Once in a while, somebody will tell me that
I have such a nice bedside manner, and for a long time I’d receive that kind of
approval with a wince. I was mortified by the praise people gave me, and
honestly, more than a little gratified too, because it really felt good to have
nice things said about me, but mortified because that night, the one I’m
writing about now, that night was a night of abject, miserable failure.
I was on another overnight shift as a senior
resident, this time at the university hospital we worked the other part of the
year. It was probably a Monday, since the beginning and end of the week tend to
be the busiest, although nowadays it seems like every day is busier than the
last, and the emergency department was in normal condition, that is to say
totally FUBAR’d – ambulance gurneys lined the hallways holding patients in
street-clothes, in house-robes, drunks in restraints, the paramedics who had
brought them chatting with each other while waiting to be told what bed to take
their charge to, the firemen’s yellow jackets smelling faintly of smoke.
Since I was the senior resident on duty, I
had the responsibility of the entire department, with nurses pulling at me from
all sides, medication needs, test results, consultant problems, new patients.
Every time I’d leave the desk to go to a patient’s bed, to the x-ray room, to
the bathroom, a crowd of RNs would swarm behind me – picture a deer followed by
a pack of wolves, a pack of wolves wearing scrubs and holding clipboards. One nurse told me that there was a new
patient in Bed 1, an 18 year old girl who had chest pain and a high heart rate.
Yet another patient.
Every time another nurse popped up with a
question or request I’d frantically fire off the first thing that came to mind
while I moved on to deal with the next one. I asked the nurse for Bed 1 to get
an EKG and told him I’d be there shortly – I was relieved that he seemed
satisfied with having something to do, which would hopefully buy me enough time
to attend to yet another high priority. But just minutes later he handed me the
patient’s EKG, which showed a heart rate of 135 – that really was fast. Not too
fast, but faster than it should have been.
I finally made it to the patient’s bedside –
the nurse had told me that she’d been complaining of crampy chest pain while
out line dancing. What an odd
detail to add, that she had been line dancing, apropos of nothing. The girl was
sitting up in the gurney, her eyes squeezed shut against the pain. She was
pretty? I don’t remember. She seemed young. Dressed to go out. Perhaps I should
stick with the details I received in her autopsy, later: “this is the nude body
of a well-developed, well-nourished young adult female appearing consistent with
the stated age of 18 years. The length is 165 cm, the weight is 62 kg. The hair
is black, the eyes are brown, and the complexion is fair. The body is not
embalmed. Across the right medial ankle is a small tattoo of a heart. The
finger nails are painted red.” I was able to get out, “I’m Dr. Kim, do you have
chest pain?” She replied, “my chest hurts,” when she had a seizure.
On t.v., when actors have seizures their
eyes kinda roll back and their limbs start sort of flopping around, and that’s
how you know that it’s supposed to be a seizure. In real life, though, it’s the
most uncanny, unnerving thing, it’s inhuman – her eyes were still open, but
they looked like they’d lost the animus behind them, the rational personality
who had until then been a girl out with her friends just disappeared, and all
that was left was a machine, an automaton in the shape of a human being but without
human thought or feeling. Her head twisted to the left, her eyes open, staring
at nothing. Her mouth twisted and foamed. Her limbs involuntarily contracted,
shook in a way that is impossible to do consciously, a marionette with its
strings twisted, and then dropped down when she fell back in to the gurney,
unresponsive, gurgling noises coming from her throat. Putting the head of the
bed down, I pled for the nurse to get an attending physician, quick – I figured
they might want to know that I was intubating someone – that is, putting
someone on a ventilator.
Dustin, who was chief resident when I was an
intern, and was now an attending, materialized at the bedside.
Before we intubated, the girl had another
seizure. We let it pass, and then put her on the vent. Things spiraled. Her
blood pressure started dropping precipitously. The patient’s friends and father
arrived, and it turned out that her mother had died the year before from a
brain aneurysm – the patient was the only family member her father had left. Dustin
and I had a rapid-fire discussion about what the patient could be suffering
from, while ordering IV fluids and medicines, our arms crossed, faces tight.
“What do you think it is?” “Bolus one liter, start a second line and start
another bolus in that one.” “All I got was chest pain while line dancing,
tachycardia, then this.” “Is her sat dropping? Can someone fix the pulse ox?”
“Pneumothorax? Doesn’t seem the type. Chest x-ray’s cooking.” “Can someone
please start the fluids? Call blood bank – O neg.” “Tamponade? No history. MI? Unlikely. Aorta? She
doesn’t look Marfanoid. No history.”
