Learning, as a doctor...

February 22, 2015 - Two nights ago, a patient in our care died. He was a man probably in his early to mid-40s (people here often look much older than they are, making estimation difficult; life expectancy at birth was 48 years in Sierra Leone as of 2010). He was very sick, with what appeared to be respiratory problem, his breath rattling in his chest – we actually weren’t sure he was going to test positive for Ebola at all (though he eventually did). During most of the time I cared for him, he was not very responsive, and when it came time to transport him from the suspect to the confirmed area, we had to carry him on a stretcher. No one knows exactly how he died – when the evening shift went in, they found him.

I want, first, just to pause and honor his death. This is very much the reality of this epidemic, or at least of the “contained” phase of it – people dying suddenly, without us knowing the specific reason, in a strange and unpleasant place, surrounded by people they don’t know and who know almost nothing about them, in the absence of friends and loved ones. Even if we get “better” at treatment/cure, a sizable proportion of our patients – 20, 30, even 40% - are likely to die like this. It happens all the time.

But I also want (respectfully, I hope) to use his death as a jumping off point for talking about the inner life of a doctor – the things we deal with. What we do is sometimes difficult, and very, very strange. We take our whole imperfect human machinery, including our emotions, into situations where what we do may influence life and death, but the machinery remains imperfect. We don’t always win, and we don’t always do everything right. And then we have to live with it.

You certainly know by now how important we think giving people enough fluid is. You may also remember that I have said that there are risks in doing this, the most obvious one being that you can “flood” a patient’s lungs, making it difficult for them to breathe. The gentleman who died (sorry, I can’t use his name, and giving him someone else’s name doesn’t seem right, right now) already had a lung problem, yet we gave him a great deal of fluid, in an effort to avoid all the problems that dehydration brings. So it is possible that, in trying to avoid one mortal danger, we killed him with another.

So these are some of the thoughts that go through my head when I reflect on this:

- I think it is very important to state up frot that this is not about me, not about us. Meaning – the man was alive, the man had a life, the man died. That’s the important story. Whether we did or did not contribute to his death – if asking that question helps us learn and do better next time, fine. But whether I, personally, feel proud of my work, or on the other hand, feel guilty is entirely the wrong question. This is his story. It is not my opera.

- Having said that – and since I know nothing of his story beyond what I’ve already told you, so I can’t go any farther there – what do I see, what do I think, what can I learn from this; what light does it throw on doctoring?

- First of all – we don’t know what happened. (We very often don’t, here). He may have had a stroke, he may have had a seizure; he may, in fact, have died from dehydration. Yesterday, a similar patient in similar circumstances (minus the presenting respiratory problem) also died. A few hours before, however, we managed to run a blood chemistry study on him – and the clear conclusion was that he was “hemoconcentrated,” i.e. dehydrated, i.e. he needed more fluid. Maybe in this man’s case, maybe in my patient’s case, they both needed more fluid AND were having trouble breathing (see my previous post for how both problems can occur at once – in the States, we would just put them on a ventilator so we could breathe for them while we treated their fluid status). Or maybe the dehydration was the main problem. Or maybe the breathing was; or maybe something else was. We have no idea. We are trying to walk down the center of a path, all while having almost no tools or inputs to tell us where we are.  

- Second – the strange and hard thing is, this is how doctors learn. You really would prefer not to learn on real people. But most of the time, you do. That’s just how it is. Let’s say you are trying to learn how to play tennis. First of all, no one would think it the least bit odd that, when you first started out, you were not nearly as good a player as after you’d been playing for a while. That’s what learning is, right? And, also, you might be able to work on some techniques and skills in a simulator (do these exist, for tennis?), with a machine throwing balls at you, for example. But, eventually, if you wanted to actually play tennis, you’d have to do it with another person, and that would be different. The thing is, though, that when you’re a not-as-good-as-you’re-going-to-be player, what’s the worst that can happen? Your opponent might get bored and decide not to play with you any more, but he/she will go on with his/her life just fine. And certainly the ball and the racket won’t care one way or the other. When you’re a doctor, however, the ball and the racket DO care. Meaning – when you start out, as in anything else, you aren’t as good as you are later, and when you’ve been doing it for 10 years, you aren’t as good as you are when you’ve been doing it for 20 – but, all that while, you are treating real people, who matter to themselves and others, and who care about the outcome of what you are doing. There is simply no other way to do it, and no other way to learn. You can do all you want in a simulator (and my sense is that training programs ARE doing more with simulators, which I think is great). But in the end, if you are going to be a doctor at all, you have to treat people. And that will be different. And you will be worse at it at the beginning than you will be later on.

- I am CERTAIN that there are things I could have paid more attention to that might have given me a better idea if the man was, in fact, getting fluid overloaded – I have learned something from treating this man. I’m not certain that it would have changed what we did, or, if it did, that it would have made any difference. The person primarily taking care of the patient was a colleague of mine with more experience, and he elected to do the same thing I did. Who knows?

I think this is the hardest part of being a doctor, for me. Realizing that I could have taken a different treatment course that might have had a better result. Knowing that I’ll think of it next time, but I didn’t think of it this time. Learning on the job. How should I “integrate” this? The more I treat it as: Well, you know, I was trying, we all make mistakes, it might not have made any difference – the more I do that, the more I feel I become callous – treat what is an earth-shaking event in the lives of a group of particular people as though it is nothing much. On the other hand, to treat every instance of this sort of thing (happily, it doesn’t happen THAT often!) as though I, personally, had killed or maimed someone – well, for one thing it seems like it runs the risk of making it about me, not the person (see above) – but also, frankly, I just can’t do it. I can’t continue, if I’m thinking like that. So, I don’t know – I try to register it and go on. Hope it won’t happen again, knowing it probably will. Hope I’ll remember the lesson. Which does, I have to say, seem more like option 1 than option 2 (I think their work DOES make most doctors callous).

Anyone else have a better idea? Or any thoughts about this in general?