surgeries and chemotherapy. During this visit to the hospital he came because of pain. As the ED completed their workup for the cause of the pain, they discovered he had a clot in his leg and multiple clots in his lungs. They also saw a large mass in his abdomen that appeared to be malignant.

In the ICU, the primary team was treating his multiple blood clots with a heparin infusion. Heparin is frequently referred to as a “blood-thinner.” It’s purpose, in this case was to prevent further clots from developing and to prevent the current clot from growing.

When patient’s have blood clots in their lungs (usually called a pulmonary embolism or PE) this is usually the treatment. However, if a patient becomes unstable (blood pressure or oxygen levels drop) there are more drastic treatments that can be attempted. One such treatment is thrombolytics. A thrombolytic is a medication whose purpose is to break down a clot. It is reserved for the unstable patients because they are quite risky. There is a risk for bleeding and one must always consider if a patient has any contraindications for this therapy.

On this particular night, David’s nurse called me. While he had been fine for the last day or so, he was now appearing very uncomfortable. His respiratory rate was increasing. His blood pressure was trending down. His oxygen levels were also trending down.

After spending a few minutes watching him, I made the call to Anesthesiology. I explained the situation and told them that I thought David would need to be intubated as he was in respiratory distress. Within minutes they were at the bedside and preparing to intubate.

Contacting the family was my next order of business. There was a daugther listed as the next of kin in his chart. My first call went to voicemail. I left a brief message asking for her to call me back.

Within a few minutes David’s daugther returned my call. She was understandably concerned. I had to explain what had happened. I then began asking some detailed questions about David’s medical history. I needed to know if he had any contraindications to thrombolytic therapy. The answers I got were reassuring. David was stable, though, after intubation and initiation of one vasopressor. We would wait until she arrived and we had a chance to speak in person before going forward with thrombolytic therapy.

In the meantime I would have to place a central venous line and an arterial line in order to continue administering medications and monitor his hemodynamics. In between these two procedures I found out that his hemoglobin was dropping. I had no obvious source of bleeding. My heart sank as I knew I could no longer use any thrombolytics. There was enough evidence to presume he had a bleed and I had no way to rule it out at that time.

An hour later, Tonya, her mother, and two other siblings arrived. They were ushered into the conference room. I gathered what little notes I had about David, took a breath, and walked into the room. I made sure to hand off my hospital handset to the Charge Nurse so that we wouldn’t be interrupted unless absolutely necessary. She would screen the calls.

The family took in the grave prognosis with great composure. I explained that I could only support him temporarily. I could not treat the clots with thrombolytics. I could no longer treat his clots with heparin either. I could only place a band-aids. But considering the clinical picture, I expressed my doubts that David would survive into the following day.

David’s wife, though, seemed to persist on telling me what happened throughout his battle with cancer. I tried to politely tell her that we needed to address the issues at hand — not his constipation or abdominal pain that he experienced a year ago after the initial diagnosis and treatment. I couldn’t tell if this was her way of coping. As I allowed her to continue re-telling the events of last year, I looked at each of David’s grown children. They knew what was happening. They seemed to just want to let their mother go through this in her own way, though.

By the end of my shift David would eventually need 5 different vasopressors concurrently. He was maxed out on the ventilator. He had received over 3 liters of fluids and 4 units of blood. I knew it was only a matter of time. I had done everything I could. David died before I came in for my next shift 10 hours later.

There are times in the hospital when doing everything you can — when doing your best — is just not enough.

And those times suck.




I can remember a string of particularly busy nights. I was on the ICU service — sort of.

During our training, we have one month where we are assigned to “MICU NF.” The month has been described to me by previous residents as the worst month of your entire residency. There are two 3rd-year Internal Medicine residents assigned each month. They alternate weeks as the senior resident admitting patients to the medical intensive care unit (MICU). On the week you are not admitting at night, you spend your days in clinic. On the week when you are admitting at night, you spend 5 straight nights working. The last two days of the week are covered by other senior residents on their elective months so that you have a couple days off.

