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Fall Mourning

Published:December 16, 2021DOI:https://doi.org/10.1016/j.acap.2021.12.011
      Waking-up to another dark morning, I roll out of bed at 4:40 am, a day in the life of a resident in the Pediatric Intensive Care Unit. It was an ordinary Fall morning, arriving on the unit to take sign-out and get ready to start the day, until it wasn't. At 6:11 am, the code bell alarms, alerting our phones as we are huddled at the computers, gathering our numbers for rounds, sending us running to room 506 and leaving everything behind. Before I am able to round the corner, I hear a woman wailing—the kind of wailing that shakes your soul, raising the hairs on your arms in a somber salute; the kind of wailing that tells you, “This can't be good.”
      I arrive at the doorway amidst the chaos of the code cart rolling in and the chest compression line forming, as a nurse begins compressions and the fellow works on establishing an airway. Those in the room say, “She's a genetics kid with a history of a heart transplant. Call CT Surg for ECMO
      ECMO indicates extracorporeal membrane oxygenation.
      low asteriskECMO indicates extracorporeal membrane oxygenation.
      .” The one-liner sounds oddly familiar, but adrenaline stops me from thinking about it any further. Though anxious, I get in line, my knees intermittently locking and legs intermittently quivering. The room begins to fill with more people, checking rhythms,
      Name has been changed to protect patient privacy.
      calling out times, shocking, ordering medications, assigning roles. I see a glimpse of her body on the bed, pale as snow, still, lifeless, arresting.
      Soon, I am up next for compressions. I hop-up on the step stool, my lanky habitus towering over the bed as I attempt to use gravity to help compress the chest to an adequate depth. I begin compressions, playing the song “Staying Alive” on repeat in my head to maintain an appropriate rate as the surgeons begin to assess the femoral vessels for cannulation onto VA-ECMO. I don't know if my mind is singing for her or for me. My eyes are laser-focused on the sternum in front of me. Soon, my 2 minutes are up, and I get back in line. I do not look at her face, perhaps out of fear of flashback or fear of knowing that this body I callously compress is a human being and knowing the pain that would bring me. “V-fib… V-tach … PEA,” intermittently pierce the background. The team leader calls out, “If you're tired, get out of line.” I was tired, but I knew I could do one more cycle—45 minutes in and my third cycle. Stepping up to bed with “Staying Alive” again playing through my head, I feel my muscles begin to fail me. The CPR timer steps out of the room, and after what felt like an eternity of untimed compressions, I call out, “Can someone switch with me?” and I yell, “Five, four, three, two, one.” Breathe. Someone assumes my place. My arms are noodles, and I develop a tightening in my chest; I am not sure if it is an exercised-induced bronchospasm or the beginning of a panic attack. Perhaps both. I get out of line, squeezing around the sterile field to silently exit the room and preround on my patients before fellows’ sign-out.
      As I sit on the counter to listen-in on morning sign-out after checking on my patients, my adrenaline begins to settle, and I am left with nausea and my thoughts. I pull-up the patient list on my computer, searching for who is in room 506. I see a name. I know her name. I knew it was her, even though I never looked at her face. It's Joan
      Name has been changed to protect patient privacy.
      , a patient whom I've cared for and admitted multiple times on the floor during my intern year, as recently as 4 months ago. Joan had an inherited metabolic disorder that required a special oil to prevent metabolic crises and survive. Adherence and motivation had posed challenges in the past, but she always pulled through, even after being intubated and dialyzed years ago for the same presentation. I began to read through the labs, imaging, and notes from earlier in the morning when she was admitted—potassium > 9.0, ammonia of 150, and EEG with “severe diffused underlying cerebral dysfunction.” I take a moment to pray for her, but I can feel how this ends; the wail I heard while running to her room had already told me.
      With the pandemic looming in the background, the ICU census was high; we did not have time to debrief, moving on, rounding as if it were still just an ordinary Fall morning. As we passed room 506, I paused, peeking inside from the doorway. She continued to lie still, white as snow, now asystolic on ECMO. I again walked away. We finished rounding, and I gathered my things to go to my continuity clinic that afternoon, with sore arms and a spasming back, as her father walked by in a daze, holding a bottle of pop. I left for continuity clinic thinking, praying, the ending could be different.
      In between well-child checks and sick visits, I continued to “chart stalk” Joan; I had hope for an alternative ending. Her potassium remained greater than nine, she developed a troponin leak, and her heart never beat again. Soon, an organ donation referral in the setting of “imminent death” popped-up in my flowsheet, followed soon after by a death note. I sensed this was coming, but still, Joan's death was jarring.
      I lay in bed at home that night, after spending much of the afternoon and evening pretending to have had an ordinary Fall morning, thinking about Joan. Joan had been a quirky teen, having developed an interesting psychopathology, likely reflective of being chronically ill for most of her life. She always kept me on my toes and was the star of some of my most outrageous stories of intern year, including when I had to order a frog-leg x-ray to assess for a misplaced toy or all of the STAT ammonias I ordered for altered mental status that turned out to be appropriate teenaged irritability at being awoken before 10 am and eating too much cheese too fast. Then came the guilt, thinking about how I had failed her. I remained stuck on how so often, I would see Joan's name on the inpatient census or in the prearrivals and would sigh, complain, and reluctantly admit her, knowing that there would probably be yelling, tension, and what often felt like ingratitude. I felt tremendously guilty for spending much of our doctor-patient relationship feeling uneasy that she was my patient, wishing that I could take care of a patient who was easier to care for, who wanted to be cared for. I thought about how scared she must have been, stoic though she was. I knew how heartbroken her fierce, yet gentle father must have been upon withdrawing care after this morning's code, as he had months earlier told me, “I just want what's best for her.”
      The next morning, I cautiously tried to share my grief, like dipping a big toe into the swimming pool before diving in, hoping someone would validate, or even reciprocate, my unease. Although some did, I was also met with statements like, “She did this to herself,” “She never took her medicine,” and “It happens.” Perhaps this perceived callousness was a form of grief mislabeled. Yet, I worried that unlike a typical or cute child, Joan would not be missed—that few would look upon her “in loving memory.” Would anyone else care that she died? Might they come to miss her like I had? Were they wrong not to miss her?
      There have been moments in my life where I was troubled by not knowing how to help. However, with Joan, I was trained how to help and knew how to help but chose not to. I cared for Joan 3 times prior to her arrest—the beginning, middle, and end of my intern year—and after her death, I saw all of the missed opportunities, long before 3 rounds of chest compressions—the help I gave, but truly not the help she needed from me.
      Sitting with my cognitive dissonance and Irish Catholic guilt, I soon began to realize that Joan's charm was in that she was not easy to care for, challenging us to come to terms with our own discomfort to see her humanity, even when we wanted to scream, “I give up” and leave the room. I will live with the memory of Joan's death, along with the guilt from the times that I failed her as her doctor. I will also live with the memories of Joan's quirky sense of humor, no-holds-bar frankness, and obstinate love for cheese. She will remind me of the importance of being present and seeking the good; taking that one foot out of the door and instead pulling up a seat at bedside to find the beauty often camouflaged as chaos.
      Joan, forgive me for when I did not look at you, when I did not see the good in you, and when I did not help in the way you needed. I will remember you—in loving memory.
      It was not an ordinary Fall mourning