“Nothing in life will call upon us to be more courageous than facing the fact that it ends. But on the other side of heartbreak is wisdom.” — Sarah Bloom, Wish I Was Here
I wrote this in early September, on the day after my first on-call shift as a junior doctor. While I’ve participated in several more code blues since I’ve written this, I thought it would be healthy to completely process what the first code made me feel, in the interest of not becoming completely overwhelmed by death, which is a daily occurrence in this line of work, but also not becoming completely numb to it.
[Identifying details in the story have been changed to maintain confidentiality.]
It’s the weekend, early September, 2020. It’s my second day as a junior doctor, I’m on my first on call shift and it’s on a weekend. At 7:30 in the morning, my day starts. I’m excited and a little nervous. Okay well a bit more than a little.
After an hour of being lost and not knowing if and who to call, I hear the voice of the PA system announcing “Code Blue in the ICU”. I don’t think much of it, it’s my first day and my BLS certification is still a couple days away, so I thought I’d avoid being a hinderance to the resuscitation team. Minutes later I come to find out that my attending is working in the ICU already. So I go there.
As I walk into the ICU, I see it front and center: a doctor looking at his watch, mumbling the time, nurses printing out the trace of someone’s (lack) of heart activity, while others were drawing curtains and disconnecting tubes. In the middle of all of that, lied a pale, still, lifeless human being. Even now, the only way I can describe how that person looked was, “at peace”. Weirdly enough, it takes me a few moments to realize that this person has departed. I could not believe that my first patient encounter that day would be this one. There wasn’t the crescendo of slowly escalating events culminating in this moment. But soon enough, my brain comes to terms with what it’s looking at, my heart on the other hand, I’m not sure what it’s made of it.
The doctor greets me, takes my phone number and proceeds to tell me what she wants me to do that day, and what to expect from it. Outwardly I’m as engaged as one can look, but with the corner of my eye, I kept looking around at how unusually routine this looked. Nurses were reminding doctors to write the drugs they used in the resuscitation report, the porters coming to clean up. Amidst all of this, the only people still going through the motions of the “code” were me, and the ICU patients (whoever was conscious of them), looking around in complete bewilderment, too afraid to ask about what had happened, too afraid their suspicions would be confirmed. I hear a far cry in the corridor just outside, the family had been informed. Soon my tasks take over me, and all of what had just unfolded is brushed away, archived in a far corner of my memory.
My day keeps going, the sheer number of patients we need to round on, notes and orders we have to write demands my full attention, especially since this is my first on-call shift.
It’s about 10:00 AM now, I’m taking an overzealous, way too detailed history from an ICU patient who started complaining of mild pain in his left shoulder. Meanwhile, I hear some faint announcement on the PA system that I can’t really make out, mostly because I’m focusing way too much on “not screwing up” my first history by making sure I ask a detailed family history (side note: this remains the longest history I’ve taken, I really don’t know why I thought I was in an OSCE station that day), the patient has no family history of ischemic heart disease, for that matter.
My attending comes in, rudely interrupting me before I ask whether or not my patient has pets at home, and asks if I’m done. I say that I’m wrapping up, but she takes none of it (understandably). She asks if I have an N95 mask, I say I don’t, she grabs one, shoves it at me and tells me to rush down to the ER. While I was confused by all this sudden urgency, mildly annoyed that I still don’t know if my patient has pets or not, she tells me that I need to walk faster to this code blue happening in the ER.
As we enter the resuscitation room, we see a woman at the door, I’d say mid-30’s, red and teary-eyed. She was the patient’s wife -you could just.. tell-, alongside her were a man and a woman, who I’d soon find out were family friends. On the resuscitation bed laid a slender, motionless body — our patient. Atop him was my friend, my roommate, there performing chest compressions. He’s alternating with the other nurses and doctors. The patient was intubated, and on a vent.
My thoughts, now racing, are trying to piece together the accurate technique for compressions. My hands, now fidgeting to get into position: one atop the other, with my elbows straight. With my BLS certification course a week away, I’m hoping I’m not called upon to do compressions. Thankfully, no one does, instead, I’m called upon to “get any history you can, we have no idea about the patient”. I rush outside.
The woman’s eyes are wide open, full of anticipation, worry, disbelief? She certainly was looking for answers, not more questions, but questions were all I had.
-How old is he?
-40
Her voice was trembling, the tone confused.
-What happened?
-He suddenly had severe chest pain, clutched his chest, vomited once and then passed out
-When was this?
-30 minutes ago
-Was he unconscious?
-Yes
-Was he breathing?
-No
It’s bad. She looked as if she was hoping she had better answers.
-What did you do when it happened?
-We got into our friend’s car and came here as soon as we could
-How long was that from door to door?
-30 minutes or so
I ask a few more very quick questions. Any comorbidities? Any medications? Smoking? etc.
As I turn to rush back in, she calls on me. Her voice trembling more than ever, her tears now masking her view.
-What is happening? What are you doing?
I don’t know what to say. It is my first day. Do I say the truth or do I speak in vague doctor-y language? I mumble something.
-We still don’t know, we’re doing our best
I go in, divulge all I got. All we know is that this is bad. Anoxic brain injury is a foregone conclusion, a certainty even. I wonder -and I hate myself for even wondering- if death isn’t the worst case scenario.