To be honest, the nights are “hit or miss.” After all, you cannot predict what comes through the door of the emergency department or when patients will decompensate on the wards. In addition to fielding calls from the ED for admission, you are responsible for carrying the Rapid Response pager. A rapid response can be called for any patient already admitted to the hospital. A staff member, usually the patient’s nurse, can call a rapid response on the ward when they feel their patient is decompensating and requires rapid intervention and/or transfer to the ICU for higher level of care.

On this particular night I was coming in to my 3rd night in a row. As I arrived I went to speak to the on-call MICU attending to find out our bed and team capacity for the night. She told me I had room for four patients. I nodded and went to the call-room.

Later that night, after I had already admitted one transfer patient I was sitting at my computer when the admission pager went off. It was the ED and they asked if I had a bed available. I answered “yes,” and proceeded to take down the information.

When I arrived in the Emergency Department I found “my” patient. I shall call her Dinah. She was intubated and off sedation. I glanced up at the monitor above her bed; her heart was racing. Her blood pressure was acceptable. I glanced over at the IV pumps, though, and noted that she was on levophed1.

I spoke with her RN to get a bit more detail about what had transpired since Dinah had arrived in the ED. I also spoke with Dinah’s husband (whom I shall refer to as Husband from here on out).

Dinah was young. She was in her late 30s. She and Husband had a couple teenaged children at home. For the last week she had been under the weather. But it was not totally unexpected. Others at home were also sick. They probably all had the same bug going around. But a few days prior she developed a productive cough and shortness of breath. These two symptoms did not improve and finally she agreed to come seek care.

When she arrived, she was hypoxic indicating that she wasn’t getting enough oxygen. She was started on supplemental oxygen and then subsequently was tried on BiPAP. Unable to tolerate that, the physicians in the ED decided to intubate her in order to mechanically ventilate2 her.

By the time I was called and arrived in the ED to evaluate Dinah, she had already coded once. That complicated matters even further. She had not woken up after the cardiac arrest. But it was difficult to tell at that point if this was due to the arrest itself or the medications that had been running to keep her sedated while she was on the mechanical ventilator.

Soon after arrival to the ICU, Dinah would code again. The team worked efficiently performing chest compressions, recording the events, and pushing medications as I called them out. After ten or so minutes we got a pulse back.

I updated the family who was still present at the hospital. The number of people had grown. Watery eyes looked at me for something — anything. They wanted hope. I wished that I could have confidently given that to them. But I couldn’t. By this time there were signs of multiple organ systems failing. She wasn’t producing any urine. She was in shock requiring vasopressors. She was in respiratory failure with a machine breathing for her. She had yet to show any signs of waking up after the cardiac arrest earlier despite being taken off medications that would sedate her.

I knew the prognosis was grim. I tried to explain that to them. I then asked if there had ever been any discussion of end-of-life care. Would she want to be on all of these machines? But it is very rare for a person in their 30s to have serious discussions of this nature. People don’t talk about dying — at least not their own deaths — at this age. They talk about growing old together with someone they love. They talk about watching their children grow up, go off to college, get married, and have children of their own.

Husband confirmed my suspicion. They had never discussed these issues before. For now, he insisted, we would continue doing everything we could — including keeping her a Full Code3. I didn’t argue with the decision. Had Dinah been 95, I may have. But Dinah was in her 30s. She was supposedly healthy just a week ago.

Thinking back to that night I am not sure when I started to sense my own helplessness. I think it hit me after Dinah arrived on the unit from the ED and I started counting up the organ systems that had failed. It definitely hit me after she coded again.

For the rest of the night she continued to decompensate. She was dying in front of me. And all I could do was throw temporizing measures at the situation. Her oxygen saturation kept dropping. The respiratory therapist kept increasing the support provided by the ventilator. Her blood pressure kept sliding down, slowly but surely. I kept ordering additional vasopressors until she was maxed out on 4 different ones. I think the helplessness hit me with each vasopressor I ordered.

Of course, the helplessness hit me every time I turned to the family to offer an update. Every update was negative. I don’t think I delivered an ounce of “good” news that night. I watched as family streamed into the room two-by-two (per ICU policy) with tears streaking down their faces.

Before my shift ended Dinah passed away. She did so with her family present, surrounding her hospital bed.

And I stood by, helpless.

