Not Even A Month Out Of Med School

Intern (1st year resident) in Internal Medicine here. My 3rd week out of med school, and I was in the ICU on night-shift. ~30 extremely sick and complicated patients for me and my senior resident to handle, and a few more coming in from the ER. My senior told me to manage the current patients while he did the new admissions. I was “signed out,” meaning given information from the day team, about all the patients and what I needed to watch out for/follow-up on at night.

One patient in particular, Mr. X, was an elderly man in his 70s with altered mental status (he was acting loopy and nobody knew why) and nobody could get any information out of him. He was in arm restraints because he was pulling out his IV lines and acting aggressive towards the staff. He was also developing what appeared to be signs of sepsis. He needed a CT scan of his abdomen that night to look for a possible source of infection, and it was part of my job to follow-up on those results and start any necessary antibiotics/consult surgeons/etc if needed. No problem. About 30 minutes into my shift, I get paged that the patient is supposed to go down to radiology, but he’s too agitated to sit still for the scan.

So I decide to give him a medication called Ativan to calm him down enough for the CT to be done. It’s common practice to give a small dose of a benzodiazepine (a medication that works similarly to alcohol in its sedation-inducing effects) for agitation.

About 10 minutes after I gave the phone order, I hear the alarms go off and the overhead announcement of “Code Blue – CT scan. Code Blue- CT scan.” My heart skipped about 5 beats.

I run down to radiology and call my senior to meet me there. As I arrive, the patient is laying on the scanner, unresponsive and not breathing. His nurse said his breathing became shallow then abruptly stopped. His adult daughter was standing beside him glaring at us.

But we were capable and ready to revive him without a problem – he just needed some respiratory support (a little help breathing). I got the bag/mask and meds ready. That was until his daughter said “Don’t touch him!”… I had forgotten Mr. X was on file as DNR by his family’s wishes. I knew I could save him, but my hands were tied.

In those last minutes, I had to watch my patient die. I anguished over my decision to give him the sedative. Did I give him too much? Should I have not given him the sedative and just cancelled the CT scan outright? What would have happened if we never found the source of his infection? Mr. X’s daughter wasn’t surprised that her father died that night. She was upset, but not at me. She was a better person than I would have been in her shoes.

The next morning my attending physicians (supervising doctors) told me Mr. X was on the edge of death to begin with, that he probably would have died of his infection in the next few days, that I didn’t really make a mistake. I didn’t and don’t see it that way though; I knew they were just trying to be supportive. They all answered that if they had been in the situation they would have used an antipsychotic like Haldol instead of a benzo like Ativan. I still wonder how that night would have gone differently if I had known that medical fact just one day earlier.

It scared the hell out of me, and haunted me for months afterwards. But it made me a more vigilant doctor.