In 1984, in the midst of fleeing the Soviet invasion of Afghanistan, a young girl agreed to pose for a photo. In her short life, she had survived the carpet bombings that claimed the lives of her parents, trekked through mountains to escape her war-torn home, and struggled to adjust to life amongst a sea of other refugees — but she had never been photographed. Restricted by her religion from smiling at a male photographer, she gazed into the camera for an instant before returning to a life of survival — the photographer never even got her name. That instant, however, became quickly became the most famous National Geographic photo in the history of the magazine, known simply as “The Afghan Girl.” As National Geographic put it, “Her eyes are sea green. They are haunted and haunting, and in them, you can read the tragedy.”
In the first two years of medical school, we are taught the physiology and pathophysiology of the eyes. We learn how to use light to measure the reactivity of pupils, and study how and where those signals are processed in brain. We memorize all the extraocular muscles, where they originate and attach, and how to interpret deficiencies in gaze. We learn a rainbow of pathology, creating knee-jerk differentials for red, yellow and blue sclera. And like everything else we study in the first two years, we then take an exam and move on to the next organ system, with most of us (except perhaps the future opthamologists) surmising that we’ve learned everything we need to know about the eyes.
It’s not until we finally reach the wards that it becomes clear that there is an entire hidden curriculum devoted to deciphering a patient’s eyes. My patients taught me the basics.
A stoic Chinese immigrant, fluent only in her native language of Mandarin, was in a daily struggle to contain the insurmountable pain caused by her cholangiocarcinoma. She managed her disease with an expressionless resolve, burying her emotions far from the surface. As she became ascitic and the pain grew, her eyes began betraying her guise, giving me a real glimpse into her suffering. Eventually, she relented and agreed to a therapeutic paracentesis. With each liter of fluid removed, relief washed over her. That afternoon, four liters lighter, she spoke English to me for the first and only time, her eyes wide with sincerity: thank you.
A elderly woman was admitted for shortness of breath and subsequently diagnosed with advanced metastatic lung cancer, remaining on the floor for the entire month my team was on service. She progressively found it harder to move, harder to breathe, harder to speak. She considered herself a fighter, insisting on anything we could do to make her live longer, and always reminding us that she wasn’t ready to say goodbye just yet. On the general medicine floor, where so many patients are discharged within days, a month is akin to an eternity — we were with her for so long, she started referring to us as her “hospital family.” At the end of the month, the teams turned over. As we explained to her that a new family would be coming to take care of her, her eyes filled with a new pain: abandonment. “I thought you would be with me until the end,” were the only words she could muster. The day the new team began its rotation, she passed away.
In the cardiac intensive care unit, I cared for a ex-correctional officer who was admitted for heart failure. A gregarious Brooklynite, she always managed to be cheerful — and in a place like the CCU, cheer is usually in short supply. The team always saw her first or last — first if we needed a joke to start the day, or last if we needed to lift our spirits after rounds. Two days before she was to be discharged, my fellow medical student and I sat with her during dinner, as a means of saying goodbye. We never thought we would be the last people share a meal with her. We arrived the next morning to a situation that had spiraled beyond hope — our patient developed an inexplicable lactic acidosis, and was suddenly not expected to make it through the day.
Ten minutes into morning rounds, the bells started.
Whenever we walk into a room, eye contact is the first thing we notice. But for physicians, especially in a place like an ICU, there is overwhelming sense of dread when we walk into a room and a patient doesn’t meet our gaze. Our voices become raised to the point of shouting, our hands find themselves shaking the patient for any response, and amongst a tidal wave of adrenaline, time slows to a crawl.
For all of medicine’s technological advances, the basic idea behind a code is brutally simple. When a patient’s heart stops working, our hands do its work. As we started compressions, desperately trying to get blood to the brain, her eyes opened. They darted throughout room, eventually settling on me. Twelve hours ago, she had given me a wink and asked jokingly the odds the doctors would agree to let her go skydiving. Now her eyes were full of horror.
Studies have shown that when people die, they want to go peacefully, passing from this life surrounded by their family and loved ones. No one wants to imagine dying naked in a room full of doctors forcing air into their lungs and coercing their hearts to beat. And while for that first round, we stabilized her, her acidosis was a opponent we knew we had no chance of beating. Her family, after watching what we did to keep her alive, asked us to not to intervene the next time. A half hour later, she died, in the way most of us wish to go.
Seventeen years after the picture of “The Afghan Girl” was taken, the photographer returned to Pakistan, searching for the that nameless girl with the piercing green eyes. They eventually found her living in the mountains near Tora Bora. She had never seen the picture of herself, nor could she understand how her eyes captivated the world. Living though a decades old conflict that took over two million lives, she was asked how she managed to survive. “It was,” she said, “the will of God.”
As doctors, we become used to the seeing death creep up on our patients. It is never easy to watch our patients slowly succumb, but time lets us admit there is nothing more we can do, and allows us to ensure they pass away in comfort. When a patient dies suddenly, we carry a heavier load of doubt. Why didn’t we know? Could we have saved her? Trying to relieve some of this burden, I went to the autopsy of my ICU patient. As we laid her body on the table, her eyes were open. That was the first time I looked into a patient’s eyes after death.
I had to close them.