  1. Levophed, or norepinephrine, is an IV medication classed as a “vasopressor.” It helps by raising the blood pressure in a patient with hypotension or low blood pressure. This class of drugs is often referred to as “pressors” for short. []
  2. Mechanical ventilation involves an advanced airway, typically a tube that goes in through the mouth and passed the vocal cords. This tube is attached to a machine — a ventilator — that is able to breathe for a patient by pumping oxygenated air into her lungs. It can also sense when a patient is trying to take a breath and assist. []
  3. When a patient’s code status is “Full Code,” in the event of cardiopulmonary arrest, a Code Blue is called. Chest compressions, shocks (if appropriate for the cardiac rhythm), and medications are administered in the hopes of “bringing the patient back.” []

The Silence

The following is a post I wrote in medical school that I never published.


“C’mon,” my resident called out to me, “Let’s go do something.”

“Ok,” I replied as I half-jogged to catch up with her.

It was a slow night in Labor & Delivery. I wasn’t doing much. Most of the patients I saw that night during Night Float (shift from 5:30 PM – 7:00 AM) were patients in triage with various complaints. Most were women who had been feeling contractions that day. I think most were sent home that night because they weren’t yet in labor. (Labor is defined as contractions plus cervical change. Since they had contractions without dilation of their cervix, they were not going through active labor.)

The resident and I walked to triage. The nurses had told us that there was a patient in triage who was still in the early part of her 2nd trimester. She came in complaining of decreased fetal movement. The experienced ones on the unit didn’t think much of it. They wondered if she had even felt movement before this time as it was early in the pregnancy. But the patient was here; and so we went to see her.

As we walked into the room the nurse was trying to find fetal heart tones with the handheld Doppler Ultrasound device. (A Doppler Ultrasound is a handheld device that allows one to hear the fetal heartbeats.) She muttered something about the equipment in the room not working, about her doppler’s battery running out. She could not pick up any heart sounds; her probes were met with silence. This should have been my first warning sign. The nurse then left the room to allow us to do our exam.

Our patient was lying in her hospital bed. Her husband stood by her side. Their toddler sat in a chair, amusing himself with a toy. The patient explained to us that she understood it was early to feel movement. But she had started feeling movement a couple weeks ago. However she noticed that it was significantly less a few days ago. That day, though, she had felt none. She wondered if it was just because she wasn’t noticing it. After all, we often advise expectant mothers to sit still in a quiet place when they try to do “kick counts” because it is easy to block the movement out when the baby is still small.

The resident fired up the ultrasound machine and started probing. She was going to try to assess for fetal heart rate since the nurse hadn’t been able to with the Doppler.

“There’s the head,” she said as she pointed it out on the screen. She continued moving the probe around, sliding it over the jelly-covered belly. I thought I recognized the chest wall, but I was so bad at looking at ultrasound images that I didn’t think much of it when the resident kept moving.

“I usually find it really quick. But maybe the baby is turned away,” she told the couple. Again, throughout the ultrasound, only silence.

My resident then turned to me, “Can you call Dr. A on the unit? She might be better at this.”

Dr. A was our senior resident — less than a year away from becoming an attending. It made sense that she would be better at this. But this was also my second warning sign.

I left the room, but instead of getting on the phone, calling the unit secretary, and asking for Dr. A, I ran to the unit myself. I didn’t want to waste time. Besides, since I didn’t know the unit’s extension, I figured I could run to Dr. A faster than I could call.

When I returned with to the room with Dr. A, she politely introduced herself and replaced the resident at the ultrasound machine. She took her turn at the machine. Within a minute, though, she turned to the resident and quietly asked her to page the attending physician on call. And there, accompanying the silence, was warning sign number three.

The resident and I walked out. She paged Dr. B. In the hospital, they don’t like paging the attending unless absolutely necessary — especially when it is at night.

I was surprised at how fast Dr. B came. I remember thinking that the call room must be really close.

Dr. B, the resident, and I walked into the patient room. Dr. B introduced herself as the supervising physician and took over for Dr. A at the ultrasound machine. After a little bit she turned and asked us to turn the lights back on.

“I’m sorry,” she began as she looked at the patient and her husband, “there is no heartbeat.”


