The First Patient I Killed
An essay about my first feelings of guilt, and how I struggled to rationalize it
My first few essays here will be from the archive of my writings. I first published this essay on my previous platform on June 22, 2021, and am now reprinting it with some minor edits.
I didn’t even like him very much.
I met him for the first time the same way I met all my patients, on morning rounds with the surgery team: a large congregation of blue scrubs descending into his room at 6am, waking him up before the sun had a chance to try. Each day he was cranky and rude. Each day, someone rolled their eyes when we finished and left his room. It was an arrangement of mutual disgruntlement: him with us, and us with him.
At the hospital, certain patients get labeled “difficult patients,” usually an undeserving title that we use to describe drug-seeking behavior, demanding family members, or generally anyone who argues with treatment plans. Mr. Gordon was labelled a difficult patient before he even got to the hospital – a chronic pain patient, he had multiple neurologic and rheumatologic illnesses, not to mention a history of hepatitis that only served to complete the picture of “drug seeker” that had already been formulated in our minds. To make matters worse, on arrival to the surgical floor, he quickly made enemies with the staff by sarcastically calling the nurses “sweetheart” and generally mouthing off at them. A surefire way to get everyone in the hospital to hate you is to be rude to the nurses.
The days were a blur then, 14 hours of sheer adrenaline that kept me alert between the hours of 5am and 7pm, filled with stressful morning rounds and wonderful surgeries and a hastily gobbled protein bar and endless consults, until I staggered straight to bed when I got home, too tired to even make dinner for myself, and too broke to order take out. Individual patients often get lost in the mix for me – though I wanted them to be my top priority, there was no time in between trying to learn and impress my seniors to spend long hours in their rooms the way I often did as a 3rd year medical student. Yet somehow still, through all those hours I spent at the hospital, I got to know them – if not the names of their kids, at least I knew their medical problems, their surgical history, and their hopes and fears.
Yet somehow still, through all those hours I spent at the hospital, I got to know them – if not the names of their kids, at least I knew their medical problems, their surgical history, and their hopes and fears.
The longest interaction I had with Mr. Gordon happened when I was sent to his room to take out a central line (I had done this before under supervision, so this time I was trusted to do it by myself, an appropriate task for an MS4 (4th year medical student) and one less thing for the interns to worry about that day). After removing a central line, pressure must be held for at least 10 minutes, to ensure adequate hemostasis – possibly it does not take quite this long, but I assume that the time it takes for blood to form an adequate clot is inversely proportional to one’s rank in the medical hierarchy.
“Talk about baseball,” my intern had suggested beforehand, “he likes baseball.” I knew nothing about baseball, having been raised on cricket – and besides, I struggle to hold even the shortest conversation about sports. I am lucky if I can identify the home city of a given team.
Instead, we talked about politics. I know - I hate talking about politics with patients and coworkers, because I don’t want their views to subconsciously affect how I see them (or vice versa) – but he started it! The TV was blaring loudly in his room when I walked in and I didn’t bother to turn it down before I started. Once I applied the gauze over the puncture site, he turned to me (“try not to move your head, Mr. Gordon”) and he said: “Can you believe this moron?”
I glanced at the TV to see that he was talking about Trump. His face was filled with disgust and I imagined that if this were not a hospital room, and if he had fewer manners, he would have spat after saying that.
I was pleasantly surprised. Pardon my politics, but I had learned by that time that most of my older white patients from Long Island had pro-Trump leanings, and at a time when being any color other than white, and any gender other than cis male could leave you open to verbal attack by the president, this hatred from Mr. Gordon immediately warmed me towards him. I didn’t comment on the news, nor did I directly respond to his question, but I quietly wondered if maybe there was more to Mr. Gordon than what lay on the surface.
A few days later I spoke with him once again as I went to visit him in the afternoon before PM rounds – it just so happened that the way we split the list that day, I was taking the top half of the patients, and he fell onto my list.
“How are you doing today Mr. Gordon?” I asked, “Have you had a bowel movement yet?” As MS1s we were taught not to stack questions, but as MS3s and 4s, we quickly learned in the hospital that time is a precious commodity.
