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What It's All About

They wheeled her into the ER at 8:30pm: twenty-something Jane Doe, unresponsive.  EMT’s found her up slumped on the sidewalk in front of the Starbucks on 2nd avenue and 23rd street. That’s all they knew. And she couldn’t tell us more. So we 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.

I yelled into her ear, “Miss, can you hear me?” “Miss?” I screamed, I pinched and then I shaped my hand into a fist and performed a sternal rub, raking my knuckles up and down over her chest, hard. A red streak bloomed on her skin from the pressure, but she didn’t react.

This was the last night of what had been a horrible intern year. After graduating from the University of Arizona, I moved cross country to New York City to do my residency training in Emergency Medicine. I did it for the same cliched reason as everyone else: I wanted to save people.

I should have known should have known something wasn’t right when I got to Gilman Hall, a 25 floor high-rise apartment directly across the street from the hospital; So, already, you could kiss any work-life separation goodbye. The view from the roof was the unobstructed New York City skyline. But we weren’t allowed up there. The official reason was that they hadn’t finished landscaping and there was nowhere to sit, but the current residents said it was really because there was no railing and too many people had already jumped off. It was exactly the kind of thing you would say to haze the new batch of interns. But when I got to my 22nd floor apartment and realized that every single window was caulked shut, I wondered if there was something to it.  

Being an intern meant working 80 hours a week, switching rapidly between day shifts and night shifts and back to days, during which we had no set breaks and few full days off. But we only had three years to learn everything we needed, so there wasn’t a moment to waste. And any time not working was considered waste: waste peeing or eating or sleeping when it wasn’t absolutely necessary. And necessary, I quickly realized, had a much more flexible definition than I’d previously thought.

The culture of medicine demanded a certain machismo.

I remember a supervising physician who, in her ninth month of pregnancy, started having contractions at work. There were five hours left in her shift but it was a first baby and the contractions were still thirty minutes apart, so she finished her shift. But the time our day was done her contractions were five minutes apart, she went right upstairs to labor and delivery fully dilated, and gave birth.

We told and re-told many stories like that with so much admiration. And we learned that the best way to prove to our teachers that we had command over our patient’s bodies was to demonstrate command over our own.

One day I actually passed out during morning rounds. I’d been hiding an illness for days, since weakness was considered more contagious than any virus.

“Bess? Bess?” My supervisor said, peering into my eyes as I came to,  “What do you want to do about your shift?”

This was a test with only one right answer.

So I took a few deep breaths to stop the room from spinning, asked for some IV fluids, and then finished the rest of the my 12 hour shift.

There were sick people to care for.  

Somehow, we expected our bodies to be exempt from the fragile business of being bodies.

But back in the resuscitation room, Jane Doe’s body was failing in front of us. Her breathing was becoming strained and irregular, her blood pressure had dropped even farther. As my colleagues continued the resuscitation, I pulled out my stethoscope and started a detailed secondary survey. I called out every new exam finding, the way I’d been trained to: abdomen soft, skin clammy, no bruising, bleeding or signs of trauma. I peeled back her eyelids and her pupils contracted briskly under the bright fluorescent lights. Pupils reactive! I shouted. It was the first sign that her brain was receiving oxygen, that there may be someone in there to salvage. We started working just a little faster than before, buoyed by the idea that this resuscitation may end differently than so many others.

Because even after a year, it was still hard being surrounded by all the death in the ER. I hoped that every new patient would desensitize me a little more. We had to put aside empathy in order to think clearly, so there was no room for tears during a resuscitation. And after, you made room for them alone. Somehow, our attendings had learned to compartmentalize, so we knew it was possible. But when they did discuss a loss with us, it was to go back over the resuscitation minute by minute,  trying to identify our clinical failings.

So even though there was death, you learned to live with it. Just like you learned to work with fevers of 104, and learned to work the day of your Grandfather’s funeral, and learned to work the morning after your boyfriend of 4 years says he’s not so sure about you anymore.

I couldn’t admit it then, but I’ll admit it now: I was depressed, we all were.

But we didn’t show it. Because if someone in power decides you’re physically or mentally unfit to do your job, you lose the 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 Angermanagementproblem.” 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 boba 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 just 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.

And I say this to explain how I was able to plunge a breathing tube down Jane Doe’s throat with the same routine efficiency I used to snake the clogged drain in my bathroom.

Machines were breathing for her now, but her heart continued slowing. The medications we gave her weren’t improving her blood pressure. Four bags of saline had done nothing. At her age, healthy-appearing, without trauma, the answer is almost always an overdose.

So I started rummaging through her purse looking for clues: pill bottles or drugs.

One of the nurses was looking through the clothes we’d cut off earlier and found Jane Doe’s drivers license in the back pocket of her jeans. Now Jane Doe wasn’t Jane Doe. She was Sarah, 27 years old. The nurse looked her up in the electronic medical records and shouted that we’d been wrong about her health. Sarah he had been coming to the hospital since the age of 13 for a rare and aggressive form of liver cancer, had over 20 rounds of chemo, and the last note from her doctor said that, despite his counseling, she’d refused any more treatment.

She’d done the one thing none of us had been brave enough to do: look a senior physician in the eye and say, “Enough.”

Maybe this was just the natural progression of her disease.

I was about to close her purse when I noticed the piece of notebook paper. On it, was a written schedule:

11:00: Wake up and take Mimi to the dog park.
11:30: Take 5 Nicardipine
11:45: Get a bacon breakfast sandwich at Bite.
12:00: Take 3 Oxycontin
1:30: Read the last chapter of novel at Tompkins sq. park.
2:45: Take 5 Oxycontin and 5 more Nicardipine

A meticulously planned schedule of how she was going to die. Written in her small, looping handwriting. 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 just did what I’d been trained to do whenever I found new and pertinent information – I announced it. “Look what I found.”

Treatments were started. Sarah was stabilized and whisked upstairs to the ICU, her note pressed neatly into her medical chart like any other piece of data.

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 supervisor, beaming, just beatific, as if we’d just pulled a group of schoolchildren from a burning bus. I was so angry, so envious of her easy interpretation of events I wanted to strike her. But before I could say or do anything stupid, she sent me out of the room to see a patient complaining of indigestion.

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 eight hours I would have to be back for another shift. I couldn’t bear it. So I tested staying under. I spit out the straw and released my breath, waiting for that moment of bliss. But then my lungs started to burn and despite myself my body broke to the surface, gasping. And I wondered: How would I learn to save anyone else when I was barely able to save myself?

Bess StillmanComment