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February 4, 1998

Forgive Me, I'm Bleeding

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JAMA. 1998;279(5):403. doi:10.1001/jama.279.5.403-JMS0204-6-1

I let go of my bleeding hand, grabbed the steering wheel, and tried to refocus on the road, away from the angry conversation I was having in my head with Dr Lethy. I had met him my third year of medical school and thought he might be the mentor I had been seeking. Instead, as a consultant to my medicine team, he seemed to take pleasure in humiliating me, and I never again went to him with questions.

A patient assigned to me, Señora Creer, had hypertension, diabetes, and renal failure in addition to the foot ulcers that had brought her to the hospital. She and I became very close. Indeed, she considered me her doctor, and told everyone so. After several days of medical therapy without improvement and with Señora Creer in need of dialysis, my team consulted Dr Lethy, who recommended we place a central line into her subclavian vein.

The senior resident and I tried to place the line but had a very difficult time. We called Dr Lethy to insert it, and he appeared confident as he pierced through skin with the introducer. I wasn't sure which approach he was attempting but knew better than to ask.

It became an awkward situation that kept getting worse. We finally saw good blood return into the introducer, but the wires and dilators kept coming back bent. My discomfort grew, but Dr Lethy continued with a monologue about the importance of experience. With a catheter inserted, he aspirated for blood return with a syringe. Pale, yellow fluid mixed with air appeared. "Well, maybe we have gone into the lung," Dr Lethy said, interrupting his demonstration.

As we left the room, Dr Lethy stopped me to explain how he had found the vein, at the same time drawing lines on my chest with his fingers, as if nothing had gone wrong. He then left for home. I returned to Señora Creer and put my stethoscope on her chest. I heard no breath sounds on her left side.

She died that night after bleeding profusely during chest tube placement. I was nearly in tears. Dr Lethy appeared later, only to write a note in the chart and ask me if I had eaten any dinner.

The next day was difficult as my team's attending physician probed into the details of Señora Creer's death and tried to create some perspective. He told us that having responsibility can cause one to do foolish things in order to save face. He also said that a wise man is capable of learning from another person's mistakes.

Two weeks later Mr Veris, another patient in renal failure, entered my team's service. When we again consulted Dr Lethy, I realized I still blamed him for Señora Creer's death. I remained angry with him for his callous behavior and for having fooled me into thinking I could trust him.

The senior resident and I now attempted to place a central line into Mr Veris. After I was unsuccessful once and the resident twice, I said, "Maybe we shouldn't push it. " The resident agreed, and instead we placed a femoral line that I removed 2 days later. After withdrawal of the catheter, Mr Veris bled vigorously, but with firm pressure I stopped the hemorrhaging. I went to lunch and afternoon lecture. When I returned, the senior resident waved me aside and said, "You took out the femoral catheter but you didn't stop the bleeding. He is uremic, and uremic people are hypocoagulable. He was exsanguinating in his bed." My heart almost stopped. I assured the resident that I had waited until the bleeding had stopped. He studied me closely and then apparently chose to believe me, saying, "This is how you learn. It'll be all right. "

I finished my work, checked on Mr Veris, and went to my locker. As I reached inside, my hand scraped against the sharp metal edge of my locker which sliced a chunk of skin from my knuckle, exposing raw pink flesh and fresh blood. I grabbed a towel and held pressure on it until I arrived home. During the entire trip I felt blame from Dr Lethy that was actually coming from myself. I was blaming myself for what had happened. I was now the recipient of the feelings I had once directed against Dr Lethy.

My ignorance still feels overwhelming. Good role models surround me, yet each encounter with an insensitive physician shatters my self-esteem. I have to fight the tendency to become insensitive myself. I feel unwilling to forgive Dr Lethy, but I cannot help thinking that perhaps he really does understand how I feel.

The conversation with him in my head continued as I held my knuckle and the steering wheel. It took a long time to stop bleeding.

From the author: As I examined my reasons for writing this story, I realized that the process of fictionalizing a painful experience has been an integral part of my healing process. I had experienced the death of a patient, a new and difficult event in my training. I had reached for guidance from my instructors and received it, but in quite unexpected and at first unrecognizable forms. Bleeding represents a loss of oneself. For me, it also represents naiveté about what it means to be a physician. Bleeding goes along with pain. It hurts and takes time to heal.