Perspective
A Turning Point
An experience in the ICU leads a medical student to shift her focus.
By Rachel Sang, M.D.
About a week into my Medicine II rotation, I was struggling not to become too overwhelmed by my first ICU experience. I had just picked up a new patient. Middle-aged with blond curly hair and a mustache, Jim had been extubated a couple of days earlier. The previous week he had undergone gastric banding of esophageal varices that had hemorrhaged, the result of a liver plagued by chronic disease.
I launched into my well-rehearsed introduction. “Good morning, Mr. Smith. My name is Rachel, and I’m a third-year medical student.” I asked him how he was feeling and how he had slept.
Still groggy, he rubbed his eyes and responded, “Good. I’ll live. So you’re gonna be a doctor?”
“That’s the idea.”
“You guys are all angels. I don’t know how you deal with crusty old guys like me.”
I felt an immediate connection with this man. Mr. Smith reminded me of the rugged farm types I had grown up with: burly, feisty, and seemingly immune to the charm of physicians. He could have easily been my father, my uncle, or the crop-spraying pilot in my hometown of 700—a man who works hard, plays hard, and who won’t come to the hospital until it’s almost too late.
“The crusty old guys are my favorite ones, Mr. Smith.”
“Please, call me Jim.”
I finished my questions and politely excused myself to gather my thoughts so I would be ready to present his case to my resident and attending.
Jim’s wife stood outside the door. A robust, cheery woman, she took my hand and thanked me for all the work we had done. “I just can’t wait to take him home,” she said. “We have so much to do.”
I knew Jim was not out of the woods. With such advanced disease, a liver transplant was necessary for any hope of long-term survival.
I fielded his wife’s questions and informed her that our team would be back that afternoon.
She thanked me yet again, “You guys are angels.”
Angels. It seemed a bit excessive, I thought, as I hurried off to check Jim’s vitals and labs before examining my next patient. Later that afternoon, I was sitting in our team workroom when a group of nurses raced down the hallway. I peered at them through the doorway and saw that they were entering Jim’s room. Curious, I followed them. “Page the resident ... Dr. Nelson. Where’s his nurse? Blood pressure is dropping again ... beep ... Is the resident coming? Another bag of saline … We’re gonna need gloves in here … beep ... beep ... beep ... The patient has hepatitis. Is the resident coming?”
I gasped as I pulled back the curtain and saw the ghost of the man I had met earlier in the day. His hair was askew. I walked to his bedside as he heaved. Dark, clotted blood poured from his mouth, soaking his pillow and the white patterned hospital gown. Its metallic scent filled the air. His eyes were wide with fear.
My stomach was in knots. Soon after I arrived, my resident and attending appeared and immediately gave orders for blood transfusion, volume resuscitation, and pressors. A nurse inserted a second IV, and the race was on. I couldn’t believe how quickly my patient had deteriorated. Only hours earlier, I had chatted with him about his favorite rock band, and now he was fighting for his life.
I found a computer kiosk and signed into Jim’s medical record to check his last set of vitals and give myself time to catch my breath. Just as I suspected, his blood pressure and heart rate had been stable an hour ago.
I rejoined my resident and attending. Two 16-gauge IVs were in place and an interosseous IV was on the way.
“One of the bands probably came off,” the attending said.
The gastroenterologist arrived and decided endoscopy was the next step.
Twenty minutes later, 15 people packed the room, and the procedure began. Several nurses kept a constant stream of blood and saline flowing. The GI manned his scope and camera with hurried precision. Our ICU team hugged the wall as the intensivist discussed pressors with the resident. Jim was no longer awake and was bathed in his own blood. There was blood on the bed, the wall, and the gowns of half the people in the room. The rectal bag overflowed, creating a large puddle of stool and blood on the floor. The stuffy room smelled of rust.
The GI team tried to position Jim so they could proceed.
“Rachel, come here and hold his shoulders, just like this,” the gastroenterology fellow said.
I had been called from the safety of my corner to the front lines. A nurse threw a yellow gown, glasses, and gloves my direction.
As the scope entered Jim’s mouth, he choked, coughed, and spewed blood. It soaked the front of my gown, saturated my scrub pants, and seeped into my socks.
I braced myself and focused on stabilizing Jim’s head while the GI struggled to find the source of the bleeding. Jim’s skin felt cool and clammy. His hair was sticky with blood. I could feel my pulse throbbing. The beep of the monitor filled my ears. I looked at Jim’s pale face and thought “This man is dying in my hands.”
Jim Smith did die later that day after receiving 20 units of blood, a dozen bags of saline, and several emergent procedures.
I don’t remember much of what else went on in the hospital that day. I don’t remember the bus ride home. I do remember seeing Jim’s wife after she was told her husband had died. Her world had turned upside down. Her husband was dead. Her kids no longer had a father. She had a funeral to plan and a pile of medical bills to contend with. She hugged me, a stranger she had met that morning.
“He’s in a better place,” she said as tears rolled down her cheeks.
That night, I cried myself to sleep. I cried for Jim and his family. I cried as I recalled the macabre scene that had played out before me. I cried as a way to cope.
The decision to go to medical school, as with most of the decisions I had made up to that point, had been about me. That day, I realized it wasn’t about me. It was about my patients. I needed to be knowledgeable and decisive. I needed to be there for them and their families. Who else are we here for if not for them? MM
Rachel Sang is now a first-year internal medicine resident at Abbott Northwestern Hospital in Minneapolis.
A version of this article was published in Becoming a Doctor: Reflections by Minnesota Medical Students, University of Minnesota Press, 2011. It is reprinted with permission.