We placed large intravenous catheters and
resuscitated the patient – she went into cardiac arrest several times, and we
kept bringing her heart back, the number of techs and nurses in the room
growing, frantically performing CPR, calling out orders, voices strained. It’s
always hard when someone’s dying, tougher still when she’s so young, and even
more difficult still when she’s the only child of a widowed father standing in
the hallway, standing quietly, alone, head down, arms crossed.
During one of the episodes of arrest we
discovered that she was, curiously, bleeding inside of her chest. It’s often
common procedure in these resuscitations to “needle the chest,” that is, place
large catheters in the chest wall to relieve pressure that builds up inside the
thorax. I sloshed maroon-colored iodine solution just under her collarbones and
slid the needles in place, first on the left side, then on the right – what the
fuck? Blood started fountaining out of the right needle, a freshet pulsing out
of the catheter with every chest compression. I placed two chest tubes to drain
the blood. The presence of that amount of bleeding inside the chest can
actually prevent proper circulation, and part of the treatment is to drain the
fluid off. The blood drained… and drained… and drained. The girl had already
received several transfusions, and we started transfusing back the blood coming
out of her chest, and it was clear that she was bleeding to death.
We called the chest surgeons who we learned
were in the middle of a thirteen-hour heart transplant and therefore unable to
take this patient to the OR – she was too unstable to be taken anywhere anyway,
and anything resuscitative would have to be done in the emergency department. The
girl kept going into cardiac arrest, had done so five or six times already, and
opening her chest in the ER to stop the bleeding was probably futile, but come
on – she was 18. Her father alone… You could feel a raw, anxious energy in the
room, everyone felt helpless but we had to do something, everything, anything.
But without someone to take her to the OR afterwards, there’d be no point to
trying to stabilize her in the ER. Dustin called the trauma attending, Dr. O – as
a trauma surgeon he’d be the only other doc in the hospital who would routinely
know what to do with a cracked chest. An older Irish man, with a thick accent,
he was infamous for being so compulsive that he’d often round until midnight,
unheard of for a surgeon, but someone totally committed, so committed that he
agreed to come in for this patient, appearing at the bedside when I had the
knife poised above the girl’s skin.
We cracked opened her chest, first the right
side, then extending the incision to the left, opening the chest to access the
organs. Scalpel on skin, curvilinear incision, straight through yellow fat,
down to muscle. Scissors in thorax, gloved finger guiding, zip through the
intercostals. Weighty stainless steel rib retractors, wedged in placed, cranked
open. So strange – for a young, otherwise healthy woman, the body would be a
secret, the breasts an intimacy hidden from the view of strangers like us, but
in the moment, there was nothing particular about her chest, just that we had
to open it. It’s funny – I don’t remember much of what her face looked like,
but I remember in intimate detail her thoracic cavity, the surfaces glistening
with pleura, the individual articulated spinous bodies, her spongy, pink lungs,
and everywhere, everywhere, blood, a rising tide of blood that we would suction
away only to have it fill right back, ebb and flow. It was like something had
exploded in there.
Her heart was flat. Imagine, if you would,
the heart roughly like a water balloon, one that actually pumps blood around
the body, so it expands, contracts, expands, contracts, but it’s always got
something in it, a water balloon made of muscle. Her heart, however, was an
empty balloon, nothing in it, all of the blood that was supposed to be filling
it seeping in to her chest cavity instead. Her heart was a flat meat balloon. Blood,
or at least what was now pinkish tinged fluid having been diluted with all of
the fluid we had tried to replace it with, kept welling up from somewhere, more
blood than anyone in the room had ever seen come out of a chest, blood from
nothing that we could clamp off and prevent her death, and we were at a loss,
Dr. O turned to me and stripping off his gloves said, “well, Tae,” in his thick
Irish accent, “I tink we’ve dun all we can,” and we called it, my arms were up
to the elbows in her thorax, blood was everywhere, and it was done. Later, we’d
learn from the autopsy that she’d died from a thoracic aortic dissection, the
same thing that later killed John Ritter, rare, unusual, a unicorn of a
diagnosis, especially for someone so young.
We covered her up. You may think it’s a
cliché, but we really do use a white sheet. I remember Dustin talking to her
father in the hallway, the man quietly listening to the news. Dustin found me
at the desk, “hey man, here’s the key to my office. There’s some caffeine in
the fridge, take some time for yourself.” Okay – wow, that was some traumatizing
shit, that’s a good idea. I sat in his office by myself – okay, I’m processing
things, that was kind of horrifying, but I’m okay… no, really, I think I’m
okay. I’m sitting in Dustin’s comfortably padded office chair, staring at the
white door. I can hear housekeeping vacuuming the floor down the hallway. There
is a fake potted plant in the corner. There are pictures of Dustin on various
trips abroad lining the shelves. My right hand, wrapped around a can of soda,
is starting to feel cold and numb. All that comes to mind is the stack of fresh
charts piling up in the rack, patients waiting to be seen.
