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Gift of Gratitude

We all remember our patients who die, though the first patient death really stands out from the rest. This was certainly true for me.

I was just starting the second year of my internal-medicine residency. This wasn’t the first time I’d seen someone die, but it was the first time I’d seen someone who’d been alive and well, and talking to me that morning, be dead by the afternoon–a shocking dichotomy that haunts me to this day.

The patient wasn’t an eighty-seven-year-old grandfather on his deathbed, reaching for his daughter and grandsons to tell them, “It’s okay to let me go. I’ve had a fulfilling life.” It’s tempting to take comfort in the rationally predictable demise of an elderly patient who has lived a long, full life and is ready for what lies beyond.

I met my patient, Aaron Jenkins, on the oncology unit. He was a different soul—not at all the classic cancer patient. Aaron was young, in his forties, and fit, too, his muscles apparent through his meek hospital gown. Earlier in the week, I’d cracked jokes with him about his team, the Eagles, winning their first Super Bowl, while my Steelers had six Super Bowl wins. I’d seen him greet each floor nurse with a radiant smile as he walked through the oncology halls. His complexion looked healthy, his face youthful.

Despite his seeming health, the biopsy results told a dismal story: Alas, his sentence was lymphoma. His wife, Nicole, was the only one in his family who knew.

“I haven’t even told our kids,” she confided. They had a son and a daughter; one had just started elementary school, and the other was beginning senior high.

“We thought it was better to wait until summer camp was over,” she added. “So it wouldn’t be a cloud hanging over their heads.”

I nodded. It made sense to let the children enjoy their image of their father as healthy for just one more week.

And then he coded.

It happened in the interventional-radiology suite, right after an innocent intravenous line had been placed in preparation for his eventual chemotherapy. His oxygen levels were low, which sometimes happens after receiving anesthesia. His nurse called me to say that she was concerned and had called the critical-care physician to come and evaluate him.

I walked into a serene environment—the nurse calmly exchanging fluid bags, the critical-care attending texting his fellows and residents about other patients who were seemingly more ill.

In the blink of an eye, all of this changed: Aaron’s eyes rolled back in his head, and he stopped moving.There was an eerie pause. Then the overhead speakers blasted: “CODE BLUE!”

The room filled with nurses, residents, crash carts and, most noticeably, adrenaline.

The attending started doing chest compressions.

“Run the code,” he told me. Scouring my brain for life-support algorithms, I began to direct the other providers.

“Push one milligram of epi,” I said. Hearing myself say those words, I wondered, for the first time, whether Aaron would survive.

We heard his ribs crack from the compressions, and still there was no pulse. His lungs’ only movement came from the gusts of air being forced into them via a bagged mask.

We pushed on for an hour. Finally, in exhausted resignation, we acknowledged the grim truth: Aaron was dead.

I will never forget Nicole’s heartbroken wails. The attending and I guided her to the family meeting room and gently closed the door. Was there any right way to explain this catastrophe? I could only sit, hold her hand and try not to blame myself that my first code had gone so horribly wrong.

What moved me even more profoundly than her tears were her words to me:

“Thank you for all the care you have given. Thank you truly for the daily updates. They meant so much.”

“You’re welcome” seemed a weak, inadequate reply to this women who, in her darkest hour, had found reason for gratitude.

“I’m so sorry,” I repeated, wondering, However can I ask her the final, necessary question: “Do you want an autopsy?”

She agreed to the autopsy. But learning that a blood clot in Aaron’s lungs had been to blame didn’t change the tragic reality: He was gone. His wife was now a widow, and his kids had lost their father.

Like many other physicians, I harbor a mental graveyard that shapes my care. These graves—Aaron’s was the first—have instilled in me a special kind of anxiety: a mix of guilt, anger, fear and regret. They have conditioned me to look twice at every diagnosis, even the simple ones that I’ve seen a hundred times. They spur me to keep learning and searching for medical answers, so that maybe next time I can save a life.

Reflecting on my patients, I’ve become more deeply aware of just how much I owe every one of them, regardless of their outcomes. They each permit me a glimpse into the narrative of their lives, paving the way for the unique connection we share as patient and provider.

To my patients who leave the wards in better health and spirits, I offer my gratitude and appreciation. You have shared your vulnerabilities with me and allowed me to take joy in the part I’ve played in your healing.

To those who have died, I offer a different kind of gratitude, learned from a newly widowed woman: the gratitude of a bond that makes saying goodbye so hard.

