Losing them, fixing them, forgetting to put them in
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My first reaction, when I saw a hospital number on my buzzing cellphone, was annoyance. I wasn’t on call. No one should have been phoning me at home at 10 PM. I’m embarrassed to say that, as I stared at the phone, I felt myself becoming “that” doctor — the one who is emotionally distant from the situation, certain that her experience is more important than anything that could be happening around her.
Becoming “that” doctor is a result of the frenetic pace and unrealistic demands of my days. Call it “burnout” or “compassion fatigue,” it’s born not only from jampacked schedules but also from the energy it takes to be present for patients’ joy, pain, grief, and death. The emotional exhaustion can make me seem cold and unavailable, even though I love this job.
I specialize in family and community medicine, but in addition to being the doctor you see when you have the flu or a swollen knee or a lump or a bump, I am a teacher who oversees residents — recent med-school graduates receiving on-the-job training in my specialty. I work with them both in the clinic and in the hospital. When I am on call, I have to be available to them at all hours of the day and night: to help pick the correct antibiotics for a patient with pneumonia; to generate a differential diagnosis for a low sodium level; to discuss what to do about someone’s chest pain.
When I was a resident, we sometimes worked thirty-six hours straight. I was chronically sleep deprived and often afraid to drive home in case I fell asleep at the wheel. Today there are laws limiting residents to working twelve-hour shifts in most cases. Though the laws were intended to protect patients from errors made by overworked doctors, they have been good for the residents, too.
I am devoted to medicine and teaching, but I am also protective of my off hours. People tug at me from the moment I walk through the hospital’s automatic doors to the time I slide into my car at the end of my day. My schedule at the hospital affords no breaks, and sometimes not even a chance to steal away to the bathroom. My thoughts roil as I walk from room to room, listening to the patients and the residents and assembling pieces of data into cohesive diagnoses. Then I somehow have to relate my thought process to the residents so they can learn to do this themselves. I can’t make a mistake, and neither can they, or else a patient might be harmed or even die. Lives are in our hands. There’s little room for error, or even a break in concentration. But it’s unrealistic to expect perfection, because even the best of us sometimes err despite making all the right choices, ordering all the right studies, prescribing all the right medications. Complications occur. The kidneys shut down; the liver gives up after years of abuse; the heart finally succumbs to exhaustion and stops beating. The human body cannot always be forced to do what we want.
When the unthinkable happens, the self-indictment hits me: Did I miss a symptom? Should I have ordered a potassium level? Did I misdiagnose that shortness of breath? Am I a bad doctor? Then there’s the indictment from my peers, the second-guessing and criticism: You should have gotten a sed rate, done a CT scan, consulted neurology. And the patient’s family often blames me for an unexpected death. It’s easier for people to tell themselves that it was my fault than to live with the idea that there is no control; that sometimes bad things just happen, even under ideal circumstances.
The most overwhelming part of the day, and the hardest to describe, is when raw life unfolds in front of me: Catching a newborn, still wet with amniotic fluid, and seeing her open her mouth for a first breath. Watching an illiterate meth addict — toothless, dirty, and disheveled — cry with relief when the residents tell him that they will help with the paperwork if he’ll just show up at the clinic. Listening to a grandmother rage in her ICU bed, tearing at the sheets and her oxygen mask because her tobacco-damaged lungs have chosen this weekend — the weekend her grandkids are in town from Tennessee — to give up.
Although sharing the tribulations of patients’ lives is a privilege, it is also draining. I strive to remain composed and compassionate, but some days I have to remind myself to make eye contact, to nod, to express understanding. Then I must ready myself for the next patient, in the next room. There’s no time to step away, shut the door, dim the lights, and just breathe.
So when my phone buzzed against the kitchen counter that evening at home, I answered with my jaw clenched: “This is Dr. Nicolette.”
“I just want you to know,” the intern on the line said, “that John died tonight.”
“Oh.” I could tell she was upset. Even so, I reminded her that I was not on call, an edge creeping into my voice.
“I just thought you’d want to know,” she said.
I stood for a moment, considering. I realized the intern — a first-year resident — had reached out to me because, like her, I’d gotten to know John: his snaggletoothed grin, his coarse voice, his clear yet lost-looking brown eyes, and his ambivalence about continuing his fight to live. For weeks the team had been caring for this irascible, yet somehow irresistible, loner as he struggled with a terminal illness. Still, there’s a protocol. Another attending physician was supposed to have been the intern’s resource that night. My finger tapped on the counter as I made a plan: Find out if there was immediate need, so I could direct the intern, but establish a boundary. Let her know I was not available. Always being available gives birth to “that” doctor.
“OK,” I said. “What happened?”
John had bled to death, she told me. Through his mouth. “We think he was bleeding from an esophageal variceal. We couldn’t stop it.”
