Indexing Title: DCHUA’s Medical Anecdotal Report [04-5]

MAR Title: First Death

Date of Medical Observation: August 1998

Narration:

Everything has a beginning.

Patient exposure for medical education starts with clinical clerkship.  Six years ago this month, I entered its most awaited rotation, that of Internal Medicine.  I was assigned a twenty-year-old renal failure patient with an illness not of his own doing.  Accompanying the patient to private renal dialysis centers, we developed a rapport that bounded on friendship.

During one of his subsequent admissions, he developed a generalized weakness and would have difficulty of breathing episodes.  He was admitted to the isolation ward where laboratory work-ups were done to search for an occult source of infection.  Echocardiography done on him revealed an ultrasonographic picture of fluid beneath, enveloping the heart.  This minimal amount of pericardial effusion, my readings told me, would not significantly restrict the pumping function of his heart.  The recommended treatment for this complication was dialysis itself.

Over the next couple of days, the patient’s condition worsened in spite of medications given.  As the one in charge of the regular monitoring of the patient, I detected an interesting aberration- that the sounds during blood pressure measurement would appear and disappear with each breathing cycle of the patient.  This pulsus paradoxus, was strong enough to make the pulses on the wrist disappear every time the patient inhaled.  I asked a colleague to verify this unusual finding and reported it to the resident-in-charge of the patient who casually brushed it aside.

Eventually, the patient was brought to the in-hospital dialysis unit for urgent treatment.  In the middle of the procedure, he complained of a worsening of his labored breathing, became delirious, combative, and unstable.  I sounded an emergency code, bringing most of the medical staff to the cramped unit.  While handling some medications, I accidentally pricked myself while capping a syringe with both hands.  Portable chest x-ray was done and supportive medications given.  The patient never left the dialysis unit alive.

I remember crying in my sleep, for being unable to save my patient, for not recognizing the importance of my findings about the patient, and for the lifetime of experiences lost by someone so young.  Fairness aside…

Everything has an ending.

Insights (DISCOVERY, Stimulus, Reinforcement):

That for doctors, actual learning starts only with patient exposure during clerkship.

That decreased blood pressure and weak pulse from the pooling of blood inside the veins of the thorax during inspiration signifies compression or tamponade of the heart from the outside, usually by fluid in the pericardial sac.

That a pear or flask-shaped heart on chest x-ray (which for the patient, on retrospective analysis with older plates, showed a progressive widening of the heart shadow) signifies a significant amount of fluid accumulated around the heart.

That this amount of pericardial effusion is not treated conservatively but with pericardiocentesis, i.e. drainage by aspirating thru a properly placed long needle.

That hemodialysis is not without its risks- that the decreased blood volume of a patient during the procedure can push an already poorly functioning heart to failure.

That my superiors are fallible.  That their failure, is my failure.

That too close a rapport with patients is a double-edged sword.

To voice differences in opinion even with superiors, and persist especially when the welfare of the patient is at stake.  Do so respectfully, and mindfully of the context that one has limited experience and may prove wrong.

To recap needles in the proper way thereby preventing occupational injury and decreasing the chances of accidentally acquiring blood-borne diseases.

To advise all medical personnel of the importance of anti-hepatitis vaccinations.

That circumstances and lessons leaving the greatest impressions are those surrounding life’s end.