Finding My Rhythm: Healing, Leading, Becoming

The Night a Patient Died—and the Kind of Leader I Swore I’d Become

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The walls of the county hospital were the color of old dishwater—dingy, streaked with wear, and steeped in fatigue. Fluorescent lights buzzed overhead like gnats, the air heavy with the scent of antiseptic and something less clean: fear, maybe. Or failure.

I was a third-year surgical resident—new to urology, still green, and desperately trying to stay afloat in a brutal call schedule. On call every third night, I lived in a fog of exhaustion: pre-rounding at 4 a.m., operating all day, re-rounding at night, and collapsing into a call room where rest was more myth than reality.

That night, I got paged.

A woman, post-op, was agitated. Confused. Refusing her oxygen mask.

I hustled to her bedside. Her face was flushed, wild with distress. She clawed at the mask as if it were trying to kill her, not save her. She was breathing, talking, restless—but nothing added up. I ordered a full workup—labs, EKG, blood gas. No signs of PE or MI. All normal. I called my chief resident. He said to contact the surgeon who’d operated.

“She has psych issues,” the other chief told me. “This is probably just post-op delirium.”

He wasn’t coming in.

So I trusted that. Her physical exam looked okay. The blood gas came back showing dangerously low oxygen—but I assumed it was venous, not arterial. I ordered Haldol, just enough to calm her and keep the oxygen on, and ordered another gas. I told my intern to call me with the results.

Then I got pulled to an emergency at the pediatric hospital. I didn’t return until 3 a.m. My body throbbed. I hadn’t eaten. I lay down for the first time in what felt like days.

And then the code call came.

She coded.

And she died.

I found out the next morning that the second blood gas also showed life-threatening hypoxia. But the intern assumed it was another venous draw and hadn’t called me.

She thought she was sparing me.

She thought wrong.

The regret hollowed me. I had missed it. I hadn’t followed up. If I had, she might have lived. She would have gone to the ICU, been intubated, stabilized. Instead, she died under my watch.

My chief resident said he would speak to our Chair since this was such a significant event. I had no prior experience with situations like this and naively trusted him to tell the full story.

At grand rounds the next evening, Dr. Skinner—the revered department chair—stood up before the entire room.

“There was a death on our service last night,” he said. “I will never again have a resident who gives Haldol to an agitated patient.”

He didn’t name me. He didn’t have to. Everyone knew.

I wanted to disappear. To evaporate into the linoleum. I bolted as soon as the session ended, shaking, humiliated, alone.

That night, I thought I’d never recover. I had been thrown under the bus by my chief, who I had trusted. He had failed to mention that I had called both him and the other chief resident, asking for help—asking them to come in. That I’d explained I wasn’t sure what to do. That they had declined and given me cursory advice over the phone. That I knew I was in over my head. None of that was shared.

They’d erased their part from the story. But mine was laid bare.

The next morning, I made a decision.

I asked to speak to Dr. Skinner directly.

In his office, with sweat on my back and my voice trembling, I told him everything. The call. The workup. The phone consults. My plea for help. How I’d tried to do the right thing, how I’d been advised to stand down, and how ultimately—I hadn’t followed up when it mattered most.

He listened in silence.

Then he asked, “Who was the intern who didn’t call you?”

“Does it matter?” I said. “That’s on me. I was the more senior. I was responsible.”

He looked at me, and for the first time, I saw something shift in his expression—not forgiveness exactly, but recognition.

That was the day I decided what kind of leader I would be.

Not the kind who disappears when things go sideways.
Not the kind who blames down the chain to protect their own skin.
Not the kind who throws a colleague under the bus to preserve their reputation.

I would lead with accountability. I would own my mistakes. I would face the music—every time.

Because leadership isn’t about looking good. It’s about doing right.

That night in the county hospital, something broke in me. But something else was forged. A sharper clarity. A fiercer conviction. The kind that only comes through failure, shame, and fire.

I carry that patient with me still.

And I carry the vow I made in the aftermath:

I will never be the kind of leader who hides. I will be the one who shows up—even when it’s hard. Especially when it’s hard.