They wheeled her into the ER at 8:30pm. 27 year-old woman, unresponsive. EMTs had found her up slumped on the sidewalk in front of a Starbucks on 2nd avenue. That’s all they knew. And she couldn’t tell us more. So we did what we always do: put her on a monitor, cut off her clothes, started two large bore IVs. It was the same way we handled every critically ill patient who came into the resuscitation bay.
This was the last night shift of what had been a horrible intern year. I’d moved cross country to New York after med school to do my specialty training in ER for the same cliched reason as everyone else: I wanted to save people. I was scheduled to work 80 hours a week , switching rapidly between day and night shifts during which we had no set breaks. In residency, you learn to work with a fever of 104 , sneaking off to the bathroom to vomit, one day after your grandmother died and your boyfriend of 4 years tells you he doesn’t think you’re such a great idea. But you don’t call out of work or you’re publicly shamed as weak. You get depressed. But you don’t talk about it, because if someone in power decides you’re physically or mentally unfit to do your job then you lose amazing opportunity to learn how to help others. This learning that is killing you and what could be worse than that?
We all had our own coping mechanisms. Casual sex was one. Of course, it wasn’t like the emergency rooms on TV. with “Dr. McSteamy” or “Dr. McDreamy.” In real life, it was more like “Dr. McSweaty” and “Dr. Mc Angermanagementproblems.” So, I mostly stayed away from that. Then of course there was drugs and alcohol; not my thing. What I liked to do was lie in the bathtub with my face under the water breathing through a straw wondering if it’s true what they say – that just before you drown you feel euphoric. With the light off in the bathroom and the water at body temperature it felt like having no body at all. I would dissolve into the quiet: no beeping monitors, no constant criticism from the physician in charge, no screaming patients. It was the only time during residency that being stripped of feeling didn’t feel like being numb.
All this to explain how, staring at this unconscious young woman, pretty, well-dressed, my age – could have been any of my friends – it explains how I plunged a breathing tube down her throat with the same perfunctory efficiency I used to snake the plugged drain in my apartment.
Machines were breathing for her now, but her pressure was dropping, her heart slowing. Four bags of saline had done nothing. At her age, healthy-appearing, without trauma, the answer is almost always an overdose. I started rummaging through her giant purse looking for pill bottles or drugs. A nurse had found her driver's license in the pocket of her jeans and looked in the electronic records and shouted that we were wrong about her health – she’d been coming to the hospital since she was 13 for a rare and aggressive form of cancer. Had over 10 rounds of chemo and the last note from her doctor said she’d refused any more treatment, things were so advanced. She didn’t look like the usual wasted, skeletal elderly patients we saw regularly dying in the ED. Her youth, her pretty features... Maybe this was all just the natural progression of her disease. I was about to close her purse when I saw the piece of notebook paper. On it, was a carefully written schedule:
8:00: Wake up and take Mimi to the dog park.
8:30: Take 5 Nicardipine
8:45: Get a bacon breakfast sandwich at Bite.
9:00: Take 3 Oxycontin
9:30: Read the last chapter of novel at Tompkins sq. park.
9:45: Take 5 Oxycontin…
A meticulously planned schedule of how she was going to die. A moment ago she was lying naked in front of me as we stuffed her with tubes and needles, but it was reading this that felt like a violation. I folded it and hid it in my hand. I had to tell, right? No one else knew what she’d taken. But I did. And so I knew how to treat it. I had taken an oath – do no harm. But I wasn’t sure what was more harmful. Bringing her back? So she could face another day like today or die of her cancer in a few months? Letting her go? What if she regretted her choice? I felt paralyzed, so I did what I’d been trained to do – I held the schedule out like a prize and announced, “Look what I found!”Treatments were started; the patient was stabilized, sent to the ICU, the suicide schedule pressed neatly into her medical chart.
When she was out of the room the physician in charge turned to me and said, “See, this is why we got into emergency medicine. This is what it’s all about. Great job.” This? I was horrified. This is what it’s about? This is what we’re killing ourselves for? I took an oath. And I still couldn’t figure out if I’d broken it or not. And there was my boss, beaming, just beatific, as if we’d just pulled a group of schoolchildren from a burning bus. I was so angry, so envious at her easy interpretation of events I wanted to strike her. But without a moment’s break, I was sent to another room to evaluate a patient with belly pain.
That morning, after the shift, exhausted and sick, I went home and filled the tub. I turned off the lights and slipped beneath the water. Everything was so peaceful, so much easier in the quiet dark. In 8 hours I would have to be back for another shift. I couldn’t bear it. I tested staying under, letting out my breath until my lungs started to burn and despite myself, my body broke to the surface, the sloshing water a shush shush shush of comfort. And I wondered if I would ever learn to really save anyone when I still hadn’t figured out how to save myself?