 

Naveen Menon, an internal-medicine resident at Cooper University Hospital in Camden, NJ, hopes to pursue a fellowship in hematology/oncology. “Throughout my life, I have always had a creative outlet. Until recently, this was music. Through playing in my high-school jazz ensemble, performing at the University of Michigan graduation and jamming with other medical-student musicians, I’ve gained a deep appreciation for the creative arts. In residency, I’ve been excited to find a new outlet, writing, that combines with my passion for medicine. This is my first narrative-medicine piece. I hope this new pursuit will launch me into a deeper connection with the medical humanities.”

Comments

13 thoughts on “Gift of Gratitude”

  1. Thank you for sharing and definitely thank you for service provided.
    I started nursing at 17 so when my first hospice patient died I was given the option to dress him and help prepare for services or have someone else do it. My professor agreed to be the one in charge of me that day so we could get him ready. The love and empathy that day was beyond what I’ve experienced. My professor was an army medic and having her guide me in that experience was so touching. Everything down to how we placed his socks still so fresh in my memory. Rest in paradise and thanks to my patient as well for teaching me that death is inevitable and compassion goes a long way.

  2. Roger W. Schauer, MD (ret)

    Thank you, Dr Menon, for your beautifully written piece. For over five decades I’ve remembered the death of a patient assigned to me as a 3rd year student on my first Internal Medicine clerkship. She was about 68 years old and had been in the hospital for some time with profound depression. I talked with her at lenght daily, and finally learned she had not seen her only son in more than two decades although they lived in the same community. I was finally able to connect with him and inform him regarding his mother’s wishes. He came to the hospital to re-connect with her, and had promised to bring her to his home when she was discharged, which she beamingly related to me the following day, my last day on that service. The following week I returned to that ward to get an update about her discharge. The nurses told me the son came, but as she got out of bed she suffered a pulmonary embolus and died. While I did not witness her death, her memory has been with me for this time, and likely was on my subconscious mind when I selected a Family Medicine Residency soon after that type of residency programs began.Your writing brought her death back to mind immediately, and it is with gratitued I was able to use her memory during my practice years, and lead me now to submit this long response.

  3. Roger W. Schauer, MD (ret)

    Thank you Dr Menon, for your beautifully written piece. For over five decades I’ve remembered the death of a patient assigned to me as a 3rd year student on my first Internal Medicine clerkship. She was about 68 years old and had been in the hospital for some time with profound depression. I talked with her at lenght daily, and finally learned she had not seen her only son in more than two decades although they lived in the same community. I was finally able to connect with him and inform him regarding his mother’s wishes. He came to the hospital to re-connect with her, and had promised to bring her to his home when she was discharged, which she beamingly related to me the following day, my last day on that service. The following week I returned to that ward to get an update about her discharge. The nurses told me the son came, but as she got out of bed she suffered a pulmonary embolus and died. While I did not witness her death, her memory has been with me for this time, and likely was on my subconscious mind when I selected a Family Medicine Residency soon after that type of residency programs began.Your writing brought her death back to mind immediately, and it is with gratitued I was able to use her memory during my practice years, and now submit this long response.

  4. Thank you for sharing this story, Naveen. You are not alone even though your experience of this universal moment in medical training is uniquely your own. I just got funding to launch the podcast, “Dying To Talk: UCSF Heart Sounds” promoting wellbeing and community through conversations with new doctors at UCSF about the universally experienced moment in medical training: the first patient death as a doctor. Invitations for community engagement through “Huggles” will be part of every episode. You can learn more at: https://dyingtotalk.com/new-page
    I hope you will tune in and form a “Huggle” or two within your community of residents, too.

  5. David Coulter, M.D.

    You will remember all of your patients who pass on, despite your best efforts, because you care and share your humanity with them. From my first patient who died in 1971 until my last patient who died in 2021 (I am now retired), I remember them all. Writing their stories has always helped me to deal with the emotion. I encourage you to continue to write, even if just in your own notebooks. It really helps.

  6. Well written and good for you to take pen in hand and write of these experiences. It is both therapeutic and more importantly, allows you to process your participation in these life changing events which we health care professionals take part in. Our role at the bedside is intense and critical.
    Take care of yourself!

  7. Dr. Menon, I have always thought that living with the memories of patients we’ve lost is one of the defining characteristics of being in healthcare, and a significant reason why what we do affects us so profoundly. Not that it impairs us from functioning, nor that it makes us callous, but rather that it instills in us an appreciation for how precious life is, and how easily life can be lost. That realization makes us cherish the interactions we have with our patients and our colleagues as we go about our day. It allows us to celebrate those moments when our efforts make a real difference in the course of someone’s illness or disease process, whether that difference is a complete cure or giving comfort and companionship at the bedside when a cure is not possible. It gives us the strength to keep learning our craft and doing the work, and not succumbing to despair.

    Thanks for sharing your writing with us.

  8. Thanks for sharing.Despite all our clinical skills we can’t always save our
    Patients. It helps to know they are in Gods hands now.

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