LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog
This is a guest post from an anonymous author, the details are fictionalised.
I will not cry.
I call her Marisol in my dreams. 31F to triage.
1542. Indigestion. “Está pateando muy fuerte. Te amo mucho, mi bebe hermoso,” she smiles, rubbing her belly. 35 weeks pregnant.
1733. She is restless. Her husband worries at the pain in her face. She kisses her son, saying, “Necesitamos ir. Ahora.”
1734. Dilated to 9, fully effaced. Liver enzymes elevated. Platelets 176. Will continue to monitor.
1735. Decels noted, prep for cesarean.
1736. Type & Cross sent, prep complete. Patient to OR, anesthesia at bedside. Spouse updated, waiting room.
1737. VSS. Hb 6.4, awaiting PRBCs. Abdomen STTP, staples noted. Male singleton APGAR 6, dispo NICU.
1738. Return to OR, s/p acute hemorrhage, see report.
0028. S/P hysterectomy. 4 PRBC, 2 FFP, 6 plt.
0441. Patient to IR, s/p recurrent bleed. Levophed. Tx ICU.
0442. Arrival ICU, s/p coils, s/p hyst, brady 30, PEA. See code blue record. Hb 4.1, see massive transfusion record
0443. Return to IR d/t recurrent bleed.
0444. See code record. ROSC 1134. Levophed, vasopressin. Spouse and sister at bedside, extended family in conference room.
2312. See code blue record. ROSC 2337. CRRT initiated.
1436. NICU nurse at bedside with baby, patient awake, appropriate, tearful.
2355. Patient exhibiting acute mental status changes. Pupils blown bilaterally. CT = cerebral edema, correlate clinically. Mother and father in Mexico, consult Social Worker for visa/transport.
0821. Cerebral blood flow < 8, palliative at bedside.
0936. Terminal extubation performed per protocol, family and chaplain at bedside. May she rest in peace.
There were 4 more in the next few months, but I carry her with me.
0823. “The chaplain is available for those who need assistance. There will be a formal debriefing.” The CVICU manager’s words are cold. We all know the story. One peripheral IV. Anesthesia and the nurse arguing, pitocin or blood. She got both, and now she’s dead.
“Will the debriefing include L&D?”
The room falls silent; my manager’s face is flat as she turns to me. “They will have their own debriefing. Thank you.”
Gossip rises as the meeting ends. “Jen,” her voice carries over scraping chairs and locker doors.
“Jen,” my manager says again. “Will you talk to the chaplain? We’d hate for you to get burned out.”
“You have to take care of yourself.”
“Do you hear me?”
The chaplain. I shrug. Of course I will. A line forms behind me. I turn to see eight dayshift nurses, eager to hear about the scheduled debriefing, all looking to me, expecting answers. I can’t meet their eyes, so I leave for the sterile taupe of the CVICU.
The debriefing is delayed. The chaplain is unavailable. Weeks pass. There will be no debriefing. Other nurses are complaining. I will not complain. Chrissy and Sarah, my orientees, already left. OR instead of ICU, down the street at another hospital.
I look up from the chart, mandatory boxes unclicked.
“Jen, right?” It’s the chaplain. “They said you wanted to speak with me.”
“Do you have time?” Yes, I have time. We walk to the family conference room, the room where all conversations take place.
We sit. The room is clean and quiet. When I breathe I hear a thousand breaths from the families before me. Their suffering hangs in the air, unspoken.
I suffer with them.
He asked me a question. With effort, I bring attention to his words, pushing the ghosts aside. “How are you?” he asks again.
Such banality. How am I. She’s dead, and how am I. How am I doing.
He ignores the lie. “How are you sleeping?”
The clock ticks. September 4. 1326. I have three meds and a blood sugar on a post op coming up. There is only my breathing, and the sound of the clock.
I take a breath. My eyes close. I hear a voice, timid at first, then rushing.
