Morning rounds passed without a hitch. I felt the usual: limited understanding and poor clinical synthesis. The residents assured me that this was normal. After morning rounds, my team, composed of the attending internist, a second-year internal medicine (IM) resident, a first-year radiology resident, and three third-year medical students, ascended to the computer lounge. We chatted about life as third-year medical students, patient conditions and the questions we wanted to ask our patients. We exchanged courtesy greetings with the team’s pharmacist, case worker and social worker.
We began our rounds. The mood was relaxed with a twinge of nervous anticipation as the students knew that oh-too-soon they would present their patients to the attending and then receive responding critique. We headed around the corner and arrived at our first patient. We prepared outside his room and reviewed his laundry list of co-morbidities and non-specific symptoms. Frequently, he had been in and out of the hospital over the past few months, and now, his wife was present to discuss his options. The patient was under methicillin-resistant staphylococcus aureus (MRSA) precautions; thus, only the attending and residents, donning gowns, gloves and masks, entered the room. I and the other medical students eavesdropped from outside the door.
Soon, we were jolted to attention by an overhead announcement, “Attention, code blue. Six south. Attention. Code blue. Six south.” No one batted an eye: my team and I were on seven north. “I wonder if we have a patient on six south,” wondered a fellow third year medical student. She glanced down at her pre-round notes and was mildly surprised. “Huh, I guess we do: I have a patient there.” Suddenly, her head cocked to the side, and she squinted. “Well, he could have become septic,” she postulated. Then, the second-year IM resident walked out of the MRSA patient’s room.
She looked distressed as she quickly de-gowned, de-masked and de-gloved. Immediately, she was on the phone speaking in a concerned yet quick manner. The radiology resident and the attending quickly closed the conversation with the patient and congregated with us. The IM resident briefed the team as the radiology resident took the mobile workstation to the elevator. The rest of the team headed down the stairs, around the corner and into a crowd of nurses. The IM resident took command and in a booming voice, announced, “We are the medical team in charge of this patient’s care. What’s going on?”
The nurses began to explain in choppy sentences. Apparently, about five minutes prior to our arrival, the patient’s nurse walked in to administer an injection and saw the patient sprawled across the short side of the bed: He was unresponsive. A code blue was called. Quickly, the triage team attached the electrocardiogram (ECG) leads, and a dangerous, yet shockable rhythm flashed upon the ECG screen. Just as the triage team was ready to shock, the patient’s code status was discovered to be ‘do not resuscitate’ (DNR). The team turned off the automated external defibrillator (AED), and the patient expired. When the blood cultures had been returned, they resulted in four out of four cultures positive for gram-negative rods.
Our team was in disbelief. The patient was seemingly fine last night and even this morning during my fellow third-year’s pre-round visit. He was a bit hypotensive but without change from baseline. He was a bit delirious but still oriented to time and place. He had been walking around and talking freely with the nurses the previous night. What could have happened within the last hour and a half for him to completely decompensate? The IM resident then confirmed the expected sepsis caused by bacteremia and exited the room. I looked at the patient and could only see his feet upright and hidden under the blanket. It was my first and last image of that patient.
Our medical team collected in the hall while the other team’s resident rushed to print the ECG strip. Understanding the situation, our attending responded appropriately “Alright, anyone want to take a shot at what we could have done?” We were silent. I wasn’t sure if this was because no one knew the answer or if no one wanted to acknowledge it. The attending went on to explain the proper management of bacteremic sepsis. He was also quick to note that specifically, in this case, he believed that no dose of antibiotics following admission would have saved this patient. We agreed in silence.
And with that, we moved on. The IM resident detached herself from the team to call the patient’s family members and inform them of the patient’s status. Despite its limited utility, she also offered the family the option of an autopsy. I checked my watch and saw that I had to be back on campus in ten minutes. I said pleasantries to our team and left. As I walked to class, I felt a sense of gloom. It wasn’t sadness, and how could it be? I didn’t know the patient: I had never met, talked to or even seen him prior to that day. It was more of a realization of the role vigilance will play in my medical career. However, vigilance would not be the only requirement. In order to be a competent physician, I needed to know how to cope with patients’ deaths.