Pulse newmasthead 10th anniv 2252x376px

Subscribe/Energize


new subscription

Join the 11,000+ who receive Pulse weekly



energize subscription 
Energize your subscription
with a contribution and
keep
Pulse vibrant



Katie Lin

It's 2:00 am, and the fluorescent bulbs flicker gently overhead along the quiet hallways of the intensive-care unit.

Tonight I'm the ICU resident on call, and the weight of that title sits heavily on my shoulders. My team is in charge of keeping our critically ill patients safe from harm overnight. Although the supervising physician is only a phone call away, I'm the acting team lead for any codes called during the night on patients elsewhere in the hospital who may need our life-support services. Code Blue: cardiac arrest. Code 66: anything else requiring assistance.

The metronomic beeping of the life-support machines keeps time as I blink the weariness from my eyes and share a few muted smiles with the nurses who work tirelessly alongside me while the rest of the world sleeps.

Then the call comes over the intercom: Code 66, unit 74, Highwood Building.

We fly into action--a rush of wrinkled scrub tops, stethoscopes and coffee breath. The elevator ride up to the seventh floor is interminably slow; it's rendered all the more surreal by the number of people crammed clown-car style alongside the crash cart, and by our jesting banter, born of shared exhaustion. But when the doors open onto our destination, we're all business.

We can tell from the moment we walk in that this is a tragedy unfolding.

Mr. Smith is a seventy-nine-year-old man admitted for shortness of breath, otherwise healthy. Expected length of hospital stay: two to three days.

That's when the story goes downhill.

He fell a few hours ago and bumped his head on a ledge, report the nurses, but he seemed to be doing okay. Sure, he was a bit confused, but he shook it off and went back to sleep. Now, as the nurses try to rouse him for his routine vital-signs check, he won't wake up.

In fact, as I quickly evaluate him, I realize that he's very nearly brain-dead. His pupils no longer react to light. He has lost most of his reflexes. He doesn't respond to any form of stimulation.

Every step we take is calm, cold and clinical. He requires intubation for airway support: He's intubated. He requires a CT scan of his head: He's rushed to the scanner. His family must be notified: They're on their way.

By phone, we inform the neurosurgeons and our supervising physician of the situation and transfer Mr. Smith to the ICU for further management.

The only surprise in his CT scan is how extensive the damage is. The bleeding has unceremoniously displaced the rest of his brain in a process that will slowly take his life throughout the predawn hours.

The neurosurgeons tell us there's been too much damage for any meaningful intervention to take place. My supervising physician tells me that she will see us in the morning. She instructs me to keep him alive as long as I can--hopefully until his family has had a chance to say their goodbyes.

Then the phone goes silent, and I walk down the hall to tell a roomful of hopeful strangers that there's nothing more we can do to save their loved one.

In medical school, they teach us how to break bad news. There are rules and etiquette that help to ease the process for families. But we're never taught how to keep our own raging, desperate helplessness in check at moments when we realize that modern medicine cannot stop a life from slipping away.

Experience has taught me that the stages of grief are messier and more heart-wrenching than any textbook could possibly convey.

First, there's denial.

"I don't understand. We were told just yesterday that he would be coming home soon."

"If we could fly him to the Mayo Clinic, do you think they'd be willing to operate on him?"

"Are you sure you're old enough to be a doctor?"

Denial, I've learned, is best countered with patience, Kleenex and truth.

Next comes anger. This is what happens when overwhelming sadness descends for the first time, but doesn't yet have anywhere to land.

"How can you just let him go like this?"

"We don't have time for this right now! You need to do something!"

"Don't you realize that his children and grandchildren need him? I need him...."

More patience. More Kleenex. And more truth.

Then comes bargaining.

Bargaining is hard, because saying no to a desperate loved one feels unbelievably cruel.

"Why can't we just do the surgery and see what happens after?"

"Are you sure there are no neurosurgeons in the city who would try?"

"I'm sorry, but..." is how most of my responses begin. The bargaining stage usually ends when families are brought to the bedside to see what life support really looks like.

Sadness comes next. Surprisingly, this is actually one of the easier stages to manage, because it is the one that most accurately reflects how we, as physicians, feel when we are helpless in the face of a patient's death. I offer a few hugs before making my exit--an exit intended to give myself a moment alone to breathe and reflect as much as it is to give the family some privacy.

Finally, there's acceptance.

For me, this is by far the hardest. I can take rage or criticism in stride, because I know they're not really meant for me.

It's the kindness that I find so incredibly hard to accept when I feel I've so utterly failed.

Several hours have passed since I first walked into the room with Mr. Smith's family. The talking is winding down; I manage to slow the bleeding with specialized blood products and clotting medications in order to protect what precious little is left of his brain until they've said their goodbyes. The morning crew begins to trickle in.

