Let me make it clear that when I saw the patient six hours after his surgery, I recognized right away that he was not fully awake. That was why when I noticed you and your co-intern sitting behind the desk just beside the patient’s bed, my first question was, “Gising ba siya kanina?”
You had been monitoring him since he was transferred to the recovery room.
“Opo, sir,” you replied.
I looked at the monitoring sheet, and indeed, you indicated in it that the patient was Glasgow 15 throughout (i.e., every 15 minutes during the first hour, and every hour thereafter). Only 20 minutes had elapsed from your last monitoring till I came to check on him.
Just looking at the patient though, I knew immediately that something was wrong. I needed to tap him vigorously to wake him and he could not sustain attention. He was restless and kept on vomiting. After a quick neurologic exam, I assessed him to be Glasgow 11.
“Ngayon lang po ‘yan sir, nagfo-follow pa po siya kanina.”
There was a sincere look of alarm on your face. I asked you to retake the patient’s vital signs, and observed as you wrote the more accurate neurologic status on the monitoring sheet. I called for the nurse-in-charge, but he, too, could only tell me that the patient had been “fully awake” earlier.
Gising na gising? Parang ikaw at ako, na nag-uusap ngayon at nagkakaintindihan nang masinsinan?
In resignation, I reviewed the patient’s chart and requested for an emergency cranial CT. The scan revealed a post-operative hematoma, necessitating transfer of the patient to the intensive care unit.
When all this was done, I went back to the recovery room to talk to you and your co-intern. My intention was neither to reprimand nor embarrass. I was not angry. More than anything, I was disappointed. You should know that I knew you to be a conscientious medical student, compelling me even more to ask you questions, so that we could figure out why there had been a lapse in clinical judgement.
I tried to level my expectations, but no matter which way I looked at it, a four-point stepdown in Glasgow score should not have been difficult to detect. Assessment of sensorium was integral to our Neurology courses in medical school. Could the patient have deteriorated rapidly, in between the times you and I examined him? Perhaps. I would never be able to say for certain. But if you did make a mistake, I wanted to make sure that you realized it.
Let me tell you about the first time I cried for a patient.
I was a medical clerk then, and it was my first week in my first clinical rotation: Internal Medicine wards. A brand spanking new medical clerk, wearing a pristine scrub top and armed with a fully loaded carabiner, clanking and jingling with my every step.
The most senior intern on duty gave me my first task of the night: I was to accompany an intubated patient to the Radiology department so that he could get an x-ray. Earlier that afternoon, this 50-year-old male had a cardiac arrest but he was revived after a few minutes. We needed to check that the endotracheal tube was in the right position and to find out if there was radiographic evidence of new-onset pneumonia.
I took the patient’s blood pressure (borderline, 90/60 mmHg) and then asked the utility worker to help me push the patient’s stretcher and his oxygen tank from the Medicine ward to Radiology. The cardiac arrest earlier surprised the patient’s family, which was probably why the entire clan accompanied us. One of them compressed the ambu-bag.
Unfortunately, there was a long line of patients waiting to get an x-ray that night. Forty-five minutes had passed and we were still waiting to be called.
Ayos lang. Hintay lang muna tayo.
I knew I was a smart student; the task at hand should have been easy.
Then shit happened.
Suddenly, it seemed I could not hear my patient’s arterial pulsation anymore. There was no flicking of the dial on the sphygmomanometer. But I was not sure. I tried both the bell and the diaphragm of my stethoscope. Still, there was hardly any sound with either. Perhaps there was no sound at all. I put my stethoscope on my patient’s other arm (Parang wala) and then on his chest (Parang wala pa rin).
“Dok, ano pong problema?” asked one of the relatives.
“Chini-check ko lang po ang puso ni Tatay.”
I did not look up. Copious amounts of sweat began to form on my forehead and neck. Drops started to fall on the patient and on his stretcher. Panic had set in.
A surgery resident apparently noticed my frantic attempts to hear a heart sound and said, “Code na yata ‘yang patient mo.”
Code? Are you implying that my patient’s heart has just stopped again, right here and right now, under my watch?
“Sandali lang po,” I told the relatives who had now created a commotion. Imagine the mixture of “Tsk, tsk” and muffled cries I received in reply.
Distraught, I went back to the Medicine ward to look for my intern.
“Sorry Ofelia, pwede mo bang silipin ‘yung pasyente ko? Parang hindi ko yata marinig ‘yung BP eh.” (Even at that point, I could not commit!)
“Ha? Eh nasaan na ‘yung patient?”
I left my patient, who was possibly in cardiac arrest. Not the smartest thing to do, eh?
That was how my senior intern and I ended up running all the way back to Radiology, where she auscultated my patient’s chest and said, “May heart rate pa naman, pero sobrang faint at brady. Code na ‘to, Ronnie.”
“Sumampa ka na sa stretcher, pards,” suggested the surgery resident.
So I did. I started chest compressions as fast and as hard as I could, as if wanting to make up for lost time. Intern, utility worker, and relatives pushed stretcher (now twice as heavy) back to the ward, where emergency medications could be given in an attempt to rev my patient’s heart back to life.
“CODE! CODE! CODE!”
In the ward, a classmate took over and continued chest compressions.
I walked away.
My senior intern eventually found me in the hallway leading to the ward entrance. I was teary-eyed from guilt. I castigated myself for being undecisive, panicking, and making the wrong decision at the most critical moment.
“OK ka lang, Ronnie?” she said. “Ganyan talaga sa simula.”
I wiped my eyes and forced a smile.
“Thank you ha.”
I fixed my eyeglasses, and walked back to the call room where paperwork was waiting.
I know how it feels to be monitoring patients day in and day out. It is repetitive work with seemingly no other purpose than to induce fatigue among medical students. One of the best things about graduating was realizing that I didn’t have to bring my BP apparatus anymore every time I went on duty.
But when you become a resident, you realize how accurate and timely referrals could spell the difference between life and death. When we fail to recognize signs and symptoms on time, it is the patient who pays for the delay.
You are still a student. You should always have a low threshold for patient complaints. Never dismiss them as “Wala lang.” Neither should you adopt an “Ayos lang ‘yan” attitude when patients or relatives notice that something does not feel quite right. Whenever something feels amiss, seriously consider the possibility that you are missing something. If the patient later on turns out to be OK, there would be no additional harm done.
Look back at the events of that afternoon. What went wrong?
I hope you learn from this, as I did from my mistakes.