Death by the Numbers



 

Wesley Chou1

Perm J 2020;24:19.231 [Full Citation]

https://doi.org/10.7812/TPP/19.231
E-pub: 04/21/2020

“Your patient is trying to die on us,” the nurse practitioner chimed in through the doorway. As I sprang up to follow her already receding figure, I wondered about this choice of phrase, one that made death sound like a tantrum put on by a sullen toddler. It lent an air of petulance to the patients who more often than not hovered in a strange purgatory between consciousness and oblivion.

For my fellow medical students and me, our week on the surgical intensive care unit (ICU) was a “chill” one, seen as a break from the surgery rotation’s grueling schedule. Expectations were lenient. My main tasks were to present 1 or 2 patient cases on morning rounds and then watch any procedures being performed that day. The attending physicians would often be kind enough to let me out by early afternoon, telling me to enjoy this freedom while it lasted. I would pack up my belongings and leave them, still in a reverie, reminiscing about waking up at 3 am to take vital signs on patients and hunt down paper charts.

As I slipped into the ever-increasing crowd perched outside my patient’s room, I thought about how it felt like death was happening by the numbers vs whatever macabre caricature I had envisioned. There was no dramatic bleed-out, screams of agony, or heroic resuscitation efforts. Over the next hour or so, I received a blow-by-blow commentary of climbing lactate levels, resistant to the fluids the healthcare providers were pushing in, as well as blood pressures that remained tolerable only by virtue of the astronomical volume of vasopressors pouring in.

It was all happening so fast. The patient had required a little bit of help maintaining her blood pressure in the operating room yesterday but had been stable immediately afterward. This afternoon was another story. Throughout the quiet chaos, the vague familiarity of the patient’s name made me realize that she had been one of the patients followed up by the urology specialists when I was with that team 2 weeks previously. I had not been following up this patient specifically, and try as I might, I could not recall a single moment with them amid the various gown changes and dashes between rooms on morning rounds.

Besides the morsels of information available in the social history in past medical record notes (that she had been an activist in her community, for example), I knew little about who the patient was as a person. It was only when various relatives began arriving that her existence began to feel truly reified and gave me a sense of the impending loss at hand. Seeing the sister weeping, a lump in my throat began to rise. And even if that was reflexive, it made the surreal slightly more recognizable.

Later that night, as I rode the subway to meet a friend, I found myself reflexively scrolling through the patient’s electronic medical record on my smart phone app, tracking various notes from spiritual care staff and nurses anticipating extubation. A doubting notification popped up: “You are entering the chart of a deceased patient. Are you sure you want to continue?”

That patient’s death was a little more than a year ago. Did it upset me? Yes, but I was not haunted by her death in the same way as by the deaths of other patients whom I had known better. And yet it gnawed at me, even though I know full well that this same drama has unfolded innumerable times in wards the world over; I can see how someone could quickly grow accustomed to death in this environment. But I wish that her death had been brought up by attending the next morning on rounds. I had been unsure about how to broach this the next day: “So about the lady who passed away last night…” I imagined a confused reply: “Oh yes, the lady in 11A, what about her?”

I am reminded of an earlier time, when my classmates and I began laboratory sessions for anatomy. I had loved those sessions, the visual and tactile nature of appreciating anatomical structures, even if they did not automatically present themselves in the beautiful fashion of our surgical atlas. That excitement of learning the body’s roadmap has persisted, such that I plan to enter a surgical field. But I remember amid those highs, how at the end of anatomy, we zipped the cadavers back into their bags and pushed their carts into a corner. I felt an unease, not dissimilar from the one I experienced returning to the ICU, at this seemingly unceremonious departure. In talking with classmates afterward, I learned how for many of them anatomy had been an upsetting experience. Perhaps they felt guilt at having “squandered” their donor’s final gift by not learning as much as they should have or were reminded about their own experience with a deceased loved one. At the time, those conversations and my own unease motivated me to help organize a memorial service for our anatomical donors. I aimed to provide a space for my peers to express their emotions and to give a more proper goodbye to our donors, even if we had not known who they had been in life.

I want to similarly recognize the disparate reactions that a shared experience may provoke. I hope that as a future physician, I will remember that medical student who attempts not to jut out awkwardly and pokes his head up hopefully when it looks like something interesting is occurring. I want to remember that what is another Tuesday afternoon for me might be the student’s first time experiencing something, be it thrilling or harrowing. And I hope that after one of those moments, even if the list is overwhelming or the hours long, that I can take a moment to pause and ask them: “How are you feeling?”

Author Affiliations

1 Harvard Medical School, MA

Corresponding Author

Wesley Chou ()

Keywords: death, medical education, narrative medicine

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