“No,” he grunted, shifting in his bed and fussing with the sheets. “And I’m not very comfortable here.”
“I know, it must suck to still be in the hospital,” I said, walking over to his bed. “Would you like me to raise the bed for you?”
“No, no it won’t help, I just feel uncomfortable. My chest feels strange and my stomach won’t move. And this pain is just awful, can’t you get me something stronger?”
Cranky Mr. Gordon was back. While he was focused on pain medications, I wouldn’t be able to get any useful information from him. I assured him that I would check with the team, as I had no authority myself to adjust his pain medications, and asked if there was anything else I could do for him. He rolled his eyes and grumbled that no one ever heard him or helped him out, and I took this moment to give a sympathetic nod and quickly exit the room.
The next morning, I got to the hospital early in the morning, and when scrolling through my patient list I noticed that Mr. Gordon was no longer there. Confused, I searched for him using his medical record number, and within his chart I found a host of notes from the past 12 hours, the most recent titled “Patient Expiration.” I was shocked. In warp speed (it was already 5:20am, and even though one of our patients had died, I still had 10 other patients to check up on before morning rounds started) I replayed the events from the previous day in my mind as I read through the medical record.
Had something been wrong? Well, yes – he had said he was having some chest discomfort. I thought I had done the right thing at the time – I had passed on the information to another member of the team who outranked me, hoping they would be able to address the issue. Should I have asked him about arm pain? About sweating, and nausea? Was he having cardiac ischemia, or an early MI? I continued reading the notes, which included a Code Blue note around midnight, still shocked by what had happened. When we started rounds, no one so much as mentioned it, other than in passing to say that the intern who was covering overnight was swamped. I was preoccupied all day as I sat in a 10-hour robotic case watching the surgeon struggle with difficult anatomy. It was a terrible day.
It wasn’t my fault, I know that. It wasn’t the other team member’s fault, who didn’t work up his chest pain, or maybe the patient didn’t report it as a genuine symptom. It wasn’t the intern’s fault, who was cross-covering multiple teams overnight, and had a hundred other more urgent things to do before he could assess Mr. Gordon’s chest pain – or maybe he never got to it. It wasn’t the chief resident’s fault, who possibly didn’t even get to see the patient because she was in the OR operating all night. It wasn’t the attending’s fault, who in all likelihood didn’t even know any of this was happening until the early morning, when he learned of Mr. Gordon’s death. It wasn’t anyone’s fault. And yet, somehow, it felt like everyone’s fault.
It wasn’t anyone’s fault. And yet, somehow, it felt like everyone’s fault.
Maybe it is dramatic for me to say that Mr. Gordon was the first patient I killed. Perhaps the first patient I couldn’t save would be more accurate.
And now, it is almost a year later, and I keep coming back to it every once in a while, because time has a way of making us think we had more control over things than we actually did. What if I had stayed in his room longer, and actually asked him more about his symptoms? What if I was able to tease out the fact that he was having chest pain? What if I had worked it up myself, asking some questions and doing a focused physical exam? What if I had taken note of his vitals, and what if his heart rate was elevated, or his blood pressure was low? What if I had reported my findings to the team and asked to get labs and imaging? What if after running the list with the team at the end of the day, rather than heading home, I had logged back onto the computer and checked up on those labs and imaging? What if I had seen elevated cardiac enzymes, and we had started treatment, and gotten an urgent cardiology consult? What if, even after doing all that, he had still died? The what ifs don’t stop.
There were so many other patients I had as an MS4 that I fiercely advocated for, and as a result, they probably got more attention than if I had not been around. I had patients that trusted me more than they trusted the attending surgeon. I had patients that insisted on calling me Doctora despite knowing that I was a medical student. But even knowing the nature of the job, the joys, thrills, and rewards that come with it, sometimes the failures hold a much larger space in my mind.
As medical students, we all heard some variation of this truth: “everyone in this room will kill at least a few patients in your careers” is announced to the first year class – not to be cavalier, but to be honest about what we are getting ourselves into. Perhaps a kinder way to say it would be: we cannot save every patient. But regardless of how it is phrased, the implication is the same: some patients live, and others die. We play varying roles in determining those outcomes. And trying to figure out when, what, and why can be maddening.