It was Valentine’s Day morning with about thirty minutes until rounds when I noticed Madeline, one of our medical students, approaching. I took my eyes off the WOW to greet her, and she shakily said that the nurse had just told her that a patient was pulseless. Without registering the nature of the information she just shared, I told her to tell our senior and stayed in place to finish drawing the chemistry fishbone on my patient handoff list.
Almost immediately afterwards, whether it was a flash of blue light or the deafening alarm bell, I was shaken out of my flow as my legs sprung into action. Before entering the room of the patient, I confirmed the patient’s code status with the nurse. As the first person at the scene, with some trepidation, I went to the left side of the bed and did a quick scan. He was unmoving, almost frozen. The pallor of his skin gave a wax-like appearance; his cachexia was profound. There was an eerie stillness that was magnified by the uncaring sunlight filling the room. Those few seconds stretched in a slow-motion reel that bordered derealization. Breaking my trance, the nurse came in with the bag valve mask and suddenly, something came over me. I mumbled something about compressions and at the nod of her head, my body got into position to begin the resuscitation.
Though my head was facing down, I felt the scene start to shift around us. I had to reposition my hands a few times because they kept slipping over the patient’s papery skin. Other hands were reaching around me. They wanted to adjust the gown, log-roll the patient for the board, and maneuver his jaw open for intubation. The electronic sound of pulsatile blood flow started registering within my consciousness. Someone was asking for the time the patient was last seen awake. Laryngoscope. Epinephrine. Step stool. Pulse check. Pulseless electrical activity. A question about a pacemaker. It was only when someone took my place as compressor that I noticed the crowd that had gathered.
Directly in my line of vision amidst the sea of people was Madeline’s face staring back. Her wide gaze was pleading for an explanation, but I stayed in place where I was needed. The code continued for a little longer until the leader asked if anyone else had any ideas before calling the time of death. Upon entering the hallway, I heard my co-intern, Kira, delivering the news to the patient’s daughter, whose howls pierced into the phone. People were scattered inside and outside. The chaplain said a prayer and thanked everyone for our efforts. Our attending, Dr. Asam, was standing by. Slowly, the hallway started to empty, but there was still an element of lingering. Although the air remained heavy, the hospital had to beat on.
***
Towards the end of rounds, Dr. Asam left to take care of some of the paperwork related to our patient’s death while everyone else remained seated. Drew, my co-intern who was taking care of this patient, threw his head back and mentioned something about expiration. I asked him if he was okay and he replied that he was. Both he and Kira went about explaining the clinical aspect of the morning’s event with the students.
“He had likely gone into asystole, an unshockable rhythm. The patient had a pacemaker that detected the lack of spontaneous heart firing, and that was responsible for the electrical activity that we kept seeing despite the absent pulse.”
“Was he ready for discharge?” I asked Drew. He said the patient was nowhere near being ready to leave the hospital. I thought to myself, perhaps he was ready for discharge, just not the kind physicians hope for.
As we reviewed this patient’s most recent chest imaging, Dr. Asam came back and shared that the patient had an implantable cardioverter-defibrillator (ICD) and that I could have been shocked.
“Would it have caused an arrhythmia in me?” I asked.
Drew said, “No, but it would have hurt, at least a little.”
Kira added that this was why she had been trying to find a magnet, the purpose of which was to inhibit the electrical wave of the ICD had a shockable rhythm been present. I was both surprised by the intricacy of ICDs and appreciative of my co-intern’s proactivity. Thinking that the debriefing session had come to an end, we disassembled only to reconvene at our workstation to run the list. Madeline asked if there was anything she could help with before going to lunch.
“Why don’t you try writing a hospitalization course for our patient? It’s a good skill to learn, and we can go over it later.” I saw my co-intern Nina come by and we walked out together. When I briefly turned my head back, I saw Madeline concentrating hard on her computer screen.