And then Mr. Smith's wife and son turn to me.

"Thank you," they say. "We're glad that he had someone with him for his last hours. We know it's been such a hard night for you."

They don't get to see it, but it's this kindness that makes me curl into a ball when I finally arrive back home at the end of my shift. As I lie drifting to sleep in the dark safety of my room, that moment replays again and again in my mind. It nearly breaks me.

And then 6:00 am comes again. I put on a fresh pair of scrubs, sling my stethoscope around my neck and embrace the inevitable coffee lineup. My tears have been traded in for a fresh, albeit unsteady, smile.

Sometimes, it takes a lot of effort to remember that this job is worth it.

As I walk past Mr. Smith's room--his bed now occupied by another critically ill soul--the thank-yous still echo in my mind, but they begin to feel less hollow. They represent a moment shared, a life remembered and the human connection that runs deeply throughout these otherwise sterile corridors.

Sometimes, it just is. Worth it, that is.


About the author:

Katie Lin is a second-year resident in emergency medicine at the University of Calgary. This is the first time she has ever written a personal piece about her medical experiences. Mr. Smith's story was written the morning after his death. Despite her initial hesitance, Katie was encouraged to publish this piece by colleagues who have had similar experiences. "The culture of medicine continues to shift away from the unyielding stoicism of tradition and towards a more accepting, patient-centered form of care. I hope that by sharing this story I can help to chip away at the hard-held attitudes that have forced so many physicians to keep their emotional burnout hidden away. We all have vulnerable moments, and there is no shame in our shared humanity."

Story editor:

Diane Guernsey

Comments   

# Heidi Peterson 2016-04-24 01:47
This is beautiful. Thank you
Reply | Reply with quote | Quote
# Rachel Chalmer, MD 2016-02-16 20:36
This is excellent. Thank you so much for articulating so clearly something I have experienced over and over. I plan to re-read this piece when I go through an experience like this again. Truly, thank you.
Reply | Reply with quote | Quote
# Mary 2016-02-13 09:19
A patient wasn't evaluated after a hit to the head? The nurses left it at "he shook it off"? Was this family told that?
Reply | Reply with quote | Quote
# Dr. ATB 2016-02-09 13:09
Katie,
Your expression of emotion here is beautiful, poignant and truthful. Thank you for sharing. As a physician, I have experienced situations similar to yours. I am grateful to you for expressing this so well. Best wishes to you in your career and know that what you do is appreciated.
Reply | Reply with quote | Quote
# Roger W. Schauer, MD 2016-02-07 00:35
Thank you Dr. Lin. I'm certain you were not available 45 yrs ago, but I wish someone had provided your comforting thoughts to my generation of physicians. It might have eased my pain in dealing with parents of young children who died tragically and needlessly.
Reply | Reply with quote | Quote
# Ron Katz 2016-02-06 15:42
Having spent some time in the ICU as patient in the last year I have a special appreciation for the staff that is there for the overnights. They carry a special burden and it sounds like Dr. in carries it with special grace and caring. Thank you for sharing so openly in this piece.
Reply | Reply with quote | Quote
# Susan Boyko 2016-02-06 12:20
Beautifully written. Resonant. Thank you for sharing your experience. Pieces like this one speak for those who are not able to share how much they feel about their work.
Best wishes.
Reply | Reply with quote | Quote
# Muriel Murch 2016-02-06 04:10
Dear Katie,
Lovely piece. Facing and receiving the stages of acceptance from family members in these situations is never easy. You did a great job and articulated it well. It is in the acts of human kindness and 'thank you' that we are bound. Good Luck.
Reply | Reply with quote | Quote
# Barbara Young 2016-02-06 01:31
Dr. Lin,

Exceedingly valiant efforts were made by you and others in the hospital to save your patient, I think anyone would agree. However, given the condition of the patient, it was impossible.

When he was gone and family members expressed their thanks to you, I don't understand why this prompted your use of the word "hollow." Can you explain why such thanks made you feel bad?

Meantime, my thanks (now don't feel bad!!) to you for a beautifully written piece. I hope you continue writing--

