Failure

In Samuel Shem's House of God, the residents espouse a law of medicine: the patient is the one with the disease. This crude and insensitive statement has a very important purpose: when a bad outcome happens, as it inevitably must, the physician should not (in most cases) be wrought with guilt. Although some people might read the sentence as a grossly mean thing to say about a patient, I recognize what it stands for. We (and especially those of us in intensive care) all have patients who die despite everything we do, get worse despite our surgeries, fare poorly despite our medical decisions. We sometimes question ourselves, but almost always, it is not lack of doctor that kills the patient. It's not a lack of knowledge or dearth of skill. It is simply the ravages of disease and injury and the limitations of what modern medicine can promise. Patients aren't the only ones who expect miracles. Sometimes as physicians, we devote ourselves so entirely, invest ourselves emotionally, physically, and mentally to such an extent that we cannot tolerate failure. And when it happens, we are devastated. We second guess ourselves, question our judgment. Could we have averted a crisis? Were our skills inadequate? Could there be a scenario where the patient sprang back to life?

I recently had the anesthesiologist's nightmare: a patient who could not be intubated, could not be ventilated, and in fact, was a near-impossible cricothyrotomy. Although the patient was a known difficult airway, those of us who respond to codes through the hospital did not know that (as he was not on the medical intensive care service). He has all the risk factors of difficult airway: morbid obesity, obstructive sleep apnea, large neck circumference, poor mouth opening. He also had many inpatient risk factors: recent head trauma, altered mental status, and an intubation course of over a week. After extubation, he developed stridor, and after severe desaturation, the code was called.

Despite all the tricks I and four other anesthesiologists who responded had, despite all our video laryngoscopes, fiberoptic bronchoscopes, different types of LMAs, we could not put a breathing tube into the windpipe. We asked a surgeon to try to access the windpipe by cutting into the neck, but this was complicated by severe bleeding. Even the ear-nose-throat surgeons had tremendous difficult getting to the airway. The patient passed because of an impossible airway, the one thing that gives anesthesiologists nightmares.

My first reaction was to question my decision-making and my skills. And although I know there are a lot of things I could improve, and perhaps the right person could have put the breathing tube in, after talking to all the other anesthesiologists, I was reassured that I had no glaring errors or deficiencies. I was reminded that despite the importance of reflecting on our clinical experiences - and especially - failures, we cannot be locked into the idea that we are guilty and at fault for everything that goes awry. When I say the patient has the disease, I don't mean anything bad about the patient, but simply that he had an injury or disease process that lead to a code blue. As an ICU fellow, I was simply a responder who put all my heart, skills, acumen, and ability for over an hour in resuscitating him and it was not enough. At the end, we held a moment of silence for his passing.