Do no harm
Sometimes a doctor can’t help but kill a patient
A few weeks ago I killed a patient. The patient wasn’t someone I’d met a few times on a ward round, them in extremis, their personal characteristics all out of focus. I’d known Jim since I was a registrar.
We met in an outpatient clinic. He was in his mid 80s, tall and solidly built with neatly clipped white hair. He had severe osteoarthritis of the spine, which had fused the bones of his neck and fixed his head at a downward angle. He walked with a polished wooden stick. He had usually attended one of the recently closed community clinics and was put out at having to come to the hospital.
How was he? Fine. Anything to report? No. I listened to his heart, his lungs. “So,” I said, “what do you do?”
He shifted in his seat. “Oh, I have a few jobs.”
“What are they?”
For our eyes to meet he had to turn his head sideways and roll his eyes to the side. He did that for the first time, briefly. “You don’t have time.”
“I’m having a slow day. Tell me.”
He delivered pamphlets and cleaned houses, for exercise. He had once been a professional florist and now made bouquets of dried flowers. “As you can see, it makes a mess of my nails.”
He started on the past, a story he continued over the years of our meetings. In his 40s he’d had his heart broken by his long-term boyfriend and had never recovered, the way some people don’t.
“Look at you,” he said in his slightly British camp, mopping his eyes. “Sitting there, psychoanalysing me. You’re so … present.”
He called me “darling” or “delicious”. If I wasn’t rostered for the clinic when he had an appointment, the nurses would call me so I could run up from the wards to say hello. He made my family a bouquet of holly and berries for Christmas last year. So when I saw his name on the list of overnight admissions, I said, “He’s one of mine.”
With my registrars and intern I walked to the emergency department, where Jim was waiting for a ward bed. The curtains around his cubicle were drawn. I peeked in. He was standing up, head down, trying to urinate into a bottle. We waited outside. “Damn it all,” he cursed. Seeing our shoes lined up under the curtain, he said, “It’s all right, come in.” He twisted his head sideways and saw me. “Oh darling, I’m so relieved it’s you.” He started to cry. “It’s too terrible,” he said, holding his hospital-issue pyjamas up in one fist, empty bottle in the other. “I can’t pass water and …” – he lowered his voice – “I’ve just dirtied myself. I’m so ashamed.”
I reached up and hugged him. He rested his big skull on my shoulder. “Don’t worry, we’ll take care of you.”
He had a badly infected ulcer on one heel that needed antibiotics, and a blood clot in a deep vein of one calf that I wasn’t sure what to do about. I checked the guidelines and called a colleague: anticoagulation, for six weeks.
He improved slowly. The morning after he’d started holding court from his crisp white bed, I walked in and his face was pale, his hands like marble. He said he was scared, that something was wrong. His blood pressure dropped. My mind flipped through the differentials. I laid my palm on his cold forehead and told him everything would be OK. We called a code. The intensive-care team arrived. Ten of us crowded around him, sticking him full of IV lines, taking blood tests, pumping him with fluid. He groaned when I pushed his abdomen, and I was cold with dread. The surgeons arrived and wheeled him away to the scanner. I stood in the steel-lined pan room, eyes closed, hand against the wall.
He’d lost a couple of litres of blood directly into a large muscle in his back: a small artery with a fragile spot on its wall antagonised by my anticoagulant treatment. They sedated and intubated him, tried to block the artery, sliced him open from breastbone to pubis, transfused him, flooded him with inotropes, filtered his blood.
I went to see him in the intensive-care unit. His grand old body, splayed out on a metal bed, his split abdomen held together temporarily with surgical tape. Tubes to and from his neck, bladder, arms, belly, down his throat. His vitals, up in multicoloured lights, all of them utterly, unreassuringly, within the normal range. Jim. A sack of skin left at a crime scene and kept pink with machinery, saline, drugs and blood. The ICU physician looked at my face. “We’re doing everything we can … But it’s 50–50.”
The retrospectoscope is a medical instrument a doctor wields against herself or – in spite and relief – against a colleague. You look back through this scope and see that you should have or shouldn’t have, you would have or wouldn’t have. I trawled through the notes, the tests, rechecked the guidelines, consulted clinical studies – I could have elected not to anticoagulate. I could have waited. Many wouldn’t, but I could have. I sweated and flinched.
I dragged myself to work each day, hollowed out and refilled with something dense and very heavy. I came home, fell asleep immediately and stayed that way till morning. My colleagues uttered words of comfort. “Don’t worry about me,” I said. “I’m not the one who’s dead.”
I met with a physician, a friend and mentor. I told him the whole thing from the beginning. “Yes, you killed him,” he said. “You’re a doctor, not a naturopath, so you gotta treat people … and sometimes it kills them. I tell you what I wouldn’t have done – held a man who’d just defecated on himself. I’m not sure I could’ve done that.”
I wipe my eyes with the back of my hands. “If you’d known Jim, you could have.”