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.