I don’t know if I still remember the mother’s face. I think I do. But it isn’t a very clear picture in my head. I didn’t want to stare as the tears started streaking down her face so I looked away. It was tough. Labor and delivery is usually a unit of such joy. The patient’s are generally young and healthy. They leave with brand new bundles of joy.

But that night, instead of joy and new life, I came face to face with silence.


Code Status

Every single patient that gets admitted to the hospital needs to be asked about their “code status.”

I usually ask about this in this way:

Now I have to ask this question to everyone I admit, regardless of what they are being admitted for.

In the event of an emergency, if your heart were to stop or beat ineffectively, if you are unable to breath on your own, what would you like us to do?

Do you want us to do everything to bring you back? This includes doing chest compressions, shocking your heart (if it is appropriate) and putting a tube down your throat to help you breathe with a machine.

Some patients who have been admitted frequently will be familiar with this question. They will immediately answer and ask that we either “do everything” or do nothing and just “let them go.”

Others stare blankly at you because they have never been forced to answer this question. They may look at their spouse. For those that hesitate I explain that there are risks to these attempts at resuscitation and that the older a patient is and the more medical problems they have, the less likely a full recovery should be expected.

I also allow them time to think about it and discuss it. I tell them that they don’t have to decide now. I also tell them that the decision they make is not final and “set in stone.” They can change their minds later. However, if they are unable to make a decision at this time, they will default to a “Full Code” status until they tell us otherwise.

Asking the question(s), regarding code status, is easy. Hearing the answer, on the other hand, can sometimes be difficult.

What about the senior citizen with medical comorbidities — who is unable to answer questions on their own due to the severity of their medical problems — whose family insists we do everything to keep them alive? It is not rare.

As physicians, we look at the patient from an admittedly detached point of view. Sometimes it is out of habit. Sometimes it is out of necessity.

It is difficult when we see our patient, who has poor functional status by any standard of measure and who would likely incur more harm than good by performing resuscitation measure in the event of cardiopulmonary arrest, carry a “full code” status in their chart because family is unable to come to terms with their state of health.

I do realize that there are many reasons a family will have for not rescinding a full code status. That is probably a topic for a whole different post.

This post, to me, seems more like a stream of consciousness post than a post that was well thought out and that had a point to prove or make. I apologize for that. It is just an issue/topic that has been on my mind recently.

For those of you who have had to carry this type of conversation regarding code status, how do you approach patients? How do you approach families? How do you discuss this issue regarding patients who are unlikely to have any benefit from resuscitation but whose families are adamant that all measure be taken?


Again, MICU

This year I was one of the “lucky” residents who were assigned two MICU months and two CCU months.

I am finishing my 2nd year of residency in the MICU. It has been a long and exhausting month. My last call was probably my most emotionally draining one.

The call day had ended and I soon found the MICU empty of other residents. I was the senior left on duty. Around 10 pm, one of the nurses came up to me and told me that an arterial line was no longer functioning properly. The line was needed as the patient was on a couple medications to support her low blood pressure and the arterial line provided an accurate measure of her blood pressure. This patient also needed frequent blood draws to check her pH, CO2, O2, and HCO3 levels in her blood.

I asked the nurse to get things ready and I would attempt to try and place another line. After notifying the attending, I started scouring the MICU for our ultrasound machine. Knowing that the patient was on pressors (medication to maintain blood pressure), I figured her artery might be small and I would use any help I could get.

To make a long story short, I made 3 attempts with the help of the ultrasound. First attempt I got a red flash of blood in my catheter that indicated I had hit the vessel. However I could not successfully advance the guide wire. As I re-checked the location of the vessel on the ultrasound, I realized that her vessels were clamping down even tighter. I had to try further up her arm for attempts #2 and #3.

After three attempts I threw in the towel. I paged my attending and asked for help. He came back and suggested we try a femoral arterial line instead of one in her wrist. Having never placed one I was eager to at least try. In the end, though, the attending ended up placing one.

Minutes later, the patient would code. She went pulseless and chest compressions were immediately started. We brought her back. But she would do it again later that night. The second code was not successful. And in the early morning hours I phoned sleepy relatives to deliver the fatal news.

