Jamie Riches, DO, is a 2016-17 Chief Resident in Medicine at Memorial Sloan Kettering Cancer Center
We had known Ms. B. for weeks. She was a “bounce-back” to the unit. Every day, an intern would enter the ICU room and ask, “How do you feel?” “OK.” Do you have any pain?” “No.” “Any trouble breathing?” “No.” “Tightness in your chest?” “No.” “No? OK.”
I was the senior resident following the case, 1 of 22 in the ICU. I walked in that morning and asked, “How do you feel? Are you nervous?” “Yes.” We’re trained as physicians to accumulate and analyze large amounts of information and condense it all into one-liners. I had known this patient as “a 74-year-old female admitted with acute hypercarbic respiratory failure in the setting of a large pleural effusion, atrial fibrillation with RVR, diastolic heart failure, and an extensive prior course complicated by an acute cardiac ischemic event, refusing catheterization.” That morning, the patient, whom I had also come to know as a dedicated mother, a strong-willed woman, and a funny, caring human being, was, in a one-liner, “tired and scared.” She was scheduled to have a thoracentesis that morning; we would remove fluid that had been occupying her lung space and test it for infections and cancer. We hoped the procedure would be diagnostic and therapeutic. She said she might not want to know if it was cancer. She just wanted to be able to go home. “We want that too, Mrs. B.”
Checklist: The patient was prepped in sterile fashion, and the area was cleaned and dressed appropriately. Risks and benefits were explained: check. A time-out was performed: Patient name—correct; Procedure—correct; Site—correct. Site was marked.
The patient sat at the edge of her bed with her arms outstretched across a rolling tray table. This was the table that usually held snacks, her small blue leather Bible, and the phone to call her son and daughter. Her children came to visit every single day and night. Today, the table held a plastic pillow, which crackled with the slightest movement. I squatted in front of the table and held her hands, while the fellow prepped for the procedure. “What procedure are you having, Ms. B?”, the attending physician asks. “They just told you. I’m having a thoracentesis.” “And what does that do? What is the purpose of the procedure?” “To take the fluid out of my lungs so I can breathe better.” The checklist was complete.
Ms. B held her small blue leather Bible by her side every day. She prayed and thanked the Lord every day she awoke to breathe. Despite 18 years of Catholic school, I probably haven’t “said my prayers” since I had to be reminded to take a bath.
“Were you born in New York?”, I asked. “I was born in South Carolina. My mother brought me here when I was 2… to be educated. I was educated in New York City.” She spoke with a pride that not only filled me with a sense of gratitude, it fractured me with guilt. I too was educated in New York City. I had always regarded my education as an expectation, as opposed to a gift, despite neither of my parents having attended college. Knowledge was, to a certain extent, a collector’s item, to be acquired and displayed within various carefully chosen venues. My mother was hard on me when it came to my performance in school. If I scored a 98% on an exam, she would ask, “What happened to the other two points?” I had never been any more proud of my education than proud of my ability to wake up every day and brush my teeth. I’ve been reminded on more than one occasion that I do not have a “pedigree.” As an older African-American woman, Ms. B remembered a time when simply attending school was a right to be fought for.
“I like your scarf,” I said. Ms. B wore a bold orange headscarf with an asymmetric bow. I’d seen her wear it many times over the course of her stay. There was something fearless about that scarf. Silence. “Are you nervous?” “Yes!” Silence. “What kind of music do you like?” “The Blues… and I love Christmas music. It just makes me happy.” I placed my iPhone on the tray table and opened a Spotify playlist called Christmas Hits. “I’ll Have a Blue Christmas Without You” was the first song. I made a joke about the song being best of both worlds. Silence. I found out during our conversation that she loved scary movies and zombie shows. “I love The Walking Dead, Night of the Living Dead, all those shows.” I told her that I can’t watch those shows because I am actually afraid of them. “They don’t scare me.”
Her hands were small. There was a cyst on her left little finger, which I hadn’t noticed before, any of the times I’d seen and examined her. I wondered what other observations I’ve failed to make. “Does this hurt?” “No.” “Has it always been there?” “No.” “What happened?” “I was carrying a heavy grocery bag, and it never went away.” When she felt discomfort or anxiety, she would quietly dig the tip of her fingernail into the pad of my gloved finger, staring straight into my eyes. I have the same self-soothing mechanism: I press the pads of my fingers, subtly and often subconsciously against the edges of my fingernails, bilaterally and symmetrically, until I’ve traveled from my indexes to my little fingers, and occasionally I’ll start the process over again from there. I usually don’t recognize my own nervousness until someone looks at my hands and says, “Are you OK?”
I whistled along to “Let It Snow” as the fellow continued with the procedure. The procedure was simple, “uncomplicated” as we say, no bleeding, no hemodynamic instability, no pain. Her son and daughter came in patting her on the shoulder, “You did great mom! See? You did great.” We all left the room to begin rounds. A post-procedure chest x-ray was unremarkable; decreasing pleural effusion, no evidence of pneumothorax. Ms. B spent the morning with her children and sister, breathing more comfortably. “She’s doing great!”
