Doctor blogs and books intended for laypeople tend to follow a set framework which follows the pattern set by “new doctor” story arcs on the TV shows. These people all picture themselves as Dr. John Carter or Dr. Meredith Grey. And within this structure, there comes the inevitable chapter where the author describes in loving detail the first time he reached down and saved a life.
The scene is never all that much different than the TV shows they follow: the breathless nurses, the cardiac monitors going crazy, the calm and controlled senior doctor, the young hero just barely keeping it all together in the face of overwhelming stress. This piece quoted in Slate is a typical specimen, serving first and foremost as an advertisement for the doctor’s own greatness, name-checking in the very first sentence his Harvard education and Columbia training. Whee!
On my end, the first time I did chest compressions on a patient was when I was a fourth-year med student, and let me assure you, it was nothing like ER. Everyone was pretty calm about it, even the greener-than-green student (that would be me). After all, in the ICU, this sort of thing is a regular occurrence, about as exciting as a food delivery. Scratch that — food is always far more exciting to the ICU staff. Anyway, I was given the duty of chest-flailing because it is by far the least complicated, most labor-intensive part of the ACLS routine. The critical-care fellows (post-grad residents training to become ICU attendings) oversaw and handled the drugs, the RNs placed lines and bagged, and the student handled what they saw as the scutwork (yet very important scutwork) of compressions. The author is right about one thing — the beat of Staying Alive really does closely resemble the recommended 100 compressions per minute. And my patient too survived, incidentally…
… which just pissed off the senior CC fellow. You see, the patient was seen as slowly circling the drain, but the family refused to give a DNR order, and he felt the successful resuscitation just put off what is euphamistically termed “disposition” by a few days. Like all residents and fellows, he was interested in disposition first and foremost, which translates to getting patients off his service by any means necessary (which begets the phenomenon of “turfing,” which is for a separate discussion).
And feet-first is considered an acceptable disposition from the ICU.
That brutally cynical side of real-world medicine never really makes it onto the doctor books and blogs, outside perhaps House of God; neither does the teamwork of a code. And the author quoted in Slate is not ambiguous about his importance: the patient he did chest compressions on was the life that *HE* saved, despite the presence of a senior resident who did the decision-making, and the RNs who in real life would have done the lion’s share of the work. Do I feel the same with my case? Absolutely not. The TEAM saved that patient’s life, and I consider myself blessed to have been on that team, even as the lowest-ranking member.
So let me tell you about the first life that I really did save. I didn’t have to wait for residency or even fourth-year for this one. It happened during my very first rotation as a third-year med student.
There was no dramatic code blue. There were no paddles, no “CLEAR!,” no wizened authority figure whispering in my ear to be cool. And there was no near-death patient, possibly oozing blood from one or more holes, grieving family looking through the glass. The patient was instead quite alert and healthy-seeming, sitting in a sparsely-appointed exam room of the hospital’s sparsely-funded family practice clinic, there for nothing more than a routine checkup. He had diabetes, like so many of our patients, but was otherwise fine. Mr. Madison (not his real name) was African-American, early 60s, retired Navy, and enjoyed spending time outside with his grandkids. His wife was in an adjoining room for the same thing.
After fumbling through one of the first real history and physicals I had done in my life, I exited the room to await the dramatic arrival of my attending, Dr. Chaka. Now Dr. Chaka was an extremely arrogant and intimidating woman, seemingly better suited for surgery or perhaps loansharking than family medicine, and I was going over my notes at the nurses’ station to ensure I gave a pitch-perfect delivery.
The clinic’s records were all in paper charts, as most clinics’ records were in the dark ages of the ’00s, and there was nothing else from previous notes that was all that exciting. The hospital had a primitive electronic record, but that was kept separate from the clinics’ records for obscure reasons that probably seemed like a good idea to someone at some point in time.
And as I sat at the nurses’ station, making desultory smalltalk, it just hit me. To this day, I am not sure why. I just really needed to get at Mr. Madison’s hospital electronic record right then and there.
I had yet to be issued credentials for that system, nor even knew how to work it, so I begged the nurse to look through his files. She shrugged and logged on. Dr. Chaka was late as she always was, and the nurse had time to indulge the silly, brand-new MS3.
This was an ancient, MSDOS text-based EMR system which was about as easy to read as the glowing green letters in The Matrix. When I said as much, the nurse shooed me away and simply printed off his most recent reports.
At the top was a report from a CT scan of the patient’s abdomen which had been obtained the prior year for abdominal pain. That scan had noticed nothing wrong with the patient’s gallbladder, appendix or intestines.
It had, however, made incidental note of a roughly 3x4cm mass on his left kidney which the radiologist called “highly suspicious for malignancy.”
Please note again how the report was from a year prior.
I dipped back into the patient’s room to see if he had heard about it. He said that nobody ever called him back after his CT, and so he figured that everything was fine. No mention was made of it in the paper chart — either no report was faxed to begin with, or else nobody bothered to show it to Dr. Chaka. Nobody had bothered to call anyone, either.
It had simply slipped through the cracks.
All visits to the family clinic used the paper chart as the documents of record. No nurse or attending looked at anything else. Any hospital visit or other document from the hospital EMR got printed out and attached to the paper chart. If it was not in the paper chart, it may as well not have even existed.
Therefore, had I not checked the patient’s separate hospital EMR that day, he would have been dead within a few years, tops, from what was later determined to be renal cell carcinoma.
That was a… pretty boring way to save a life. No denying it.
No charging paddles, no cracking anyone’s chest open. There was no following of any doctor-book or doctor-show cliche. The cutting that did happen occurred in the calmer confines of the OR later on, as the urologist took out the patient’s kidney without the pressure of a cardiac arrest to manage. The tumor had not spread due to the graces of a benevolent deity; the patient was seen as cured.
From my end, it was indeed boring. But that is how lives are saved in the real world. By writing down the proper referral. By sending a patient to the hospital because they just don’t look right. By following proper procedure when deciding what labs to order. Or simply thoroughly examining a patient’s multiple charts.
All of that would make for some frankly shitty TV. Saving a patient just by asking for his EMR records to be printed? Worst episode of House of all time!
But Mr. Madison is alive and well thanks to me. And that is a gift I can hold on to for the rest of my own life.