I was 28 years old the first time I killed a man. I don’t remember his name or his age, but I do remember the look on his face when I told him he was fine to go home.
He had come to the ER with flu-like symptoms during flu season. After a few liters of fluids and some ibuprofen, he seemed like a new man. Still, before he left, I double-checked his labs, took a new set of vital signs and reviewed the return precautions with him myself. Even though attention was the resource spread most thin in a busy ER, I tried to spend just a few extra moments with each patient. I was six months into residency training and may not have been the most experienced, but I tried to make up for it by being the most observant.
I remember how the birthmark on his left cheek flushed when he smiled and said “Thanks doc, I feel better.” See, this was the pleasure of the job. Knowing that amidst the heart attacks and strokes and horrible traumas, sometimes people looked happy as they walked out the door.
On the last day of medical school, we took the Hippocratic oath: First – do no harm. It seemed like an easy, obvious goal. That’s what the decade of education, the crushing debt, the sleepless nights, and the Eighty-hour workweeks had prepared me for. I had gone into emergency medicine to help people. As many as I could in a twelve-hour shift.
Six hours and twenty patients later, I hear a loud crash come from across the ER. There’s a long pause and then my colleague Dr. B shouts, “No pulse, code blue! I need the code team!”
I squeeze through the crowd of spectators at the door of the resuscitation bay. Nurses are hanging fluids, a tech is performing CPR. I snap on some gloves and step closer. Even though Dr. B is covering most of the patient’s face with an oxygen mask, preparing to intubate, I immediately recognize the birthmark on his left cheek.
“What’s happening?” I ask even as everyone in the room looks to me and Dr. B to answer that question.
Fine. He’d looked fine when he left.
The phone rings with a critical message from the lab: Staph bacteria, so numerous they’re visible on a basic blood smear, are sprouting like clusters of dandelions in the patient’s blood. They float across the microscope slides like a bad wish.
Dr. B looks at me. “Didn’t you send this guy home earlier?” he says, “Was there staph in his blood before?”
“Would I have sent him home if there were? How many hours was he just sitting in your hallway?” I said.
Both of us are irritable and terrified, unsure whom, if anyone is responsible, our adrenaline making us look for a fight we might actually win, because we are clearly losing the one in front of us.
I climb onto the stepstool and take over chest compressions, putting all my weight behind them.
I replay the morning in my head. Labs. Fluids. Motrin. He walked out smiling.
The phone rings. His lactate level is over 15: a sign his organs are shutting down from lack of blood flow. It’s called demand ischemia. Because that’s what the body does - demands, demands, demands until we can’t keep up with it and everything just quits.
Time of death: 7:45 pm.
The room clears out and I uncover the body, examining every inch, willing him tell me what I missed.
When I talk about the mistakes I’ve made, I’m really talking about the patients I’ve lost. Like keys, or a wallet. As if a life, once gone, is something I could find if I just searched hard enough. But when I look, all that’s left is data. The tiny clues that, in hindsight, feel like fingers pointed right at you.
I open his chart but everything checks out – normal - just like it had that morning. Then I start to notice all the empty spaces, all the things I didn’t do. The ER is about calculated risk: you can’t admit everybody, can’t order every test, can’t anticipate every unlikely outcome. But maybe if I had, I might have seen something, even as the monitors beeped, and twenty more people poured in from the waiting room, and patients said things like “I feel better.”
Here’s what I didn’t know on the last day of medical school. They make use take the Hippocratic oath knowing that we will all become hypocrites. That this would be my first loss, but It wouldn’t be my last. Not even close. And that even as I do better, I will still do harm, regularly, in sometimes very small and sometimes irrevocable ways. Just by showing up to do my job. Someone has to.