Prognosis

Content Warning: Medicine, as you all know, deals with illness, death, and dying. This post centers around some of that dark stuff.

As I described in my previous post, there are some bad shifts because they’re chaotic, and then there are some bad shifts because they’re sad (and probably chaotic as well). One of my saddest shifts thus far was a night that I was covering the Trauma and Acute Care Surgery service, during which a patient looked me square in the eyes and asked, “Am I going to die?” and I guessed entirely wrong.

As the nighttime trauma intern, my role is three-fold. My first task is to make sure all the patients on the floor (people who have had surgeries, will need surgeries, or require monitoring by a surgical team) are stable and “tucked in” for the evening. My second job is to go to any Code Blues that occur in the hospital, which is when a patient enters cardiac or respiratory crisis, requiring a large team of specialists to work toward resuscitation. My third task is to venture down to the Emergency Department (ED) whenever a new trauma activation is called. In the trauma bay, the intern mostly hovers in the background: we input orders into the computer (“let’s get a pelvic X-ray”), call necessary consults (“someone page neurosurgery”), help move patients from the stretcher to the CT scanner, and occasionally, when we’re lucky, get thrown in to help with procedures (you can Google chest tubes and central lines, for reference).

Despite the depiction on TV, usually traumas are fairly calm, well-orchestrated events. Patients are stable enough for us to walk through a well-established order of operations (first we survey their airway, check their breathing, assess for circulation). But every now and then, we do have to rush a patient to the operating room or perform rather invasive, emergent bedside procedures (you can cautiously Google “ED thoracotomy” if genuinely curious).

On my saddest night we had several traumas roll in at once, and all of a sudden, I could sense that the team was stretched thin and things were no longer as calm as usual. Distinct moments stick out in my memory like scenes I was watching instead of participating in.

The first trauma to come through was a teenager who had a bad accident, but seemed to be doing ok. He had our full attention, until several more acutely-ill patients came into the ED. “You get the first patient to the scanner, alright?” my chief said. In the CT room, I watched the black and white images appear on the screen, head-to-thigh slices of the patient’s internal organs. Although I thought I saw some blood near the liver, the radiologists reported that the initial images looked just fine. I’m an intern and can barely read scans anyway so I took his word, checked the portable monitor: normal heart rate, normal blood pressure, good oxygenation. I helped get the patient out of the CT scanner and back onto the stretcher. While standing at the side of the bed he looked at me and asked point blank: “Am I going to die?” He was shaking. “I’m too young to die, I can’t. I can’t.”

“No,” I said confidently, placing my hand on his shoulder. “We’re going to take good care of you. You’re gonna be just fine.” I believed it. I paged the orthopedic surgeons to come look at his ankle injury, and excused myself to help with the other patients.

Then I was standing in a pool of bright red blood, helping my senior resident place a chest tube. I remember feeling confused: he was both asking me to be there to help grab supplies and hand him instruments, and was simultaneously giving me instructions to go to another trauma bay and assist with a different patient. I remember looking down at my black clogs, well-accustomed to stomping through all kinds of body fluids, wondering if I was going to leave footprints marking my path from this patient to the next.

I made my way to the next trauma bay in time to hear that the team needed to take this patient down to the operating room. I picked up the phone to call the OR staff, forewarning them. I could practically feel the hustle through the phone cord, as the staff rushed to get the room ready with sterile supplies and equipment.

That patient died in the operating room, and my senior resident called my cell phone, “We’re going to tell the family. You should come with me.” I stood outside the room, but heard their screams, watched the door slam open, and jumped as a family member threw a soda can at the glass door, causing a sound like a gunshot. “I always say it directly,” the Real Surgeon told me as we walked away from the scene, “and then I leave, give them space. I’ll go back later, give them my contact information. No one ever contacts me again, but at least they have the option.”

We went back to the teenage boy who I helped through the scanner. His heart rate was going up. The Real Surgeon ordered to start giving him some blood. I heard the Emergency Department doctor on the phone with the radiologist on speaker, they were looking through the CT scan: “There’s a blush around the liver,” a sign of blood loss. One minute the orthopedic surgeons were examining the patient's ankle, the next we’re rushing him down to the operating room. I followed, wondering if anyone had taken time for a snack or bathroom break between the last case and this one. I watched as the anesthesiologists sedated him and my team opened him up quickly. The Real Surgeon grew red in the ears. I couldn't see her hands from my vantage point, just her elbows bobbing furiously. My pager went off, and I left — thirty minutes before the patient died.

I never got to hear how they told his mother, I had to go back and attend to my other patients on the floor. The next morning my senior resident sent me a text: “That was the worst night of my residency. We should debrief.” The patient had a non-survivable injury, my senior told me when I saw him later that night. There was nothing we could have done differently, he assured me, in the same way we’d relay that message to a family member. But what if we hadn’t had so many traumas at once? What if I had spoken up about what I saw on the scan?

Recently I told my friend this story, and he asked if I had known that the patient was going to die, would I have said anything differently to the patient when he asked about his prognosis?

Doctors, the only people besides fortune tellers ever asked to guess around death, are notoriously bad at prognostication. I do believe we should avoid it at all costs, but where’s the line between prognostication and assuaging fear? How can we provide hope without a, often false, claim?

“You’re gonna be just fine.” I’d say it a hundred times over if it would’ve saved the patient. But truth be told, I’d say it a hundred more, knowing full well that it would not.