Suddenness

Note: Details of this case have been altered to protect patient identities.

Upon receiving the personal preference sheet for pediatrics, I was faced with a bit of a conundrum: I had always intended to avoid kids and consequently had done little in the way of thinking about pediatric subspecialties. Given that two weeks of my inpatient experience was to be concentrated on a specific aspect of pediatric care, I knew that I ought to choose something that would be of interest to me. After reflection, I opted to spend two weeks in the pediatric heme/onc service, figuring that it would be a very educational experience.

I expected and accepted that the service would be sad, even depressing. I mentally prepared myself for working with kids who had been diagnosed with horrible cancers and were being treated with some of our most toxic armamentarium. I knew that it was entirely possible that I would be taking care of kids with a terminal diagnosis, and not outside the realm of possibility that one of my patients would die while I was on service.

When it happened, it was not what I was prepared for.

I found that I enjoyed my first week on service; the heme/onc ward was not nearly as depressing as I had imagined it. Sure, the kids were sick – in many cases, very, very sick. Most of the floor was on isolation. There was the occasional diagnosis that we could do little for. A few patients were new diagnoses: kids who had been previously healthy.

Still, overall, I was impressed with the fortitude of the kids and parents. They weren’t – for the most part – depressed or angry or grieving (though I do not doubt that most had gone through these stages at some point or another). The physicians on service cared and taught me that kids are resilient, even against cancer – much more so than the average adult.

So it was on my second call day, at the end of my first week, that I was caught surprised by suddenness.

Most of my patients, indeed most of the patients on the inpatient service, were of the oncologic variety. I had a single heme patient, an African American teenager with sickle cell disease, one who had been in the hospital enough times to be bored with the process. I was used to the slow, methodical diseases of cancer, and the slow, methodical treatments of cancer.

Friday afternoon, we had a young boy transferred to our floor from an outside hospital. Up until a few days ago, he had been completely healthy. Briefly, he had mild symptoms: nosebleeds, bruising, malaise, a bit of a fever. We (the resident on-call and myself) interviewed his dad and spoke with him. The story wasn’t terribly remarkable, and the patient was stable when we walked out of the room. Since another patient had just been transferred up, we went to interview that second patient.

At the end of that interview/physical, perhaps thirty minutes later, we were paged that the first patient was not doing well. Joined by the senior resident, we immediately returned to the room and found the boy to be almost unresponsive and hypotensive. Obviously, we were quite concerned, and the decision was made to call the Medical Emergency Team and transfer him to the Intensive Care Unit. Our senior started consenting dad for blood products, and the father reacted quite badly – becoming fearful and crying – eventually proving that a parent’s intuition can sometimes be more insightful than years of medical training.

We accompanied the pair up to the ICU, overseeing the handoff to the ICU team.

On our way back down to the floor, our senior remarked on what a quick decline in status – from being fairly responsive to almost out of it, just within a half hour’s time. As this service was only short call for medical students, I was dismissed shortly thereafter and went home for a brief bit of sleep.

The next morning, as I greeted the interns and started looking at overnight notes, the resident I was with the previous day took me aside. In a whisper, he told me that the patient had coded shortly after I left and that resuscitation efforts were unsuccessful.

It took me a moment to process what he had just said, to work through the medical jargon and understand the bluntness of the event that he had tried to professionalize.

This young boy had been in our hospital for less than three hours before dying. This young boy had previously been completely healthy.

I had actually spoken to him less than twelve hours ago.

The suddenness was dizzying.

The mood on the floor, at least among the physicians who had been involved, was subdued that morning. I could tell that it was an unusual event when one of the docs offered to talk with anyone who wanted to talk about what happened. The hematologist later told me that she had been doing heme/onc for fifteen years and had never seen anything that rapidly devastating.

There was no recrimination; indeed, ultimately, there was little that we could have done better or differently given the timeframe involved. Somehow, that was of little comfort.

There was speculation, and our hematologist offered insight as to what probably happened, but final knowledge would have to wait for the formal autopsy.

I went home with thoughts weighing heavily on my mind. Again, it was not the death itself – it was the suddenness of it. Perhaps if this was a rotation in the Emergency Department, I might have been better steeled against it, but, now, with hindsight, I begin to think that such occurrences are something that we can never be truly prepared for.

Author

Tyler Willis, M.D., Class of 2012

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