Patients with cirrhosis, like John, have a scarred liver, which causes blood to back up, putting increased pressure on the veins. The swollen veins in the esophagus, called varices, can bleed. The only way to stop it is to get inside the patient and close the vein. A gastrointestinal (GI) specialist or a surgeon has the ability to do that, but not a general hospital physician.
They had called GI, and someone was on the way. The ICU doctor had tried to help stop the bleeding. As the intern described the gruesome scene, an ache and then a numbness spread across my chest: The decision was made to let John go, and the morphine was started. They sat powerless and watched the blood pulse from his mouth, staining his gown and bedding. John’s breath generated red-tinted bubbles, which left small spatters on his cheeks and pillow when they burst. Blood dripped into a puddle on the floor. I knew it had taken courage to stay in the room as his life ebbed. I felt an impulse to dissociate — to think about something else, or to stop thinking altogether and curl into a ball as I relived the many traumatic deaths I had seen. I walked over to the couch and sat down between my husband, Ben, engrossed in a basketball game, and my dog, Bruiser. I reached to slide my fingers between Ben’s and held tight and looked into his eyes as I told the intern we could talk about it in the morning. I asked if she needed someone to help her tonight and gave her the name of the physician on call.
“I’m OK,” she said. Then, “It was everywhere. The blood. On the floor. On the walls.” She paused. I could tell she was struggling to repress the image so she could get through the rest of the night and face an emergency room full of sick patients. She didn’t have time to process this event now, but I hoped she would soon. Repressing emotions also gives birth to “that” doctor.
“It looked like a murder scene,” she said before we hung up.
My mind kept returning to that conversation as I watched basketball with Ben, and later as I read a book before turning out the bedside lamp. I woke up in the middle of the night and chastised myself for failing to be more supportive of the intern; for failing to warn the team that John might die any day, even though he was lucid and talking; for failing to recognize how important that phone call was. This had been an unusual and grisly death.
Not that any death is routine. Each is a profound event, whether the patient is a dignified, ninety-three-year-old matriarch who quietly slips away, or a bewildered thirty-eight-year-old mom who still hasn’t come to grips with her breast-cancer diagnosis. For the hospital team, losing a patient is always an occasion to pause and remember, to share a small personal fact about the patient that reminds us of his or her unique humanity. We used to light a candle during morning rounds after someone had died, until a new fire code prohibited it.
Though we aren’t blasé about death, we are accustomed to it. We know it will happen. When a person is hospitalized, it means his or her condition could turn serious, fast. A simple case of pneumonia could result in a whole-body infection that spirals and becomes fatal. A patient receiving a new hip could develop a blood clot that clogs his lungs. A heart-failure patient could suffer an arrhythmia. But hospital deaths are rarely as terrible as John’s.
John was in his fifties with no friends or family. He had schizophrenia but had managed to live independently and get by. John also had hepatitis C, contracted during a period of IV drug use in his youth. The hepatitis alone probably wouldn’t have killed him, but that coupled with years of drinking had been too much for his liver, and it had started to fail. He’d been admitted two weeks earlier with life-threatening anemia and had spent ten days in the ICU. The residents had saved his life more than once: with blood transfusions to treat the anemia, and again by getting him through his alcohol withdrawal. Next he developed sepsis — a serious, whole-body response to an infection. Then his kidneys failed. Then he became encephalopathic, because his liver couldn’t clear the toxins from his blood, and they built up, making him confused and combative.
When John was awake and stable, he vacillated between wanting to be treated for the internal bleeding and wanting to start hospice care. We knew he was still bleeding because he could see blood in the toilet, and because his blood levels kept dropping, but he wasn’t sure if he wanted any more cameras inserted into his orifices. The night he died, he had just decided that he wanted us to find the source of his bleeding, so we could try to stop it.
“Can we talk about John?” a second-year resident asked me the morning after John’s death. We were sitting at adjacent computer screens, discussing our patients’ laboratory values. Like the intern who’d called, the second-year had seen John daily and been invested in his care, and I suspected that he, too, wanted emotional support from me — something I’d never expected to receive as a resident. I felt a sudden rush of resentment toward my own training experience: the relentless hours, the fatigue, the harsh words. A faculty member had once said to me, “Look, it’s a doctor thing. People die, and you just keep working.” I had a strong desire to provide this young doctor with the healthy environment I hadn’t had.
“Let’s talk,” I said to the resident, making eye contact and turning to face him. I did this not only for him but for myself, to prove that I am better than the system that produced me. In other words, I was trying not to be the doctor I’d been trained to be.
The resident told me that he hadn’t actually been there when John had died. Then he let his face fall into his hands and started to cry. Right there on the ward. Right in front of me, the nurses, the other doctors — everyone. I felt a mixture of awe and respect.
