As an advanced heart failure and transplant cardiologist, I witness plenty of tragedy. But I don’t lay awake at night anymore grieving bad outcomes — that is the privilege and purview of loved ones. While family and friends may move through Elizabeth Kubler-Ross’ classic stages of grief, doctors do not have that luxury. To give tragedies a purpose, I take three steps when faced with bad outcomes: Separate fault from fluke, separate the expected from the unforeseen and make peace with what I cannot control.
The first step: Ask yourself, “Was it my fault?” Identifying yourself as the proximate cause is gut-wrenching. When I was a cardiology fellow, a patient with a mechanical aortic and mitral valves presented with symptomatic bradycardia and underwent pacemaker placement. The next morning, she was bradycardic and hypotensive. I spent precious minutes checking an echocardiogram to assess for a pericardial effusion (the wrong move, as tamponade would have resulted in tachycardia, of course) when she had an inferior ST-elevation myocardial infarction caused by an embolus down the right coronary artery. She passed away in the cardiac catheterization laboratory, and I replayed her case at two o’clock in the morning for weeks afterward. If I had not wasted time getting the echocardiogram, would she have survived? Probably not, but I’ll never know. But I’ll also never forget that a coronary embolism can occur in patients with mechanical valves.
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