“I feel tired,” said Mr. T. Mr. T was a 72-year-old man who came to our ED. For the last three days, he had been passing reddish urine. Two weeks before this, he had a bout of bronchitis that did not require hospitalization, just ciprofloxacin. He had made a full recovery. The emergency department ordered many tests, among which was a comprehensive metabolic panel and a complete blood count. It showed a very low hemoglobin and a high unconjugated bilirubin level. The low hemoglobin meant he had anemia, and the high unconjugated bilirubin meant his red blood cells were destroyed. The hematology-oncology team diagnosed him with autoimmune hemolytic anemia. They had started him on immunoglobulins and high-dose steroids.

I was part of the ICU team that was called due to the worsening of Mr. T’s condition. So I, my first-year resident, and my attending intensivist, Dr. S, went to see him.

“I am cold,” Mr. T said with a labored voice. His tired eyes barely opened to show their yellowish hue: jaundice.

“We would take care of you, sir,” I said, trying to reassure Mr. T, knowing his condition was dire. I tried to ensure everything was being done, asking questions from the nursing staff in the room and working with them to ensure Mr. T was getting the best care possible. Everyone in the room knew Mr. T was very sick.

Then I remembered his recent bout of bronchitis and said to my attending: “I think his bout of bronchitis was actually Mycoplasma pneumoniae, which caused him to produce cold agglutinins.” He replied, “I was about to say the same thing.” That was what was destroying his red blood cells. Cold agglutinins are antibodies that cause the clumping and subsequent destruction of red blood cells and can be produced in response to infections such as Mycoplasma pneumoniae, which may have been what Mr. T had two weeks ago.

The blood bank mentioned that his blood samples were clumped together or hemolyzed by the time the samples got to them. The temperatures were often cold in those rooms. This further buttressed our suspicions.

Over the next few minutes, Mr. T’s blood pressure dropped precipitously in spite of the multiple units he was receiving until he coded. My intern spoke with the family members who were waiting outside the room: his mother, a kindly elderly lady, and his two middle-aged daughters.

I was tasked with running the code. With me in the room were two interns, two ER nurses, three highly experienced rapid response nurses, and my attending intensivist, Dr. S. Everyone performed excellently, and we were able to get his heart restarted. However, a combination of low blood pressure, losing heart function for some minutes, and poor oxygen-carrying capacity of his blood due to the anemia was too much for his brain to handle.

Our palliative care team explained the situation to his family the next day. “He has sustained significant brain damage and has lost all brainstem function.” It was a challenging conversation to have. At the end, they all decided they would withdraw care. I kept thinking, “What could I have done differently?” His death hit hard because his condition moved like a freight train – I saw it but couldn’t stop.

While sitting at the table with the palliative care nurse, I was still pondering this, discussing the next steps with the family, when his mother said, “I remember you. You were in the emergency department yesterday. You were one of the doctors that took care of my son.” “Yes, ma’am,” I replied. She said, “Thank you. I saw how you took care of my son. I appreciate what you did.” I was dumbfounded. Before I could find my voice to say thank you, Mr. T’s eldest daughter said, “I wanted to run after you and talk to you yesterday but decided I would say thank you today instead.”

She then went on to say, “When you entered the room, I felt like the room changed. You were asking questions and trying to make sure everything was done. I appreciate what you did.”

“Thank you, that means a lot,” I said.

I felt like I had failed, but I knew there was not much we could do. Mr. T’s condition was far too severe for us to treat. However, his family knew we did everything we could.

Sometimes we are hard on ourselves, and we should be. We deal with people’s lives: mothers and fathers, sons and daughters. But we will not win every time. When we lose patients, sometimes the only solace we get is to look the family in the eye and say, “We did everything we could.” Losing patients is complex, but I would rather be a sore loser in this situation.

Always do your best; you never know who is watching.

Kenneth Salu is an internal medicine resident.