A middle-aged woman was admitted to the medical ward with a moderate case of pneumonia. After being started promptly on antibiotics and fluids, she stabilized for a few hours. But she deteriorated overnight, leading to symptoms and signs of severe hypoxemia and septic shock. The nurse paged a young physician working the overnight shift.
The doctor arrived within minutes. She found the patient confused, hypotensive, tachypnic, and hypoxic. Oxygen brought the patient's oxygen saturation up to the low 90s, and the doctor now had a difficult choice to make. The patient, confused and agitated, clearly had respiratory failure: the need for intubation and mechanical ventilation was obvious. But should the young doctor intubate the patient on the floor or quickly transport her to the ICU, a few floors below, where the experienced staff could perform the intubation more safely?
Part of this trade-off was the doctor's awareness of her own limitations. She had performed only a handful of intubations in her career, most under the guidance of an anesthesiologist in an unhurried setting, and the ward nurses also lacked experience in helping with the procedure. A third option was to call an ICU team to the ward, but that could take as long as transferring the patient downstairs.
After thinking about it for a moment, she made her decision. bring the patient promptly to the ICU. She called the unit to be ready. “In my mind it was a matter of what would be safest,” she reflected later. And so the doctor, a floor nurse, and a respiratory therapist wheeled the patient's bed to the elevator, and then to the ICU.
Unfortunately, in the 10 minutes between notifying the ICU and arriving there, the patient's condition worsened markedly, and when she got to the unit she was in extremis. After an unsuccessful urgent intubation attempt, the patient became pulseless. Frantically, one doctor shocked the patient while another prepared to reattempt intubation. On the third shock, the patient's heart restarted and the intubation was completed. The patient survived, but was left with severe hypoxic brain damage.
The young physician apologized to the family, more out of empathy than guilt. In her mind, she had made the right decisions at the right time, despite the terrible outcome.
Nearly two years later, the physician received notice that she was being sued by the patient's family, alleging negligence in delaying the intubation. The moment she received the news is seared in her memory—just like those terrible moments spent trying to save the patient whose family was now seeking to punish her. “I was sitting in the ICU,” she said, “and my partner calls me up and says, ‘You're being sued. This system is broken, and that's why I'm leaving medicine.’”1