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On Being a Doctor Empty Pockets

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any of the experiences in our work we smooth and shape in the retelling like pebbles being polished by the tides. Some are more valuable for their sharp edges and the pain and lesson they bring by holding them tight. I spent part of my residency training at a city Veterans Hospital. Overnight call meant perpetual motion punctuated by frantic episodes of critical care. On this night we had done well, and by the time the first “code arrest” sounded overhead we all had managed to keep our heads above the tide. We arrived to the medical intensive care unit, wearing the authority our white coats gave us, to a bedside now ringed by staff. A trach collar had come loose and the trach itself unseated, but all had been corrected. Sorry about the run. A curtain separated beds in this area of the intensive care unit, and each curtain had been pulled when the code was called. I lingered to one side, planning to stay long enough to see the collar retied. I was jostled by some movement at the adjacent bedside. The next time, it was followed by an arm. My name was shouted, and then I was pulled by my coat sleeve through the curtain to the next bed. The patient, a young woman of 36, had been admitted by one of the teams earlier that day. Chest pain, they said. The bedside monitor began to bleat and flash. Her blood pressure was falling with each systole, and her cardiac tracing was taking on the jagged, wide, rugged contour that meant it would be a difficult trip. Her husband and two young daughters, 8 and 3, were led away from the bedside as the intubation tray was being opened. Quickly intubated, compressions made obtaining central access more difficult, but I placed an internal jugular line hoping things would go well enough that it might be used for a Swan–Ganz catheter. Compressions, fluids, advanced cardiac life support protocols . . . all the while cardiac tracing into dysrhythmia. Occasionally, the monitor would only stare blankly asystole, across its screen. And the blood pressure. Boluses and drips and fluid, nothing would move the blood pressure. She was only 36. I reached deeper into algorithms, knowing the next vial off the code cart would run the answer into her collapsing circulation. The answer that would also push away the pain growing in my own stomach. I believe I tried everything, and trusted each new intervention would be the one. None of it ever changed the course. Boluses, drips, compressions, bagged

breaths, time, and her heart finally stopped. She was only 36. I silently asked her why. A nurse touched my arm and said the two words whose weight made my next breath difficult and whose grip was tight around the pain in my stomach. “The family.” They had been taken to the waiting room. It was pale blue and the row of lights indicated the soda machine was still empty. My throat was dry. The youngest daughter sat on Dad’s lap looking at pictures in an outdoors magazine. The older sat watching her hands rest in her lap. Her husband’s eyes lifted to me and met mine. I didn’t, couldn’t, say a word. I took in the breath to begin, and he knew. The words never meant quite enough, “All we could . . .” They seemed small, like a string of toy boats against a stormy sea, “ . . . her heart . . .” I only had to say them, they would have to live them, “So sorry . . .” He turned back toward his daughters, a single father, and they lifted their eyes to his. As he drew the breath to begin, his eldest daughter knew. Suddenly all alone, she stood and ran toward us standing at the door. Dad bent toward her, but she got past him to me. Tears an unbroken line down her face, she took hold of my coat pocket. She said words that made 6 years of medical school, residency, and late nights too numerous wither. “Give mommy more medicine. She’ll get better, but you have to give her more medicine, please.” I couldn’t breathe. I had no words, no gesture. Her dad bent to her, but she wouldn’t let go of my pocket. He nodded to me, indicating I should go, and as I did the pocket she held tore. I drove home, tears making the road focus and unfocus, replaying it all to find the why or how. Ruptured ventricular wall? Aneurysm? Pulmonary embolus? I stopped when I realized it didn’t matter. I went home to my wife, then 33 years old. I took off my coat as she stood silently watching and put it in the trash. I needed some time to explain, all I could say was, “That one doesn’t work anymore.” Kevan Pickrel, MD Phoenix, AZ 85020-2450 Requests for Single Reprints: Kevan Pickrel, MD, 9100 N. Second

Street, Suite 221, Phoenix, AZ 85020-2450; e-mail, [email protected]. Ann Intern Med. 2003;139:525.

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