The Rekindled Flame


Julio C. Ramirez, MD

Perm J 2020;24:20-005 [Full Citation]
E-pub: 07/24/2020

I describe an impactful patient experience from my early medical career that has had a lasting impression on me not only as a clinician but also as a human and, importantly, as a father. The experience is that of a patient who had undergone heart surgery and subsequently died; I identified with the patient on a personal level. The challenge was not in providing medical care, but in providing medical care that did not result in his survival. Encountering death is a difficult reminder of why we practice medicine – to help others. Yet even healers, at times, need words of encouragement.

We start the morning with CPR. “He’s coding,” a nurse said. We had all anticipated that it was just a matter of time before hearing those words. We rushed to his room and began resuscitation during his Code Blue. The patient had survived several heart surgeries since childhood, and he was determined to survive one more. After his surgery, he was placed on a heart bypass machine, and tubes were left in his chest to drain any blood that remained post-operatively. The output should have decreased with every passing day; his output only continued to increase, requiring blood transfusion after transfusion. Despite receiving near constant blood products, his heart had begun showing signs of failing, and he required an increasing number of medicines to keep it from doing so.

As we began performing CPR, I couldn’t help but think of the person that he is – a son, a husband, a father. He has kids, both of whom are about the same age as my own. I thought quietly to myself, “I would like nothing more than for you to be able to go back home to your kids like I will be able to do today.” I was selfish. I wanted him to be able to see his kids again in order to lessen my own survival guilt. I could imagine all of his family’s birthdays, the get-togethers, the movie nights – time spent together as a family. I could also imagine the worst-case scenario – all of the times that “good night” will not be said, all of the warm embraces that will not be given during the holidays, and all of the photographs that will not include him; all of the moments that he will not be a part of. I could imagine it all in that instant.

The harder I pressed on his chest, the more I felt the tears welling up in my eyes. I had to distance myself from my emotions so that I could bring myself closer to him. My compressions became mechanical – up and then down. I made a silent promise that was as much to him as it was to myself: “I have to focus on the compressions. I have to focus on keeping you alive.” That was the best I could do for him, and he deserved nothing less. I broke my own promise almost immediately, as my emotions fought to take a foothold of my focus.

The defibrillator’s automated message, “Good compressions,” was a poignant reminder that I had to keep back the tears in order to continue pressing on his chest. In that moment, it became apparent that he had touched many lives during his hospital stay, as several other members of the healthcare team began to shed silent tears. Perhaps they, too, were remembering his positive outlook on life, or the smiles and laughs shared with him and his family.

Every member of the medical team worked tirelessly and effectively to deliver high-quality, compassionate care to the best of his or her abilities in that most trying time. The experience was bittersweet; on the one hand, there was a certain triumph in being part of a multi-faceted team – nurses, respiratory therapists, residents, sub-specialists – that was delivering unwavering, unified care in the face of trepidation. On the other hand, the difficult reality was that even high-quality care turned out to be futile.

I can’t remember the exact length of time that lapsed between the start and the end of the Code. An infinity, perhaps? During some interval in time, his wife, who was present, was approached and was told the most unbearable words: “There is nothing more we can do.” The sounds of agony could not have pierced the room with greater intensity. I felt my own existence being ripped apart.

Next came the sound of silence.

Modern medicine is meant to be a beacon of light, yet its bright fire was dimmed that day by death’s grip. No longer will he be able to say that he had another heart surgery. No longer will he be able to spend time with friends and family. No longer will he be able to play with his children. No longer. The thought of facing his children, with smiles across their faces, expecting to hear the good news that daddy was safe and had had a good day, conjured up images of my own little ones. No such good news would be given, and thus I believed that they would undoubtedly be my judge, jury, and executioner. I would have been weighed, measured, and be found wanting.

We provided the family with privacy, and shared our condolences as we made our way out of the room. I felt a false sense of security out in the hall – outside of the war room. It was there that his mother found me. I expected her to cast rightful rage on me. I expected her words to cut through me like blades. As she closed the distance between us, I expected to catch ablaze from her aura that resembled that of the sun, as I expected her to emanate fury.

Instead, she gently embraced my shoulder before saying, “Thank you for everything you did. You are part of a wonderful profession.” Time stood still for a moment as the fresh memories of what had just happened all came flooding back, and I found myself being transported back to the battlefield. I again contemplated if my compressions were adequate before tears started melting down my face. I blamed myself for the defeat. The response that I considered giving was that I didn’t deserve to be there and that I was an impostor playing the role of a real doctor. I wanted to say that it was all my fault. I wanted to say I was sorry he wasn’t there to celebrate another victory. Such words began to take form on my lips. Instead, all I could say was, “Thank you.” My inner flame as a medical doctor was rekindled.

Author Affiliations

1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal-Glennon Children’s Hospital,  St. Louis, Missouri

Corresponding Author

Julio C. Ramirez, MD (


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