***
After Madeline and I were finished with our patient tasks for the day, we sat down to review the hospitalization course. She made a fleeting comment about the crazy morning we had. From the first time we had met in July to our reunion on this rotation, my impression of Madeline was that she was hardworking with a special (and sensitive) heart; it was evident that something was bothering her. The emotion she was feeling was reflected in her gaze. Her shoulders were hunched forward, and it was clear that she was affected by what happened earlier. Stumbling on my own words, I managed to ask how she felt. After a long pause, eyes sparkling with rapidly pooling tears, she whispered, “Helpless.”
Her eyes told a familiar story. They reminded me of my reaction when I was in her shoes a little over two years ago. Madeline tried to get her thoughts out but words evaded her. Everything she was feeling inside was radiating almost palpably around her. As the tears started to travel down her cheeks, my mirror neurons started firing. Yet, I did everything I could to contain my own emotions. I was supposed to be the strong intern helping her navigate her first encounter with death in a clinical setting. At that moment, she was trying to put together the pieces of what she saw. The patient was alive one moment. In the next, he wasn’t, and she had been caught right in the middle.
As we went over the sequence of events, she identified the 10 seconds of relaying the path of information from the nurse to our senior as the most impactful. Not even a quarter of a second after she said this did I realize my fault. Not only did I pass emergent information onto someone else, but I had placed the duty of reporting it on the shoulders of a third-year medical student on her third day of inpatient medicine. Although she disagreed with my blame in having placed her in that precarious position, the error remained. Secondly, instead of immediately going to assess the situation, I had stayed at the WOW until the code was formally activated. Why I hadn’t run, I have only incredulity with no explanation. As we continued to discuss what happened, I realized that it had also been my first time responding to an emergency. Even though Madeline and I were in different stages of our medical education, we both had faced a novel situation.
***
Though we did have a group debriefing after the unsuccessful code, it still felt incomplete. Ever since my first rapid response as a student, I had always been sensitive to death and have since believed that its abstract dimension should be acknowledged. With my own very central role in this event, followed by uncharacteristic silence and mild dissociation during my co-interns’ analysis, I neglected my role in the discourse. It was essential to understand what we saw from a humanistic framework beyond the sterile clinical explanation.
Outside of the hospital, if a person is fortunate, brushes with death are infrequent. But in medicine, as I’ve started to learn, they happen everyday. No physician is spared the threat of a patient’s death, and it is hard to say whether witnessing death with such frequency makes the process easier. A certain degree of emotional detachment unconsciously develops because the alternative would not allow us to keep providing care. While deaths are continually added to the “cemetery” we carry, as described by surgeon Rene Leriche, they leave a forever mark. Our instinct is to fight death; yet sometimes, we cannot do anything to stop it. When that happens, we should make death meaningful, through lessons, understanding, or reflection. In doing so, we honor our patients’ lives and their transition into existing somewhere beyond.
I will never know exactly how Madeline felt in those crucial 10 seconds. Yet she watched the same way I had watched my then-intern Micah sprint to start compressions on one of our patients. I had stood agape, horrified at the grotesque scene that unfolded, frozen in a paralysis of my own emotional shock. When Madeline and I tapped into the spiritual discussion sitting not too far away from the room from where it happened, her posture became less tense, her eyes less glassy. Echoing in my mind was Micah’s voice checking in on me as I teared up during the remainder of rounds not too long after my first code. Caught between the past and present, the cycle of the experiences in medicine became clear. We are beholden to the examples of our predecessors. Just as Micah did with me as his intern did with him, we are indoctrinated at the moment of first impact. When it’s Madeline’s turn, the sprints of interns’ past will shake her legs awake and she will run as if she had known how to run all this time.
Image Credit: “Andrea’s gaze” (Public Domain) by Clacker806
Resident Contributing Guest Writer
Albany Medical Center
Dr. Jimenez is a psychiatry resident at Albany Medical Center at Albany, NY, Class of 2027. In 2023, she graduated the CUNY School of Medicine as part of the combined 7-year BS/MD program at Sophie Davis School of Biomedical Education. She enjoys spending quality time with family and friends, playing sports, making art, reading, and finding any reason to be near the ocean.