The First Patient Who Was Yours When They Died...

Cut to the Chase: General Surgery Survival Series — Post 31

An intern asked me once how long you’re supposed to listen. She’d been paged to pronounce a man on comfort care and stood with the bell on his chest, not knowing when she was allowed to take it off.

A full minute was the easy half of her question. The other half was how long she was allowed to stay in the room, and nobody tells you that one either.

The nurse doesn’t page you. She walks down to the workroom and finds you, which tells you before she says anything. It’s 3:40, and she needs you to come say a time.

The man in 14 is the one you’ve rounded on for nine days, moved to comfort care yesterday afternoon. His daughter has been in the chair by the window since dinner.

There’s nothing to order and nothing to fix, and the list still has nine things on it, so it feels like the smallest job of the night. It’s the one where the way you do it is all that’s left, and it only gets done once.

Knock, even though he can’t answer. Tell his daughter what you’re about to do before you touch him.

Say his name. Squeeze his shoulder hard enough that a living man would pull away. Feel for a carotid and look at the pupils, then put your stethoscope on his chest and listen for heart sounds and breath sounds together.

Listen for a whole minute by the clock on the wall, even if you knew from the doorway. His daughter is counting it with you, and she’ll know if you stopped early.

Say the time out loud before you leave the bedside, so the nurse writes down the same one you do. 3:52.

Tell his daughter he’s died, in that word, and don’t be the first person out of the room.

At 3:52 his care is over. Your part in it isn’t finished, and from the hallway the two look identical, a note in the chart and an intern back at the workstation.

Finished means everyone who needs to know has heard it from somebody who was there. Your senior first, from you, before the nurse pages him for you.

Whether the attending wants a call overnight is a sign-out question, and if nobody asked it, call.

His wife went home at ten. Before anybody phones her, ask the nurse who was with him at the end, because almost every family asks whether he was alone.

Find out who’s calling the family before you pick up the phone. Plenty of attendings want to make that call themselves, and a wife shouldn’t hear it twice, from two doctors, ten minutes apart.

The organ procurement network gets notified of every death in the hospital, usually by the nurse. They’ll put her on hold. Know whether the call went out.

Some deaths go to the medical examiner, and one that comes days after an operation often does. The rule depends on the county, and your senior knows it.

Find out whether it’s an examiner case before anybody pulls a line or a tube. The nurse is waiting on you to tell her, and once the drain is out nobody can put it back.

The call to your senior is short.

“Fourteen died at 3:40. I pronounced him at 3:52, his daughter was in the room, and she knows. Nobody’s called the attending or organ procurement yet.”

That tells him what’s done and what’s still open.

The note is the same list in sentences. When you were called, what you examined and found, when you pronounced, who was present, who you told and when.

Somewhere around five the other question arrives. Yesterday’s lactate, the family meeting, the fluid order you almost wrote.

Whether anything should have gone differently is a fair question. Answered alone in a workroom before the sun is up, it only ever comes back one way.

Go through the chart once, on shift, with your senior beside you. His death will be presented at conference, and the version you bring should be the one you read together. After sign-out leave it closed, because the third pass through his labs on your phone in bed isn’t a review anymore.

What stays with you is rarely the part you’d guess.

Third year, nights, a woman who had been on the floor longer than the interns had. The family made the decision on a Sunday, and the page came a little after two.

I listened for maybe fifteen seconds, said a time, and was back in the workroom writing orders before the nurse had finished calling her son. I didn’t write the note until she paged me at five to ask for it.

What I remember is the nurse. She’d taken care of that woman for five weeks, she stayed in the room after I left, and she never once mentioned how fast I’d been. I worked nights beside her for the rest of that year.

I still listen for the full minute and say the time out loud, on nights when I’m the attending and nobody’s checking.

Expect the same quiet from most people. Your senior will probably tell you there was nothing you could have done, which answers a question you mostly weren’t asking. Most attendings won’t bring it up at all, because few of us had it brought up for us.

Ask your attending for ten minutes in the next day or two, and say what you want to go over. Very few of us think to offer, so the asking falls to you.

The intern’s other question has an answer. Stay in the room a minute after the exam, with nothing left to do. If a page can’t wait that long, the nurse will come and get you.

By five the nurse has stripped the bed. Anything about him that isn’t done by then is still yours, and it’s usually one call.

At twenty to six the pager goes off. The man in 22 wants something to help him sleep, and it’s too late to give it. You call back and say so, and start pre-rounding at the far end of the hall.

What to Read Next: Post 32, “Your First Night Running the List.” This one is about the first death that was yours. The next one is about the first night the whole list is, when the intern who doesn’t know how long to listen is calling you.