The code goes on.
Compressions.
Clear.
Shock advised.
Clear.
..
Shock delivered.
Compressions.
I become aware that the room has a window, through which the wife is just.. watching. Bearing witness to the ugly, slow, brutal process of life’s only certainty. I know she shouldn’t be seeing this. Between handing nurses things and answering repeated questions about my quick, incomplete history, I decide to stand between the wife’s line of sight, and the scene.
Compressions.
Clear.
I go grab a couple tissues.
Shock advised.
Being the only one who speaks the patient language on the team, I know it’s coming down to me.
Clear.
..
Compressions.
I ask the porter to grab the family a couple of chairs.
Clear.
Analyzing rhythm.
..
No shock advised.
-”Time?”
I feel her eyes piercing my back.
-”45 minutes”
She’s knocking on the glass.
-…
-Time of death 10:47 AM
..
Without a moment’s pause, everyone gets busy. Monitors turned off, adrenaline boluses recounted, the bed curtains wide open.
I’m still maintaining my position between the door’s window, and the patient.
I’m.. confused? Angry, even? The wife is there, standing, growing more distressed and bewildered. I rush to the doctor who ran the code.
-We need to inform the family.
-Okay
He keeps on discussing with the other doctors.
-Doctor.
Still busy. The wife now knocking on the window panes.
-Doctor we need to go now.
-Do you speak Arabic?
-Yes.
We finally go out.
The wife moves away from the door. We go through. Standing now face to face, I wonder where the chairs I asked for are. I open my mouth to speak. The doctor interrupts me
-To God we belong, and to him we shall return.
Proceeds, against all training, to break the person, not the news.
Her eyes quickly rush past him to mine, looking betrayed, broken. I open my mouth, hoping whatever I say could at least claw back some comfort. I don’t think I came up with anything remotely helpful.
-We’re sorry, we did everything we could.
She let’s out a scream. She crashes on the floor. Broken.
I stand there, helpless. I hand her friend a couple of tissues. Her friend’s husband asks me a few questions. I answer them. I say my condolences and leave. There’s so much work up in the wards.
As I walk back to finish the rounds, my friend walking with me, we look at each other. We didn’t know but to ask each other if we were okay. We both aren’t sure we are.
We go back to work.
I forget to ask my patient upstairs about his pets.
Postscript
I still can hear her scream vividly. The way she looked with eyes red with fear and yet somehow, hope? The way her eyes darted past the doctor that broke the news so harshly, to mine, hoping I could say anything different. And the look in my friend’s eyes as we walked back upstairs, at loss for words.
I’m still not sure how any of this works, but it is very clear that, to put it mildly, the process that day wasn’t ideal. This isn’t my focus, as I’m not sure what an intern can do to change protocols in a huge institution he just joined.
My main sticking point, and the reason I wrote this, is how can I process the feeling of taking part in the last moments of someone’s life. Seeing a patient come in, attempt to treat them, and then having to let them go. Not only that, but there is the expectation that you’d carry on the rest of the day like nothing happened. People’s lives and health depended on it.
How do you process grief and loss? Answer that, then tell me how to do it in bulk.
At first, I found myself stuck between a rock and a hard place. On one hand, I really do not want seeing death on the regular, and the barrage of empathy I feel for those we lose, make me emotionally numb, as I try to suppress all feeling to avoid the pain of loss and grief.
On the other hand, I know full-well that I shouldn’t open the floodgates of emotion, it wouldn’t be healthy or sustainable, and it would certainly affect my practice negatively, to the detriment of my patients’ care.
I’m scared that if I don’t draw boundaries, I would lose the ability to feel empathy, or at least suppress it, in a way that would hurt those around me down the line. I wouldn’t want to become jaded or distant, like many in the field, who have grown apathetic, at least on a surface level.
While I know the difference between empathy and sympathy, and which one to “choose” in situations like these, but I refuse to accept that I could do that at the flick of a switch and on-demand.
I soon found that the answer was to allow myself to process those feelings. To get around to the conclusion of them, so I may end up somewhere in the middle.
In order to fully process what happened, I needed to revisit my first time(s) witnessing this. To go through every motion and every emotion with a fine-tooth comb, exploring how I can do this sustainably. I had a number of conversations about this day, some lasted hours. It really did help, and I’m beyond thankful to them.
I now understand that I will alternate between the two modes, one of feeling, and one of apathy. This is due to the fact that it is really unrealistic to expect a clean, straightforward, consistently applied process of feeling things. The ways we act, think and feel ebb and flow, depending on the day, how busy we are, and how our day is going.
A nice way to think of it (and I am well aware of my hubris, this could all turn out to be embarrassing in a couple of years) is using a normal distribution curve. The variable being degrees of feeling, from “least” to “overwhelmed”.
While on some bad days my feelings might veer 2-standard deviations away from the mean in either direction, I hope that that I remain within 1-standard deviation most of the time.
In the end, I go back to the quote I put at the beginning of this way-too-long overshare diary:
“Nothing in life will call upon us to be more courageous than facing the fact that it ends. But on the other side of heartbreak is wisdom.” — Sarah Bloom, Wish I Was Here
Thank you for coming to my ted talk.
