Today I experienced my first patient death as a medical student. Intimate and up close.
He is a nine year old boy. He came overnight to our ICU a week ago with uncontrolled seizures, and I remember receiving him as a new patient the next morning, and selfishly grumbling because I had to go through his piling mountain of labs and medications. We couldn’t stop the seizures despite trying all the common go-to medications. His care quickly escalated, and we were obtaining all kinds of sophisticated lab tests and imaging by the end of the day trying to find the cause of his endless seizure. Soon enough, teams of specialist doctors got involved in his care alongside our ICU team.
Everyday, lab tests we sent off would come back inconclusive or negative, leaving us with no clue of an etiology. Meanwhile, we had extensive discussions with the neurologists regarding trying fourth and fifth line therapy that have dim promises of effectiveness yet a good deal of toxicity on his body. More and more drip medications were started to temporize the side effects, and we kept turning up their doses. When I came to work this morning and checked his labs, I was beginning to despair. All his organs were starting to fail, and everything was spiraling downward.
My patient was in a coma the entire week he was here in the ICU. I’ve never spoken to him. But every morning when I entered his room to examine him underneath all the wires and catheters, I would notice a collage of his pictures that was put up by his family on the bedside. In all of them, he was smiling from ear to ear, either sitting on his father’s lap, kissing his mom or hugging his little brother. I often wondered what his voice sounded like in real life and what he would’ve said if he woke up. Then I look aside to his mother and grandpa who are sobbing next to his bed. It’s hard to imagine what it’s like for them to have the cheery boy in those pictures that they had known so intimately fighting for his life on the ventilator in a matter of days.
Very quickly, his blood pressure began to drop, and we were maxed out on all medications. Our ICU physicians took the parents outside and broke the unavoidable news that his body was not holding up, and we were at the end of our road with available therapy. Immediately his mother doubled down and wailed in despair, gasping for air. I stood next to them, feeling almost as equally blown back and helpless, even though I had known about the poor prognosis all along. It is a dreary thing to have your thoughts confirmed out loud. We all went back to his room with the parents, and I stood in the back watching as his mom held his hands and pleaded “please you have to fight”. Trying not to take in the overwhelming wretched sadness of the scene, I stared at the vital sign monitor and his heart tracings and thought to myself, “We just need more norepinephrine, more vasopressin. C’mon, we can pull through” as if my racing thoughts would make a difference.
As his heart rate dropped to 80s, 60s, 40s and all alarms were activated on his monitor, I found myself closing my eyes, refusing to be a witness. No, no, this cannot happen. I started to pray to God, please please give us a miracle. But when I opened my eyes, his heart rate was still in the 40s, and I watched as my patient’s life slowly slipped away. My mind went blank while his parents wailed and moaned. That moment froze in my memory. The moment of excruciating pain and denial and dread overshadowed by a leaden silence, with only the sound of monitors frantically beeping in the background. It seemed to have lasted an eternity, then his heart tracings went flat and blood pressure went to zero. I bowed my head to hide the tears rolling down my chin.
The rest of the day was a blur. Much consolation happened, with the family who streamed in, with each other on the team, the nurses, residents, fellows and physicians. Our team dealt with it in our own “professional” ways. Lots of tissue paper was passed around, we researched articles on alternative seizure therapies, and we patted each other on the back and comforted ourselves that we did everything we could.
It’s not to say that we should rightfully give ourselves all the credit for fighting for the patient, or that we are justified in dramatizing our reactions to the death comparing to the parents, but I think, that deep down inside all of us as medical professionals, we all need a moment of silence. A moment to let down our walls of expertise, when we can be vulnerable to the basic raw human emotions that confronts us before death, when we can spend a moment with our patient not as physicians, but simply as people.
This post is not followed by a recipe, but is written in remembrance of my patient and in respect of his medical journey. Recipes will resume with the next posting.