A Lesson in Loss: A Novice Anesthesiologist’s Journey

It was the second week at my first job as a freshly graduated anesthesiologist. I was both nervous and anxious that morning because I had been assigned a case in the angio-suite. I had had a triumphant first week: no intraoperative complications; everyone, including my boss, seemed pleased with my performance. There was no apparent reason for anxiety except for the setting. The angio-suite was isolated on another floor. And I was the only anesthesiologist there. I was secluded and outside of my comfort zone … But that's what residency had prepared me for. — Right? — Besides, it was a simple procedure: a biliary drainage. It shouldn't pose any problems. — Right? — What anesthetic technique should I choose? I checked the medical history. The list of comorbidities was endless. The worst was a recent myocardial infarction with no possibility of revascularization: pulmonary edema, Killip III. He also had pancreatic cancer that obstructed his bile ducts. "There's no other option." The interventional radiologist said the procedure was "imperative and necessary." — Was it? I don't know … — But he seemed pretty sure, and thus, I would be the newly graduated and inexperienced anesthesiologist calling off the procedure. Being responsible for the consequent biliary sepsis was a bold and frightening decision to make. Everything told me "no": my body, my emotions, and my timid instincts. But it "had to be done.""Let's do it. But with sedation so the patient can tolerate the procedure. If I use general anesthesia, I won't be able to extubate him or, worst case scenario, I'll lose him during induction." Okay. Sedation it is. We start, and the procedure proves to be unexpectedly difficult. A history of a Roux-en-Y gastric bypass makes everything more complex. The radiologist can't seem to do the drainage. The sedation level is not enough. The atmosphere turns tense. The patient is moving and in pain. I'm alone, and the only nurse is occupied assisting the radiologist. "We have to approach this differently," says the radiologist. "An endoscopy is needed to do the drainage." — Okay … should I deepen the sedation? — However, the patient is not saturating well. His breathing pattern scares me … Do I change plans in the middle of the procedure? Furthermore, I must downgrade from a facial mask to a nasal cannula for the endoscopy to be done. Will that supply enough oxygen? Instinct warns me—screams—that something is not right… Frankly, from the beginning, nothing has gone well … — "Okay, I'll allow one attempt." — The gastroenterologist says it's 10 minutes, it's quick, and it seems to provide a way to do the procedure. — "Fine. Let's do it."Things rapidly worsen; he's desaturating, and he's had a severe myocardial infarction. It's not critical yet, but it will be. — His heart rate starts to drop. — The pressure and my discomfort become unbearable. Now I know that everything will be worse in a few seconds. I'm unsure when or why everything went wrong, but it doesn't matter. I have to fix it. — "Doctor, you can't go on. Abort the procedure. I'm going to intubate." — I need to get control of the chaos. I start induction, but the patient is going into cardiac arrest. I call the blue code and demand another anesthesiologist. — Which one? — "Anyone!" It takes 3 to 5 endless minutes for him to come—3 to 5 minutes of arrest in a very sick patient, my first as an anesthesiologist. — I have to call the shots: What do the ACLS guidelines say? I don't remember. My heart starts pounding! My first cardiac arrest on my own. I'd always had a teacher leading the way. And I had witnessed very few arrests. Anesthesia is so safe nowadays that catastrophic events during procedures are rare. — "Okay. Focus!" — ACLS, start compressions, give epinephrine. Take notes of the time, remember the quality of compressions, a million things in my head … — How do I lead this?!Help finally arrives. An experienced cardiovascular anesthesiologist. He is calm and clear. He takes the lead, calls the shots, thinks of everything, gives orders, places an arterial line between compressions without interrupting the process; I can't believe it. — How does he do that?! — He gets the patient back to spontaneous circulation. "We're out. Okay, solid ground." No? No. He codes again, more compressions. — Oh God, it can't be; it's just a biliary drainage; he's going to DIE during a "simple" biliary drainage. — I did NOT consider the possibility of death. Did I not tell the family that he could die? No? No! He's going to die, and they didn't expect it. He didn't expect it either. He didn't say his final goodbye to them. Another round of epinephrine. More compressions. His rhythm is not shockable; we need to keep doing chest compressions. There's no do-not-resuscitate order on his chart. We have to keep going. — Do we? — Meanwhile, the leader gives orders calmly. He also knows what will happen but doesn't seem distressed by the outcome. The patient goes into spontaneous circulation again. I can't believe it. Did he have another infarction? I don't know. Probably. One more time. We repeat this cycle one more time. — "Pupils? Dilated." — Death was declared after 40 minutes of effort.I lock eyes with the radiologist, both of us in disbelief over what just transpired. What started as a routine procedure so the patient would have more time with his family took an unexpected turn. — His family! We have to talk to them. Do I have to do it? Me? I don't know … — Everyone leaves. I tell myself I have to write notes. Record everything that happened. I have to be precise. — Do that first? Or talk to the family? — "No. Write it down before you forget; it's a serious event." — Besides, I can't utter a word.The radiologist goes out to speak with them. I hear the daughter scream. — Yes, scream. — He's told them. And I don't know what to do. I have a tangle of thoughts and feelings I can't unravel. Again, I tell myself to do what I do best: a good anesthetic record—a detailed description. When I'm done, the family is gone. I recount what had happened to my boss. He just asks if I wrote everything down.The next day, everything went on as usual. However, I faced a decision within: What kind of doctor would I be? One who says, "One more difficult case, one less patient?"; "Don't get involved. Keep your distance." Valid. Pragmatic. Also, cynical. Thankfully, I had help navigating this sea of confusion and chose otherwise.I still grapple with enduring shame and guilt from painful losses, a struggle intensified by a lifetime of focusing on victories rather than perceived defeats. But I now know that coping with this requires unearthing what is not overtly said to avoid burying myself beneath the weight of the unspoken.Cecile Dunn, M.A. (Bogota, Colombia), was the native English language, grammar, punctuation, and spelling editor.