Killing a Patient

People often ask me if I have ever killed a patient...

I'm never quite sure how to answer that.
My reaction is that every physician has killed a patient.
Of course not intentionally, probably not even negligently, but it eventually happens.
One that stands out for me is Mrs. M.
Mrs M was an older woman, probably 63 or so. I inherited her care from the venerable senior small town doc whom I replaced. She was short, wide and with multiple medical problems. My first impression of her is overhearing her lament the loss of her retiring physician, a man who was loved by all, and her stating she didn't want some young kid taking care of her.
She went on to tell my nurse she was only there because she liked my staff.
I immediately liked her!
She was often somewhat dishevelled, always cantankerous and difficult to care for.
We grew quite close though neither of us would admit it as her grumpy, slightly pessimistic front was never to be drawn down for a moment.
One afternoon she presented with 24 hours of shortness of breath.
Her physical exam was basically normal , but her pulse oximetry in the office hovered in the low 80% .
This meant she was not getting enough oxygen in her lungs, and as she had no signs of heart failure, two things occurred to me.
First, how happy I was that I had spent $800 that I really didn't have when I first opened my doors on this cool hand held oximeter.
The second was that my patient had a pulmonary embolism, was lucky to be alive, and needed a hospital and immediate blood thinners.
As I delivered to her my fears, she never blinked. She trusted me. I loved this woman!
I called an ambulance (a clear conflict of interest since I owned the ambulance company! but that is another story).
I called the ER and sold her to the admitting service there.
As it turned out, I was correct, her lung scan showed the dreaded ventilation perfusion mismatch.
In other words plenty of air in the lungs (ventilation) but no blood to pick up that oxygen and take it to the body (perfusion). She did well and was discharged on long term anti coagulation. Blood thinners, that dual edged sword that is the treatment for blood clots.
Our blood is an amazing thing, flowing through the body as a liquid but becoming a sticky solid when exposed to the outside world. Neat trick huh?
Well not so fast, cause every heart attack, most strokes, and blood clots are an example of that blood turning into a solid when it isn't supposed to... in the heart, the brain or a leg.
Managing blood thinners is an interesting dance with the devil. Like arming insurgents to help you fight a battle only to have those arms turned into an IED that kills or mames your troops later in the long war on disease.
The goal is to thin the blood, but not too much... lest you turn your patient into an oozing puddle of goo.
The problem is every patients body responds to the blood thinner differently and the dose is quite variable for each patient and can vary with other factors particularly diet. Vitamin K counteracts blood thinners, so if your patient goes grazing the greens at a salad bar they may end up a little thick, overshoot on the thinners and they end up too thin.
All this is followed by repeating the blood test frequently and our chubby grumpy Gussie was not an easy stick!
So she was in my office so often that she had her own coffee cup. She became quite close to the staff and I. The blood draws started early in my office. Hech, at that time the nearest medical lab was 25 miles away. Many a morning her grumpy mug met me as the nurses searched desperately for a source of the much needed blood to follow her bleeding times so we could adjust her dose of anti coagulant.
As it turns out she was the most sensitive patient to coumadin I had ever heard of or encountered in my medical career.
Most patients take about 5 mg a day or so of coumadin (yes rat poison! How do you think it kills the rats?) the hospital sent her home on 5 mg a day with follow up in my office.
After an incredibly painful and elongated series of blood tests in which she was so thin I damn near could have sopped her up with a sponge she settled out on a half a milligram every other day! Unbelievable!
There she stayed until her 6 month course of therapy was done.
Four months later she called my office with shortness of breath. To survive another blood clot in the lung...well its damn lucky. Off the the hospital, new pulmonary embolism, another round of anti coagulation possibly for life this time.
I immediately called the attending on call and discussed the patient. I told him about her unusual coumadin dosages and how I was amazed and had never seen a patient this sensitive to the drug.
We pondered a hematology workup for clotting disorders, filter placement and other issues.
5 days later she was discharged on 5 mg of coumadin a day!
I didn't receive this paperwork til days later, she was scheduled for a blood test in my office soon to check her bleeding time.
I called her in immediately to have it done, ordered the test stat.
She came back DANGEROUSLY thin.
I was upset. How could this information be lost, why did the patient take so much knowing what we went through? Why wouldn't she call me on discharge?
She would have to go back to the hospital and be placed on heparin while her coumadin effects were reversed.
I called the attending. He was busy, he was annoyed with my call. He obviously didn't share the same feeling for this grumpy patient that I did.
He talked me into a conservative approach of watching her, stopping the oral drug, and letting it fall naturally. I balked but acquiesced.
That cost the patient her life.
She was found by her family the next morning, unconscious and rushed to the hospital, a massive intracranial bleed!
Damn! The roadside bomb I had given to the insurgents, the one I was so trying to avoid, went off in my patients brain!
I was devastated and heartbroken.
I had failed her, she needed an advocate and I had caved! I knew what was right and I should have just sent her to the ER and to hell with the attending!
I was also scared, whose ass was on the line here? Mine! I made the call. The fact that the family might sue the attending from the hospital too was little consolation.
She lived several painful harrowing months, but never regained consciousness, a vegetable.
A terrible experience for all involved in her care, especially her family.
They refused my calls to enquire about her care. I heard later from one of her nurses at the nursing home that the only reason they did not sue was that the family knew the patient loved me, and would never have wanted that.
That offered me some solace, but not much.
I killed that patient.