A Routine Procedure

 We’ve all seen patients die. It’s part of the nature of the job when you work in the ER. The majority of patients that die show up dead, and we just can’t get them back. Some percentage show up on the verge of death and none of our interventions make a difference, so the patient dies. Rarely, patients show up walking and talking and die anyways, but those are definitely the hardest ones to move on from. 

During intern year I took care of a Korean woman in her late 60s. Her family brought her to the ER because she’d been having a hard time breathing for a few weeks, and it was getting worse. She was mildly hypoxic and tachypneic, but otherwise looked ok. We put her on some oxygen and started our evaluation. Her chest X-ray revealed that the likely cause of her respiratory distress was a large amount of fluid in her pleural cavity. It also looked like she may have an underlying mass in her lung. We got a CT scan, and sure enough, it looked like she had lung cancer. The patient was feeling slightly better on oxygen, but before admitting her to the hospital, we discussed performing a thoracentesis on her, to improve her respiratory function and to evaluate for malignant cells. 

I explained to her and her family what the procedure entailed, the risks, benefits, and alternatives, and she consented to it. I prepped and draped her, then, under the careful supervision of a senior resident, I slid a large needle into her back, slightly below her shoulder blade, until I entered her pleural space. I removed about a liter of yellow fluid, pulled the needle out, put a band-aid on her, and sent the liquid for analysis. She felt much better, and was able to come off the oxygen while she waited for a bed upstairs. I explained to her and her family that we were concerned about the mass in her lung, but that we wouldn’t know if it was cancer for a few days. They thanked me for helping and I continued with an otherwise unremarkable shift. 

A few days later I got an email from the attending that had been working that day. Several hours after my patient had been taken upstairs, she began to complain of shortness of breath and cough up blood. At first just specks of blood in her phlegm, but rapidly progressing to frank hemoptysis. I was not present when the medical rapid response team was activated, but I do know the outcome. She continued to cough up more and more blood, and died before she could be intubated and the source of bleeding identified. By hospital policy, any time there is an unexpected death, the case is reviewed by all parties involved in caring for the patient to attempt to identify any errors that might have been made.

I was shocked. I had seen this lady walking and talking. I had spent time with her family. I knew she was sick, and, given the size of her cancer, she probably only had months to live, but still, she was fine. I wondered if I had killed her. I’m the only one who put a needle into her chest. I didn’t think I had done anything wrong, but I was just an intern, so maybe I wasn’t even aware of whatever mistake I made. I met up with the senior resident and my attending to discuss the case, particularly focused on the procedure. We reviewed the post-procedure x-ray. They reassured me that there was no indication I had done anything wrong. 

The family declined an autopsy, so I will never know exactly what happened, but I think she died because of me. I try not to phrase it as “I killed her,” but I think I did. I don’t think I did anything wrong, but procedures have risks. My best guess is that as her lungs re-expanded after I removed the fluid, she sheared some blood vessel that was eroded by the cancer and started to bleed. Eventually, her chest started to fill with blood, causing her to feel short of breath and to start coughing. The coughing probably accelerated the bleeding, and she died before it could be controlled. 

I was very conflicted. I felt bad that she had died because of what I had done. I did the procedure correctly, there were no signs of complications immediately afterwards, and I had been supervised the entire time. I kept telling myself that I didn’t do anything wrong, yet I felt like a bad person. My patient was dead. She had trusted me with her care. It was my procedure that lead to her death, but all I cared about was convincing myself and others that it wasn’t my fault, so I felt guilty. It’s a strange feeling, to own the responsibility of causing a patient’s death, while simultaneously absolving myself of it. She died from a complication of a procedure that was indicated and correctly performed. I rationalized it away, but she was still dead. 

The case was reviewed by the appropriate committee, and everyone involved concluded there were no identifiable errors. Without the autopsy we will never know for sure what happened, but I still think about her. I think about her every time I obtain consent for a “routine” procedure. Our jobs involve risk. We work with limited information, often under time pressure, and routinely take patients’ lives in our hands. It is a privilege. But it is also scary. 

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