“She was that patient. The patient who is everything—she was everything to me. If anyone was going to live, she was. I gave her all that I had. I went so far beyond what others consider duty I can’t describe it if you’ve never been. She was my sister, my sister in my heart, in every way that mattered, and I would have given anything, anything for her to live. For her to raise her son. I did so much over those two weeks. And still, she died. And I dream at night…” here the voice rose, from my own throat, yet a foreign thing, long forgotten “…and she’s alive, and there’s the barest chance I can save her, and I try, and there is blood on my hands and she dies. I wake up. I go to work. I smile. I shake hands. I comfort the sick. I come home to my family. I go to sleep. And she dies. I wake, I work, I smile, I come home, I sleep, and she dies. And she dies. And she dies. And she dies. And she dies. And she dies. And she dies. And she dies. She will always die. I cannot save her. I cannot give her the life she deserves. Every night I see her, every single night I fail, and she dies. Every time, she takes a piece of me with her. I don’t know how many pieces I have left.”
Silence. A dry sob. The sound of my heart breaking.
John—his name IS John—has tears in his eyes. He shakes his head, and says nothing. I say nothing. I am nothing, so there is nothing to say. Nothing tells me how to deal with the death of my own soul.
“Have you considered the hospital’s EAP program?” He asks finally, the sacred silence that held us together broken. I am silent. I said all the words that can be spoken. The rest can only be felt. Time presses, and he must feel it, shifting his weight on the couch. Nothing could move me now.
“Did you attend the debriefing,” I say, my voice dropping like a stone. He looks away. I know the truth. There was never a debriefing. There are no answers in her death–I want answers in her dying.
“How,” his voice catches, higher than it should be, “how do you go on?” My eyes are dead in his, and he falters. “How—“
“How am I still here?”
“Yes,” he says.
“I had a friend,” I say, giving life to a story I never meant to tell, an ugly confession. “He went home after a long shift and mowed his lawn, then set his house on fire and died in it. We thought it was an accident at first.”
“It wasn’t.” The words hang in the dead air.
“It was suicide. He took some pills, drank a fifth, and laid down inside the fire he lit. Smelled the smoke and died in it. Burned in those flames.” My eyes close. “A couple weeks before, we were working together. He made a joke that wasn’t a joke, said he wished he were dead.” I swallow, throat tight.
“He laughed. So did I. Gallows humor, I thought. I was wrong.”
“Who’s fault is it?” John shifts his weight against the couch. I open my eyes, surprised by the question.
“What do you mean?”
“Who carries the blame?” he asks the ceiling like he’s expecting God to answer.
I lift my chin and answer defiantly. “I do.”
His eyes meet mine and the words burst out, sharp, unbidden, “Say what you came here to say. It’s me. It’s all of us. I know the questions you want to ask.”
“No,” answers John, softly. “No. What I want to know now is, what would you say?”
“If you could say anything. If you knew they could hear, the ones we tried to save, but couldn’t. What would you say to them?”
I clench my fists. “What would you say?” he whispers. We don’t look at each other again.
“I would say…” my voice cracks.
I will not cry.
I am not so naïve to think that death can be added up, sums on a page. Every death carries the weight of the past in the presence of a future interrupted, more than an if-this-then-that formula. We are more than these sums.
All of us have our own burdens, names chiselled on our hearts. We carry their bodies in silence. We carry them alone, refusing to cry. We hold them close, and keep the living at arm’s length.
We shouldn’t carry these bodies alone–just as no one should ever die alone. “Lay us down,” they would tell us. Breathe deep. Hear them whisper. They want us to carry them home—carry them home, and then let them go. They didn’t die so that we could watch each other suffer. Our patients, our families, our friends–they deserve better. They deserve more. We deserve more.
What would you say. John’s words flow over me.
“I would say I hope they know I did all I could. All I knew to do. I hope they know they were loved. That I care, that I miss them. That if I could see them again, I would save them, if only I could.”
“I think they know that,” he says. He has tears in his eyes.
My jaw is clenched. I will not cry.
If you are experiencing depression or suicidal ideation, get support now: if you are in Australia, contact Beyond Blue.
Those we carry Chris Nickson