I forced myself to sit there for a full five
minutes, checking my internal state to make sure – no, I’m okay. I’m alright. I
quickly dictated a note, and then got back out into the ER, spending the rest
of the night taking care of the patients who’d waited while we treated the
girl.
Things never slowed down that night. Trotting
back and forth, I kept spying in on room 1, where the girl’s father was sitting
by her bedside, quiet, back turned to the door. He sat there the rest of the
night. With all of the hubbub gone, I could finally see him. Brown hair, medium
length. Jeans, denim shirt. His face was sad, thoughtful. I moved on to the
next patient.
I have difficulty gauging how long to make
eye contact when I talk to people. Fact. I’ve realized that I’m either always
glancing away, or that I’m suddenly staring straight in to the other person’s
eyes, and it’s only when I start noticing their discomfort that I catch on.
There’s more: between, I think, 1984 or so and 1992, I could name every single
car sold in the U.S. by make and model, name their fuel type, engines
available, displacement of said engines, number of valves on the drivetrain,
overhead cams or pushrods, interior options available, colors, pricing, and
eventually I went on to do the same with motorcycles. It’s not that I’m Rainman
or something, and every so often someone really does tell me I have good
bedside manner, but people imagine Marcus Welby and what they get instead is
me. It’s little wonder that I’m good at the sciences and that I sometimes make
people cry when I talk with them because feelings… fuck it, let’s just say it’s
because I can list exactly why Betamax was a better standard than VHS.
I couldn’t muster up the courage to talk to
him; I couldn’t walk up and, oh, I don’t know, say something, anything. What do
you say? Man, sucks that your entire fucking family’s dead, tough times, bro? I
kept silent, secretly peeking into the room, the girl’s father still and quiet,
that night still and quiet in my memory.
It’s been a few years now and since
first writing it down I’ve struggled over how to end this story; maybe I didn’t
have the maturity or the ability to articulate what I experienced. I’ve tried a
number of different ways to conclude it with some kind of meaning. In one way I
guess you can think of it as a cautionary tale. Now, I’m not Buddhist and can’t
pretend to know anything about Buddhism, but I’ve heard a story of the Buddha
that seems to fit somewhat. In an attempt to teach his disciples to understand
the ephemeral nature of life and its boundaries, the Buddha instructed them to
meditate on the decaying corpses in the local cemeteries. But in contemplating
the inevitability of their own deaths, these students of Gautama slid into
despondency and began to take their own lives in their efforts to reach
enlightenment, and when the Buddha returned he was aghast to discover that most
of his congregants had committed suicide, and then taught them instead to
meditate on the cyclicality of their breaths. Like those disciples of Buddha,
in learning the truths of medicine and then the limits of that practice, health
care professionals can come to despair during their attempt to attain medical
enlightenment. And you do dwell on the deaths, the patients you lose, for a
long time. But I don’t think that’s what I came to take from this loss.
I told you that night was
one of failure, but not because we couldn’t save the girl’s life. We did
everything possible. I don’t regret the thoracotomy, I don’t regret the gore.
What I regret is that I didn’t – I couldn’t – say anything to the poor man who’d
lost his wife and daughter. I didn’t have the courage to walk up to him and let
myself feel something while he contemplated the decaying corpse of his
daughter.
I can imagine it now, the
way it could have been, you know, if I’d been in a movie about how to be a good
doctor or something – I’d pull a chair up next to him, put a hand on his
shoulder, look him in the eye even if it’s for too short or too long, and then
let him talk. Or let me talk. Or just have sat in silence. Instead, I left him
to sit there alone, the rest of the night, while I ran around with other
patients and stuffed my feelings down, out of sight, out of mind.
Compassion means not only
feeling for others, but permitting oneself to feel. The irony is that
compassion is easier to have for those who are like you, but of course even
though compassion begins with oneself, its ends, compassion’s purposes, are
always for the other, the one who is not you. Like I said, for a while you face
nothing but death, but later, you start to see the lives around you, the lives
of the patients saved, the lives of the survivors of those who don’t make it,
the patients whose lives were never in danger but maybe just needed some
handholding. And that was my lesson, which I have learned, and learned well,
that what I can do, always do, is breathe in co-suffering, to laugh and weep,
with compassion, with the ones who are here and the ones who survive those whom
we have lost, and although it has only been a few years, I am becoming in
medicine a bodhisattva, that is, one who will someday attain enlightenment.
