Hold back the reigns

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Death is something every doctor has to deal with at some point in their career. It’s inevitable. As a intern during my oncology rotation, patients died often, and it was our responsibility to notify their families. I remember one time an old man, Mr. Gambotti, passed away at 1 am from a long fight with metastatic prostate cancer. He had been admitted one week earlier for chemotherapy, but he was so skinny and frail that he could not withstand the grueling treatment. Looking at him reminded me of those pictures of the holocaust, where you could see a person’s entire skeleton beneath their skin. When I got the page from the nurse telling me that he had passed, my resident, a tall red head named Sheila, looked at me and said, “Well do you think you’re up to it?” By that she meant, tell the family.

I was.

Thankfully, she coached me through it. Even though I didn’t know the Gambottis well, I still felt deeply saddened, particularly when his wife’s voice crackled as she sobbed. Her last words before she hung up were, “Thank you.”

The next evening my fellow intern, Jack, a putz from Illinois, received similar news from the same nurse about one of his patients. Sheila eyed him up and down. “So Jackie poo are you up for it?”

He shook his head aggressively, but I could see it in his eyes that he was only giving in to pressure. In all fairness, she coached him very well, more than she did for me. When he was ready, he picked up the phone and dialed the family’s home. Within seconds, his eyes widened and he began to speak, “Hello, this is Dr. Draper from Cabrini Medical Center. I’m sorry to tell you this but your dad just died. Please call us back if you have any questions. Bye.”

Sheila jumped up from her seat. “You didn’t just leave a message did you?”

“Yes.”

“You don’t leave a message like that! You identify yourself and instruct them to call you back. How would you feel if someone called your mom and said, ‘Uh, your husband bit the bullet and let me know when your able to pick up the body.’ Are you a complete idiot?”

He was. Luckily for all of us, he went into radiology.

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I can’t say I haven’t had my own trouble informing a family of the death of their loved one. As a resident in the medical ICU, I oversaw all the patients. Residents refer to the ICU rotation as a “make or break” month. That’s because if you manage getting through it unscathed then you will probably graduate. If you show off your talent for saving lives, then you will be a star and likely be considered for any fellowship. However, if you don’t shine or if several patients die during your reign, then you will be branded a “weak” resident. No one will want to work with you. Your interns will not respect you, and it is quite possible that you might not advance to your final year of residency.

That month I wanted to shine. Two weeks into it, I hit my stride. A surge of confidence came over me. It was going to be smooth sailing from here on out. Then an elderly woman, Mrs. Castanetta, transferred to the ICU from one of the general medical floors. She was the mother of the CEO of the hospital. I was “talked” to by several of the doctors overseeing her care, and I even received a “friendly” call/warning from the medical director himself. Needless to say, my ability to care for this one patient was going to be the barometer for my entire month as the ICU resident. She was my “make or break” patient.

Unfortunately, her condition deteriorated to the point where everyone knew that she was going to die however, no one could say when. One Friday evening, while I was on call, I received a frantic page from my intern informing me that Mrs. Castanetta’s blood pressure was dropping. Racing up to the ICU, I took the stairs two at a time. At her bedside, the intern and respiratory tech were standing vigil. Her blood pressure was 80/60. In an attempt to shine, I  called the family directly.  I wanted to inform them of her impending fate and give them ample time to see their mother before she died. Within a hour the entire Castanetta clan filed into the ICU and with tears in their eyes, they encircled their mother’s bed. I drew the curtains myself to offer them privacy and waited patiently by the nurse’s station. Since she was DNR, there was nothing more we could do for her. I felt good about calling the family, but more importantly, I felt empowered by my decision not to call the ICU fellow or my attending first. I took matters into my own hands. I was acting like a doctor and not just an ICU resident.

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Mrs. Castanetta did not pass away that evening. In fact she went on to live two more weeks. By the time, she did pass, I was already onto my next rotation – the ER. I was mortified. Every time I saw the CEO in the halls I diverted my eyes to the floor, embarrassed by the fact that I had alarmed his entire family and made them get out of their beds. No one berated me officially, but I felt the subtle decline in my standing as a resident. My ego had interfered with my ability to act ethically. One afternoon in the cafeteria, my former resident, Sheila, who was now a pulmonary fellow, sat down beside me.

“I guess you heard about Mrs. Castanetta?” I asked.

“You mean how you called that poor family in for last rites, and then she went on to live another few weeks?” she said giggeling into her tuna fish sandwich. “Yeah, I heard. Everyone has.”

“Oh, great,” I mumbled.

“Don’t worry about it Frankie,” she said. “We all can’t be stars like me. Next time you want to act cavalier, remember to calm yourself down and hold back the reigns. Most mistakes get made by jumping the gun. Even the smartest doctors have to remember to think things through before they act. I wouldn’t worry about it too much more. Just think about it this way, you’ll never do it again.”

She was right. I never have. Not that I don’t get alarmed and well, yes, maybe I have told a patient or two that their prognosis was worse than it actually turned out to be. There is nothing wrong with being overly cautious. 

After graduation, I lost touch with Sheila. The last I heard she got married and moved to California. Someone told me she had triplets.  I can just see her walking down the street holding onto three red headed toddlers while talking on her cell phone. “Yes, I’m sorry to tell you your mom died.” All the while reigning in her three children with the greatest of ease.

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