Later that afternoon, a nurse told me that the patient was having some difficulty breathing. When I arrived in the room, Ms. B’s heart rate was rapid and irregular. Simple breathing was laborious, and her face wore the expression of desperate fear. “Not the mask! No mask!” She had intermittently required a biPAP mask to support her breathing. She hated that mask. We thought the thoracentesis would alleviate its necessity. As I placed my stethoscope on the right side of her chest, I heard no sounds to accompany the arduous rise and fall of her ribcage. “We need a STAT chest x-ray!” The x-ray looked as if the image were split in two and inverted, as if the right side was a negative. Hemothorax. “She needs a chest tube,” the attending said.
As they prepared for a second procedure, I walked outside and placed my hand on her son’s shoulder. He was a large, loud, boisterous man who many of our staff members found intimidating. He had a plethora of very specific questions every day. The attending reviewed the new procedure with him, and he looked at me, timidly, with the same frightened eyes I had seen earlier that day. “Is she going to be OK tonight, Doc? I’m scared.” He previously had never called me anything but my first name. “What’s going to happen?” “I don’t know,” I said, “but we’re going to do everything we can to take care of her.” I walked away to the next room, to check on another patient, a “sick patient,” a GI bleeder receiving his 5th unit of PRBC repletion under our massive transfusion protocol. This was my education, my training as a physician, education that I was not always grateful for in the moment.
By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Overhead, the operator called, “MEDICAL CODE STAT TO ICU SOUTH, ROOM…”There was a cardiac arrest in my unit, right where I was standing. I started to run. “Who is it?” My chest became hollow as I realized who it was. Ms. B was dead. As we rotated through cycles of chest compressions, I felt her third and fourth ribs shatter shatter under my palm. My abdominal muscles burned. I knelt on the bed next to her and used my weight to compress. Her face no longer wore any expression of fear; she was lifeless. Her orange scarf, missing. “Pulse check.” Nothing. After [what seemed to be countless] minutes, she regained a pulse, which she was able to sustain long enough for her family to come in. She was unconscious and immobile, with a tube entering her mouth and another exiting her thorax, draining liters of blood. “Mom, you were the best mother.” Her children were draped across her bed, praying, crying, praising her life and her accomplishments, pouring out gratitude. “Jesus will come to this room tonight!” We stood and watched, fully aware of the transience of the pulse.
The last time I saw my own mother alive was in the ICU. We decided to place a DNR order before she died, knowing she wouldn’t have wanted anything more.
As the line flattened on Ms. B’s monitor, I knew the next series of chest compressions, shocks, and epinephrine pushes would be the last. “I’m running this.” Running a code had formerly been my most feared responsibility. I remember my intern year as if it were yesterday: chest compressions, running to the lab, grabbing the chart, being grateful to do anything except run the code. Throughout my training, this task has become like many others: systematic, ordered, implemented without difficulty. In this moment, I felt an enormous responsibility: to assure that we had done everything possible to give our patient and her family what they needed in that moment [for them to know they had done “everything”], to provide her the dignity she deserved in her death, to spare her from any excess undue harm, and to honor and care for her until her time of death. “6:53 PM,” I said, with final and deliberate certainty. Tears immediately filled my eyes and began falling in rapid succession as I stood, surrounded, witnessed by, the entire ICU team. The nurses rushed to the patient’s body to clean and dress her for the family to view. The family stood outside, intoxicated with fear, shock, and sorrow. “Let’s go,” one of my co-residents said, as she escorted me to the stairwell where, for a few sacred and uninterrupted minutes, I cried. I cried until it was time to wash my face, sign the required documents, and gather my papers for evening ICU rounds. “Check MR. F’s urine output overnight and dose the Lasix accordingly… Try to taper Mrs. C’s levophed…”
These are days where we not only experience but also participate in and often direct the most poignant moment of someone’s life; then, we move on with apparent simplicity. I’ve not had any more intimate experience than to learn someone’s history, wishes, and fears, to listen to her words, her breath, and her heart… to feel the contours of her hands, the fragility of her ribs, her fleeting pulse… and to witness her last breath.
I walked out of the hospital at midnight and, as I waited for a cab at the entrance, Ms. B’s family emerged, one by one: son, daughter, sisters, brother, in-laws… We hugged and cried. They told me they would take her home to South Carolina to be buried. “That’s good.” They thanked me for saying “I don’t know.” I said, “I’m sorry.” I was sorry. I am sorry for their loss, their pain, their mother’s suffering. I am also grateful to have had the experience of knowing her and her family, to have taken care of her, to have learned from her experiences, both good and bad… to have been changed by her gratitude.
Days later, I couldn’t stop thinking about this patient and how much she taught me. Although it felt strange, I googled my patient’s obituary. Among the many lines, it reads: She was educated in the New York City public school system.
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