To Err is Human...

I recently had drinks with a friend of mine from residency. She was having a rough time in the ICU (intensive care unit). The ICU can be a brutal rotation for several reasons: 1) we're on call every 3rd night, 2) the patients are sick as dogs, and 3) it's a very high stress situation requiring us to be good in a pressure cooker.

My friend, J, was just about at the end of her rope. She had just experienced 2 brutal calls, the first where she admitted 6 patients, the second where she only admitted 3 patients but they were really complicated. Her problems began at the first of the two bad calls.

She admitted a patient with HIV and some kind of pneumonia. HIV patients with pneumonia are scary, because they can look ok one minute and crash the next. They can have everything from a run-of-the-mill bacterial pneumonia to all sorts of crazy stuff like fungal or parasitic pneumonias. It's not an easy situation to deal with, and they often end up requiring intubation.

This patient was no exception, and before long he was breathing an even 12 breaths per minute on the ventilator. She starts to write orders and the admission H&P (history and physical). Then the patient's family comes in.

My friend, J, doesn't know how much the patient's family knows -- do they know he is HIV positive? Many patients don't tell their families, for a variety of reasons. Some aren't open about their life style choices, some don't want to scare their families, some haven't dealt with it themselves yet, and some don't think their families have a right to know. For every person that doesn't disclose their status, there are that many different reasons for not doing so. We, as physicians, take people's medical information very seriously and do not (for ethic and legal reasons) disclose medical information without the patient's consent.

This patient, however, is intubated and sedated. No consent happening there.

"So, what do you know about your brother's medical history?" J asks the patient's brother.

"I know he said his T cells were low," the brother answers. This is a relief to J, because T cells are a marker for HIV infection and only talked about with regard to having HIV.

"So, you know about his HIV?" she asks, relieved.

"He's got HIV?!??" the brother asks incredulously. J's heart sinks. Now, if by some miracle the patient wakes up, she's got to tell him that she has just disclosed his status to his family. The patient could get angry -- irate even. He might be disowned by his family. He might even contemplate suicide.

To top the night off, the attending points out on rounds the next morning that she forgot to cover for the run-of-the-mill bacterial pneumonia. The attending is visibly disappointed in her.

After staying up all night, after trying so hard to do the right thing medically and ethically, she feels defeated. She goes home after working 30 hours in a row and cries herself to sleep.

We are talking over beer at our local pub, and she tells me she is wondering if she's cut out to be a doctor. Maybe this isn't right for her, maybe she's not smart enough or can't handle the stress well enough. Now, J is extremely bright, personable, just a terrific doctor into whose hands I would trust my own loved ones.

Nothing I can say will help get her through this. We both know this. It's something we all go through, over and over again, to varying degrees. I've made mistakes and wondered if maybe I -- and my future patients! -- wouldn't be better off if I did something else. Something harmless, like horticulture. Your confidence is shot, you second guess yourself, you stop enjoying medicine. But, there will hopefully be that next patient you connect with, who you diagnose and treat appropriately, who rekindles your passion for being a doctor.

I think it was FDR who said, "When you get to the end of your rope, tie a knot and hang on!" All I could do for J was help her tie a knot, cross my fingers, and hope that her next redeeming patient would come along sooner rather than later.

(PS...The patient did miraculously recover, and J told him about the conversation she had with his brother. The patient shook his head, "Oh, he knows I got HIV, I don't know why he said he didn't know." Crisis averted.)