The following morning as rounds began, one of my interns notified me that Mrs. X had approached him. She wanted to withdraw life support on her husband. She would later do so and request that the intern and attending be present as they disconnected him from the medications and ventilator that kept his body alive for the past week.

I watched as she wailed and cried over her husband’s body. And slowly and quietly we walked away; because we had to move on to other sick patients.

We moved on to a room where a young body lay motionless. A mother was hysterical saying that it was “too soon.” There wasn’t a dry pair of eyes in that room as our team walked in. And I watched as my attending deliver blow after verbal blow. The patient was past any intervention. There was no surgery or medication left to try. Expected reflexes were absent. There were no signs of spontaneous breathing; the patient was fully dependent on the ventilator. Our medical advice to the family? Withdraw life support. Despite initial vehement protestation by a grieving mother, the family finally made the decision to withdraw life support late that day.

One of the family members looked right at us and said, “I don’t know how you can do this every day.”

Sometimes, I wonder that too.


Very Sick and Nearly Dead

When caring for patients on an inpatient basis — that is, patients who are admitted to the hospital as opposed to seeing patients in clinic — there are many moments when you must have crucial conversations. For the most part, medical students are shielded from needing to carry out these conversations. As a medical student, I may have asked patients on admission about their code status. However, I never wrote orders based on my conversations. And if a patient stated that they did not want to be resuscitated in the event that their heart stopped or they could not breathe on their own, I always told the intern or resident so that they could confirm and document the conversation. I think it’s appropriate to allow students to begin asking these types of questions; I also think it’s appropriate (and legal) to have residents/interns confirm and do their own asking when a medical student initiates discussion of these topics.

There are other conversations that, unfortunately, become more familiar as one gets accustomed to inpatient medicine. The conversation with patients and families regarding goals of care is probably as heavy as it gets. At times, this conversation spans days. When taking care of patients who are all-of-a-sudden critically ill, it is often extremely difficult for this conversation to take place and families often need to be walked through the reality of the situation and the grim prognosis. Even with patients who are chronically ill, these conversations may take time.

One of the key pieces of information during these conversations is the severity of the condition and the prognosis. In my short experience I have found that patients and families react differently. Some will cling to your every word, writing down the way you say things and even making sure to write down your name. Others listen with a blank stare; they make you wonder if the are even listening. It is both the honor and the burden of the physician to accurately and effectively convey this information.

Unforunately, it isn’t always a burden we carry well. Too often, I hear doctors (myself included) described the state of a patient as “very sick.” I don’t know if there is a good answer to why we, as a profession, do this. Perhaps it is easier to say someone is “very sick” rather than that they “are dying.” Perhaps some of us view death as the doctor’s ultimate defeat — something that we sometimes refuse to admit. Perhaps we have our own personal issues with death and dying (consciously or sub-consciously) and treating a dying patient forces us to confront, or at least acknowledge these issues (consciously or sub-consciously). Regardless of the “why,” I think we ought to do a better job of communicating to families and patients.

I remember calling a patient’s daughter. I remember telling her that her father was “very sick.” As she tried to grapple with the words I were telling her, she asked me, “Is he dying?” As I sat holding the telphone handset to my ear I finally answered, “Yes, he is dying. I cannot say when. I cannot tell you if it is days or weeks right now. But he is dying. He is getting weaker everyday.” Five days later, after I had left the service, I learned that my patient had passed. And in finding out about his death, I found solace in the fact that I had done what I could to prepare the family.

As difficult as it is to hear that your loved one is dying, I think we owe it to our patients and their families to be prepared for whatever comes next — at least what we think is most likely according to our education and experience. Some patients and their families understand what “very sick” means. Others don’t. The words we use, though, are not important. What is important — what is crucial — is that we communicate effectively with our patients and their families.


Another Day, Another Loss

My patient died today.

It was my first death as the senior resident on the team.

Couldn’t help but think about what I could have done more.

After I was notified that my patient had passed, I went up to the unit.

The room was full of people. Slowly they trickled out. Two family members lingered, one was her brother who had been by her bedside for so many hours in the last few days.

I offered my condolences and offered my hand. He looked at me, his eyes red, and started shaking his head.

And then he hugged me. And thanked me. Thanked me for what I had done. Thanked me for my calmness through her dying.

And I hugged him back.