The resident asked if I thought we had caused John’s death while prepping him for a GI camera. The GI specialists needed John’s intestines to be empty for the camera to see the source of the bleeding, so they’d given him a solution to clean him out. He’d had a hard time keeping it down, however, so the team had threaded a nasogastric tube from his nose into his stomach to get it all in. Now the resident was worried: Had the tube caused the catastrophic bleeding?
John had been bleeding to death already, I reminded him, just more slowly. That’s how he’d ended up in the hospital with anemia. And John had agreed with the plan to try to locate the source of his bleeding. “He wanted more time,” I said.
“But the tube could have ripped open one of the varices, right?” he asked.
It could have, I said. But if it did, it was a rare event. We drop nasogastric tubes all the time, and that sort of thing doesn’t happen. We have patients with variceal bleeds all the time, and that sort of thing doesn’t happen. No one had seen it coming.
I touched the resident’s arm, and he looked at me. “You’re a good doctor,” I said, “on the way to becoming a great one.” I reminded him that the human body doesn’t follow the textbook, and we could only do our best and try to relate to our patients. “You did that with John. He liked you. He smiled that crooked smile every time you stuck your head in the room.” I repeated that the choices we’d made were what John had wanted.
We sat quietly for a few minutes. Then the resident dried his tears on the sleeve of his white coat and thanked me for taking the time to talk. “I feel like I can work now,” he said, turning back to his computer screen.
As I was leaving the floor, the charge nurse stopped me and asked if the resident had been crying about John. She said two of her nurses who’d been there that night had gone home sick. “The social worker set up a debriefing meeting for Friday night at 7 PM,” she said. “She wants your team there.”
I furrowed my brow and looked away. I was scheduled to be off on Friday night.
At the debriefing we arranged chairs in a circle, the legs scraping the linoleum. I had my defenses up, primed for the criticism I felt certain my team would receive over the management of John’s case. As I surveyed the room, I noticed there were no doctors besides those on my team: just a social worker, a psychologist, and the two nurses who had been with John when he’d died. The psychologist said we were meeting to discuss John’s traumatic death and the effect it had on us.
“You mean this isn’t a criticism session?” I asked. The facilitators stared at me, and I flushed with embarrassment. The other people in the circle laughed.
The social worker asked each person to describe what had happened. The nurses said John had started to vomit blood on his way to the bathroom and had fallen to the floor. They tried to help him up, with aid from the senior resident and the intern, but all five of them were slipping in the pools of blood. The team got John into a chair and eventually into the bed. The nurses spoke soothingly to him, asking what he needed. The residents started medical care and called the ICU attending and the GI specialists. At that point it still seemed as if John would get through this.
Then the blood came again, covering the team as well as the walls and bedding. When John lost consciousness, the doctors knew that he would not survive and started morphine to make sure he was pain-free. The intern kept her hand on John’s, squeezing his fingers. Two doctors and a nurse stayed there until John took his last breath.
“What I felt as I watched,” the senior resident said, “was how helpless I was in the face of such a catastrophic event. I mean, there was nothing I could do.” She told the two nurses that they were the true caregivers: comforting John, consoling him. “You helped him have dignity in his last moments. I just stood there.”
“I felt like a shitty doctor,” the intern said.
“Listen,” I said, speaking out of turn, “people die.” My voice was too loud. The strain of dozens of patient deaths was behind it. Trying to regain the measured and precise tone I used on the wards, I assured the residents that John was a sick man with end-stage liver disease, and he knew it. He had almost died about six times during his hospitalization, and they had saved him every time. My heart was beating hard in my chest.
“Tell us the story from your perspective,” the psychologist said to me.
I looked at a whiteboard across from me. The ghosts of the words compassion and service were still visible where they’d recently been erased. I took a deep breath and apologized to the intern for being brusque during our phone conversation on the night of John’s death. She said it was OK; if I’d let her open up, she wouldn’t have been able to get through the night. People die, and you just keep working.
“Here’s the truth,” I said. “My first concern wasn’t about what had happened to John. It was primarily about you.” I felt sheepish, admitting that the residents, not the patients, were my top priority. I wished I could have been there to shield them, I said: from the shock, the grief, the sense of helplessness. And the self-judgment.
They were all staring at me as the words continued to spill out: About the complexity of being a doctor, and the way medicine consumes you. About the system that imposes long days of fifteen-minute visits. About the way the kind and respectful patients get overshadowed by the ones who ignore your humanity: The man who calls you a “cunt” because you won’t give him oxycodone. The woman with chronic abdominal pain who has had every test and seen every specialist, but insists you aren’t willing to help her. The ones who take out their awful experiences with other doctors on you.
Finally I told them something another resident had told me: that John’s biggest fear had been that he would die alone. “And he didn’t. You had the courage to sit there with him, amid the trauma and the blood, until he was gone. That’s what you did for him.”
Tears were falling in the room, including, finally, the intern’s. I was glad to see her cry. It meant she was becoming the sort of doctor I still struggle to be.