Barbara
Reply | Reply with quote | Quote
# Eric Butler 2016-02-06 14:33
I am not Dr Lin and so I don't speak for her, but as a fellow second year resident (we're good friends from med school in fact) I felt similarly with my first case that went this way. I think it's because the doctor, too, has to transition through acceptance, and at least when we're learning to deal with these emotions, it's hard to do it until the loved ones of the patient have made it themselves. Although we know how to say the words and show the feelings, it's hard not to feel an element of personal failure even in a one-way case like this. When part of you feels like you're responsible for the patient's death, you can't hear that thanks for what it truly is until you've transitioned into acceptance yourself.
Reply | Reply with quote | Quote
# Henry Schneiderman 2016-02-05 22:11
Katie, this is a great piece of writing, and as a palliative care physician, I find it so heartening for it embodies the skills and attitudes of palliative care that every internist, every clinician, must possess and exercise to the benefit of the family, the patient, and our own selves (and not try to "outsource" to the palliative care team). I will ask our Chief Medical Residents to export your essay for all our housestaff to read, and will ask the head of our hospitalist service to do likewise.
Reply | Reply with quote | Quote
# Katie Lin 2016-02-06 15:13
Thank you, Dr. Schneiderman. I would be deeply honoured to have this story shared with your housestaff.
Reply | Reply with quote | Quote
# Pam Mitchell 2016-02-05 21:12
"There is no shame in our shared humanity." Beautiful.
I am no longer young and as a seasoned nurse I am grateful for your courage, Dr.Lin. My generation was very often empathetic but did not always express it, much less write about it. It is my hope that you will find a new freedom to experience ever-more empathy as you rejoice in your humanity and share it.Thank you. Bless you.
Reply | Reply with quote | Quote
# Katie Lin 2016-02-05 21:10
Thank you to everyone for your kind comments. They are very much appreciated.

Julie and Andrew, I completely agree and apologize if anyone was disheartened by my wording. It was never my intention to disrespect the hard work of my physician mentors and predecessors.

I will contact the editors and request for that line to be changed in keeping with that recognition. Thank you again for bringing it to my attention and for taking the time to read this piece.
Reply | Reply with quote | Quote
# Julie Schulman 2016-02-06 03:43
Quoting Katie Lin:
It was never my intention to disrespect the hard work of my physician mentors and predecessors.


Pay us no mind, Katie. Your writing is beautiful and I wasn't offended, only amused. Someday you'll be the physician mentor and you'll see how truly constant the art of medicine is over time. The practice of medicine changes -- the treatments, the diagnostic tools, the format of the medical records -- but in the end, it's always about the patient and her doctor in a room, and what happens in that shared space.
Reply | Reply with quote | Quote
# Julie Schulman 2016-02-05 20:46
Beautiful piece. There are many essays out there about the experience of being a resident and dealing with the family of a dying patient, and this is one of the best I've read.

I do have to agree with Andrew Gallan that the belief that medicine is only now becoming "empathetic and patient-centere d," as you mention in the statement below the essay, is incorrect. What is changing is the acceptability and even the ability of physicians to acknowledge and express their own emotions. They have always cared quite deeply for their patients.
Reply | Reply with quote | Quote
# Eric Butler 2016-02-06 14:41
I think it's a common feeling for us newbies, I know I have sometimes felt like we're the generation that invented empathy, even though it's a ridiculous thought. It might be because our mentors tend to be better at composing themselves, this isn't necessarily easier with experience but it's certainly harder to see inside someone with a well developed professional exterior. We also don't see our mentors at night, after the case.

Perhaps just as big is that it's heavily implied during med school that so much of this is "new", when really the only new thing is that we're making a concerted effort to teach it from the start.

I don't know what to make of that. As I transition from trainee to preceptor, I'm going to take a page from some of my best preceptors' books and make an effort to show some of my own vulnerability, and let them know it is normal. And since I got that from older doctors I'll also make an effort not to think I invented it!
Reply | Reply with quote | Quote
# Carolyn Cowan 2016-02-05 19:48
Such a moving tale of such demanding work.
It helps me as a family member who's lost parents, in-laws, a younger brother, and friends in recent years to visualize the challenges and pain on the "other side" of the story.
Thank you.
Reply | Reply with quote | Quote
# Andrew Gallan 2016-02-05 19:46
"The culture of medicine is beginning to shift away from the unyielding stoicism of tradition and towards a more empathetic, patient-centere d form of care." My, how the pendulum swings. The young feel like they are inventing empathy.

Physicians should never feel like they are in control of death, because they never are.
Reply | Reply with quote | Quote
# Katie Lin 2016-02-05 21:26
Hi Andrew,

Thank you for your feedback.
As I have stated above, I will be contacting the editors to change this statement as it was never intended to impart blame or criticism, but rather to acknowledge an ongoing challenge for those who have worked - and continue to work - in the medical field.

I also don't mean to suggest that physicians ever feel "in control of death." Even as junior learners, we are well aware that there are limits to modern medicine. However, after having spent years of dedicated training focused on the active treatment of problems with little preparation for the challenges of palliative care issues, it can still feel crushing when we lose patients despite doing the best we can.
Reply | Reply with quote | Quote
# Greg Shumer, MD 2016-02-05 19:41
Really excellent post. Thank you for sharing.
Reply | Reply with quote | Quote