Tales of Survival

June 25, 2009

bellevue.jpgBellevue Hospital, the nation’s oldest public hospital and the heart of our residency program, provides unique and unforgettable training for new physicians.  It is probably safe to say that every resident who trains at Bellevue graduates with a lifetime of stories about the experience. “Tales of Survival” was created to convey some of those experiences.

Nathan Cox MD

Entering internship, I fully expected to be presented with a wide variety of situations for which I was woefully unprepared. These situations are the reasons we enter residency in the first place – the more we are thrown into and the more we learn and survive, the better we become. Over time, there should be fewer and fewer things we feel completely ill-equipped to deal with. However, none of these concepts, these ‘this is what you’re here for’ or ‘this will make you better’ attitudes, make the situations any easier to handle when they actually present themselves.

For me, one of these difficult situations is the autopsy request. This is the type of thing it would be really hard to prepare for in medical school – it is something you’d likely never send the med student to do. But, in a twisted turn of events, days after being that medical student who would never be assigned this task, you magically become the intern who has been virtually made to do this task. And despite any prior difficult conversations I had previously had with patients and families, despite all the med school small group sessions about ‘breaking bad news’, I had absolutely no idea what to say.

I first encountered this situation during my second month of internship after one of my first (unsuccessful) codes. After the code, during which all I could contribute was a stat ABG and some chest compressions, someone had to call the patient’s family (from out of town, aware only that the patient had been in the ICU and needing a ventilator to help him breathe) to break the news. And guess who is perfect for that job. To make things even easier, I was told, “you should try and get an autopsy when you talk to the family.” Great.

I don’t really remember the details of the call itself. I bumbled around, tried to answer the family’s questions, expressed my sympathy, did whatever I could (which was not much). When it came to asking for the autopsy, I just explained that given the circumstances of his death and the fact that we weren’t completely sure what exactly had occurred, an autopsy would potentially show us what went wrong and perhaps what could’ve been done differently – that essentially it would help us learn more from the case. The patient’s daughter said they would think about it, and that was that. Later, when the family called the hospital regarding funeral home arrangements, they said they had decided against it. They just wanted to bring the patient home to rest, and I really couldn’t blame them.

The difficult part about asking for an autopsy, to me at least, is that in a moment that is probably the most painful in that family member’s month/year/life, you are asking them to let you take another step to learn from their loved one. Like learning from their treatment wasn’t enough. Sure, some families may request an autopsy, and others may want all possible learning to take place from their loved one’s case. But I am sure many just want to grieve, be with their family, and start to move forward, not to think about more medical decisions. And there is no easy way to tell the difference – we just have to ask them all, or else autopsies would rarely happen, and the learning opportunities would be lost.

As I move through internship, I have been faced with this situation a couple more times, and to be honest it hasn’t gotten any easier. I am starting to wonder if it ever will. And I am beginning to think that maybe that is the lesson I should learn from this type of situation – it won’t get easier. It will always feel intrusive and awkward, and all that can be done is to be compassionate, honest and respectful of the decisions that are made.

Dr. Cox is about to finish his intern year in internal medicine at NYU Medical Center.