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A Beating Heart

  • Christy Lucas
    Correspondence
    Address correspondence to Christy Lucas, MD, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh 4401 Penn AveAOB, Suite 5400, Pittsburgh, PA 15224
    Affiliations
    Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
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Published:April 09, 2022DOI:https://doi.org/10.1016/j.acap.2022.04.003
      "Fourteen-year-old male with self-inflicted gunshot wound to the head” was a one-liner that gave me a reflexive shiver, raising the hairs on my arms in a warning of sorts. However, after being surrounded by death and dying in the PICU, shifting into survival mode, I did not pause to think about the trauma buried in that statement, unhesitatingly saying, "I will take him.” His name was Peter*, and he had come in overnight as a Level I trauma. As I read more about who he was from his family's firsthand accounts captured in the social work notes, I attempted to intellectualize what could not be intellectualized. I learned that Peter had a history of anxiety, and after a particularly difficult day at school, where he was threatened with another out-of-school suspension, felt that there was no other way out: trapped. All guns were locked in the home, aside from a single handgun in an office drawer. He had a mother, father, and sibling who loved him very much. His family was milliseconds too late and witnessed the gun shot, then stillness. They swiftly brought him to the emergency department, trying to save him, but the bullet's relentless path across his hemispheres proved to be unsurmountable. He herniated in the trauma bay, failing the standards of medical care used to prevent herniation. Surgery would be futile.
      A complete stranger reading through initial personal and medical accounts of what was likely the worst day of their life, I could not begin to fathom the pain of Peter and his family. In 30 minutes, I had been unknowingly privy to their darkest moment without even knowing what Peter or his family looked like; I was afraid to go into the room to pre-round because I knew too much. What would I say? What could I say? Should I say anything? As I approached the room, I had cowardly hoped that at 6 AM his parents would be fast asleep, but instead, I peered through the window and found them to be sitting on the couch—their body language conveying immense sorrow as they sat silently on the couch, shoulders slumped forward to cradle their heads in their hands, side-by-side. The pain was palpable from the threshold. I found his overnight nurse, a seasoned ICU veteran with wisdom beyond my own. As a resident on my second week of ICU, I asked what he would do. I asked if he thought the parents would mind if I examined their son, or if it would do more harm than good and to simply let them be. This nurse gave me the courage, and permission, to ask if I could enter.
      I slid open the door, unsure of what to say—would I apologize for their loss, for interrupting their grief, for being another stranger saying "I'm sorry"? I chose first to ask what I could do for them, though beyond coffee and graham crackers, I did not objectively have much to offer. They declined any needs, sitting quietly on the couch in the dark stillness of the morning, the sun beginning to rise as the orange-red glow peaked beyond the horizon as their sun was beginning to set.
      With anxiety creeping-up in my throat, I asked for permission to examine their son, which they granted. I walked over to Peter's bedside, instinctively touching his shoulder before beginning to listen to his heart. Pulsatile tinnitus from my own carotid arteries bounded in my ears as I attempted to auscultate, but eventually, I could hear his strong heart beating and the mechanical breath sounds reverberating through his chest. I felt for his radial pulses, 2+ and symmetric, and instinctively patted his right hand. Stillness. I stepped back after completing my exam, confronted with his face for the first time. I looked at his swollen eyes, the endotracheal tube taped at the lip, and bandages covering the entrance and exit wounds hidden in his soft brown hair. In that moment, I realized he was just a little boy, not even old enough to shave or drive. He was too young. Too young to have felt like this. Too young to die like this.
      I thanked his parents as I left, and told them, “If there is anything at all I can do for you, please let me know," still unsure what I could do to make it better: to heal the hurt that could never be healed. My inner hyper-helper daydreamed about bringing them Starbucks, preparing the “Doctor's Breakfast” of ginger ale, graham crackers, and peanut butter, or asking if they would like to pray. Yet, I was too afraid to offer any of these, afraid to cause more pain than peace.
      His parents initially wanted to withdraw care immediately and free Peter from his earthly body, however, they learned about the potential for organ donation and chose to pursue that instead, even though it meant waiting 24 additional hours for two separate brain death exams. They decided that as painful as it was to prolong the life of their son, it was important that some good be able to come out of this irrevocable pain so that another family did not have to know this loss.
      Much of our first day together was spent watching sodium levels, urine output, blood gases, and mean arterial pressures, titrating medications as needed to keep him alive. But was he “alive”? I struggled to conceptualize what it meant to be alive, wondering if all that was required for life was a beating heart, or if being alive meant being able to think, talk, love. Perhaps, being alive was different from living. I began to digress in my own head the longer I thought about it, trapped in a cycle of mental somersaults. I wondered, if wherever Peter was now, he could he hear us around his body, wishing to say something. Most of all, I wondered, if he could feel in that room how so very loved he was and that no bad day at school could have changed that. I also struggled with reconciling my faith and medicine, wondering if I was trapping his soul in a limbo of sorts by keeping his body alive for the greater good, unable to find peace or rest.
      The next day, I peeked through the door and found his parents standing vigil at his bedside, wearing the same clothing as the day before. “Why buddy, why?” his mother tenderly repeated to him amidst wailing—the kind of wailing emanating from an irreparably broken heart. His father stood beside her in a daze as he began to realize their new and unimaginable reality without their little boy. Peter was so clearly his family's rock, without which, their foundation would never be the same. I again asked permission to examine Peter, placing my hand on his right shoulder, perhaps to comfort him, perhaps myself. His father gently talked to him about all the children he was going to save—all the good he was going to do.
      I had noticed the parents were intently watching my exam from the other side of the bed, seemingly waiting in suspense, for perhaps they too were struggling with an alive versus a living Peter. I thought the chance to hear his heart beating could be a way for him to “speak” to his parents, and again overcome by an immense desire to make it better, I offered them a chance to listen to his heart. His mother listened first; as I moved throughout the precordium to make it easiest for her to hear his heart beating, her eyes began to well with tears and the tension released from her shoulders before passing the stethoscope to her husband. He listened for but a moment, jolting back with a startle. I could see that he was in pain. It felt like I had helped his mother while harming his father. Before leaving the room, I again asked, “Is there anything I can do for you?” His father replied sharply, “No. You have done enough,” cutting through my composure in what would be our final interaction.
      Later that day, Peter underwent his second brain death exam, officially declaring him brain dead. The appropriate referrals were made to begin the process of organ donation and remaining family was brought-in to say goodbye. On what would be his third and final morning in the hospital, Peter was alone after his parents had returned home to make funeral arrangements. It was eerily quiet as the sun had begun to light-up his room, with the hush pierced only by the ventilator's artificial breaths. I ritualistically put my hand on his shoulder one last time, listening to his heart and lungs as my own distorted goodbye. I talked to him in a hushed tone, walking him through my exam, so he would know that he was not alone. Though I knew what neurologic outcome and degree of functioning resulted from a subarachnoid hemorrhage, edema, and herniation through the foramen magnum, I still felt like he needed to know that it was okay, that he was okay, even if in the end, the only person who could actually hear me was his bedside nurse. That day, we did not round on Peter, the parade of computers rolling past his room; he had a beating heart but was now no longer alive. He was alive but also dead.
      As I worked on finishing notes and clip-boarding that afternoon, the organ procurement team passed by on their way to pick him up. Peter was then rolled past my workstation, as if an ordinary day and a routine procedure: a humble exit to provide the greatest gift. I paused, watching him until he was out of view, whispering, “Goodbye.”