I recently asked my neighbor Terry, a trial attorney, if he’d ever had to defend a murderer knowing full well they were guilty. His riposte unnerved me:
“Have you ever killed anyone, doctor?”
“Of course not,” I replied.
And it was, on the face of it, true. I have not killed anyone. But his question prompted a series of reflections. Reflections on culpability and accountability punctuated my thoughts for days, weeks, and months after that. Death is a complex subject for a physician. There is nothing binary about it when we lose a patient. While I’d satisfied the legal clause for culpability with my answer, it was far from an open and shut case for me.
I am now a seasoned consultant with well over thirty years of experience. But what about my Internship years at SUNY/ Kings County Hospital?
Today I know how to respond when I hear that one of my patients has died a sudden, unexpected, premature death of unknown causes. My professional response to a non-traumatic, unanticipated death of a patient, of any patient I’ve cared for, goes through five distinct stages of shock.
Stage 1: Put yourself, willingly and voluntarily, in the position of a person of interest (POI). Stay on the POI list for the foreseeable future. Conclude that your professional colleagues have already convicted you of the crime of causing your patient’s death.
Stage 2: Ask questions. Did you prescribe the medicine correctly, or was the surgery that you recommended appropriate? Did you not think through the consequences carefully? What did you miss? Did you document document document, record record record, for “If it isn’t documented, doctor, it didn’t happen, Remember?”
Stage 3: Litigate yourself. Prosecute for one minute. Defend for the next three minutes. Prosecute for two. Defend. Equivocate between arguments and counter arguments. Dial up your emotional responses.
Stage 4: Seek out supporting documents for closing arguments — dash to the medical library, run literature searches, read medical journals, call a colleague at a University center, make desperate calls to other consultant friends, repeat the story over and over again, ad nauseam, seek reassurance. “You think the aspirin I gave Mrs. G caused the incident? You think that the aspirin I did not give Mr. K caused the incident? Do not ever use the “D(eath)” word.
Stage 5: Go back to stage 1, rinse, and repeat.
Even in an ideal world, such an exercise is probably necessary, if only to approximate better metrics, avoid repeating human errors, deliver appropriate care, and ensure the best possible clinical outcome.
I look back to my days as a novice intern, working forty-eight-hour shifts. Calling it indentured servitude would not be hyperbolic. A typical day would entail drawing blood, labeling and transporting specimens to different venues in different buildings in between admitting gunshot victims, wheeling patients to radiology, from pathology, over interdepartmental bridges, through basements, drawing blood, managing the airway of intubated patients, making rounds, writing notes, admitting and discharging, and did I mention drawing blood? Then there’s the flotilla of walking-talking-demanding patients, demanding the things that a patient rightfully must and should demand. They’re not alone. Their demands are matched and sometimes exceeded by supervisors: chief residents, attending physicians, the admin staff, the social workers: all get to have a piece of us. You begin seeing yourself as a kill that predators are fighting over.
Then there are the special cases — the terminally and critically ill, who were admitted through the ER. I remember so many of them with their haunting youthful looks, horrified visage, beseeching eyes, rattling breaths. On any given day, there were dozens of these patients, all under the age of 25, young men and women with full-blown AIDS/HIV who were intubated, and whom I had to wheel to the regular medical ward as the ICU wouldn’t allow them.
The Medical establishment knew very little about the AIDS epidemic then. Our resources were scant, moral and ethical questions were inconvenient, and no one wanted to even breathe the same air (much less touch) the patients.
Enter the overworked intern.
Those were the days when I fell asleep at the wheel crossing the Verrazano Narrows Bridge, or on a couch after removing one shoe but not the other, days when the sole purpose of my existence was to secure intravenous cannulation into human bodies.
I wandered supermarkets at odd hours looking for pre-packaged meals, eyes dutifully tracking every stranger’s arm for vascular access. How easy or how hard would it be to slip a beveled 21-gauge needle into those veins. I could almost hear the “give” of smooth entry — metal tearing through flesh — the swoosh of blood return. I stared enviously at the bloated veins on a butchers’ forearms. If someone had held me up at gunpoint, I would not have missed the opportunity to determine availability for a proper venipuncture in the hand holding the trigger. We lived and died by access into human vascular systems.
One time, I pleaded with a mother not to sign out her very young sick son against medical advice. My chief resident cornered me. I feared he was about to physically assault me when he hissed: “Are you stupid, Dr. R? Don’t you have enough work to do? Let them go.”
Only now do I recognize how restricted my visibility was, how many natural and appropriate emotional responses I’d been forced to suppress. The notion of self-care wasn’t even a fantasy. Medical ethics and humanitarian concerns became abstractions under the press of daily emergencies.
What role did I, did all of us in the medical field, play in what had too quickly become routine death marches? We lacked the resources and skill sets (and most of all the time) to care for just one AIDS victim adequately. At times, I had twenty-five under my care.
Medical science put the breathing tube into someone’s throat to alleviate their air hunger, then made us wheel them via the medical floor into the morgue. Medical science turned its back on these patients — and then turned its back on us, its disciples in training.
I remember signing a pile of death certificates on a daily basis. My job was to do scut work towards the finale.
That was my initiation into my profession.
Sometimes, the beginning gets us to the end, with all the right lessons learned for all the wrong reasons.
“So yes, Terry, I have killed. Even if I have the perfect, perfect alibi.”