As My Patients Die

I anticipated that I would encounter dying patients during my third year of medical school. Every patient has been unique and different, and each one has elicited from me a variety of feelings: the unknown, helplessness, disappointment, numbness, sorrow and even peace. My experiences have been ones that have taken place within multiple specialties and disciplines from the intensive care unit to the trauma bay of the emergency department. My patients have allowed me to be one of the final characters in their chapters of life, and I will be forever grateful for them to have participated in their closing moments.

The Unknown.
I will never forget seeing my first dead patient in the hospital. I was on my internal medicine rotation, and my team was admitting patients to the teaching service from the emergency department. He initially presented in a lethargic state – minimally responsive to my attempts to communicate with him, and was weak, deteriorating, and severely ill. After our evaluation, my team had a working diagnosis of liver failure that was causing his altered mental status and current presentation. After stabilization, he was transferred to the intensive care unit (ICU). Unfortunately, after speaking with our attending physician that evening and the next day, it was found that he was suffering from end stage heart failure. His heart’s function was diminishing rapidly, and I was told that he would only have a day or two to live. During this time, he was in a comatose state while intubated in the ICU. My patient’s wife was at his bedside the majority of the time, and she understood the gravity of the situation. I was most taken aback by her quiet patience and faithfulness to her husband despite the circumstances. During the day while my medicine team was rounding on the floor, my resident received a phone call from the ICU nurse. He had passed away.

We quickly walked to his room to find him lying in his bed, lifeless. According to his medical record, our patient was DNR, meaning, “do not resuscitate.” The nurse explained that she had been moving him to a different position when he coded on the monitor. As I stood in the back of the room, I watched as my resident calmly assessed him in order to legally pronounce him dead. As soon as he finished, the wife walked into the room. I watched her become weak at her knees, as my resident found a chair on which she could sit. Hands trembling, she asked, “Is he gone?” It took her a few moments to realize that he had moved on from this life, as he told her, “Yes, he died just moments ago. I am so sorry for your loss.

We then walked out of the room to give her some privacy, and we headed to the nurses’ station to obtain the death certificate forms. As my resident began to fill out the forms, I watched as the patient’s whole family came walking through the ICU down to his room at the end of the unit. I could hear their cries of agony and despair from the opposite end of the unit, as a feeling of the unknown came over me. I had just witnessed my first patient die.

Feeling Helpless.
It might just be me, but I feel as if many medical students will feel helpless throughout the duration of a patient’s care in the hospital. At this point in my medical career, I realize that I am not yet a physician. I am unable to legally diagnose disease, prescribe medication or make the experienced surgical cut during an operation. As someone who has always wanted to work with his hands in medicine, it has been especially tough to withhold my enthusiasm to “jump in” and help the team. I find myself confident, yet timid sometimes. There have been many instances that I have had an internal battle in my head, not knowing whether to participate or remove myself from a situation in order to both learn and not screw something up that could endanger the health of the patient. I feel this most during the times that I have witnessed patients code on the floor.

A code is when a patient goes into either respiratory or cardiac arrest, necessitating prompt emergency life support efforts by the medical team. It often involves the doctors nearest to the patient’s room along with nurses and a resuscitation team. It is a scary situation to all those involved, as the patient is on the cusp of dying. Imagine seeing a patient’s visiting family members rushed out of the room, as nurses and doctors sprint in to begin assessing the airway, breathing, cardiac status and vital signs. Standing on my toes and peering into the room, I will watch as the medical staff takes turns providing compressions to a heart unable to beat. Cracking the ribs is common during manual compressions, and many patients are intubated because they are unable to breath on their own. I can safely say it is more intense and nerve-racking in real life than on Hollywood television shows.

I remember a patient in particular who coded in the intensive unit. The patient’s daughter had been in the room. I heard shouting down the hall and witnessed the same unfolding of events occur like they always do. However, this time I stood right next to the daughter who had been escorted out of the room. I watched as this woman screamed, shouted and wailed as she looked on through the same window I was looking through to the room.

I felt helpless in that moment. Part of me wanted to provide compressions in the patient’s room, but I did not want to screw up. Yet, the patient’s daughter stood next to me in tears and weak at her knees. I did not know what to do. Out of the corner of my eye, my upper level resident came with a chair out of a room next door for this woman. She placed it next to her and helped her sit down. Though the woman stood right back up, my resident embraced her and held her hand during the entire code. She would not let her go. It was in that moment I realized that you should never feel helpless. I witnessed compassion in its truest form that day.

Disappointment.
Death is disappointing, especially to those in medicine who invest so much of their time trying desperately to prevent it. It has been difficult to experience continuity of care with patients as a medical student. You are constantly changing from rotation to rotation. One day I might be at a private clinic, and the next week I am up on a floor in the hospital. Still to this day, I will always remember a patient I followed during my neurology clerkship, only to meet him again months later while I was on general surgery.

When I first met him, he was very sick. With multiple problems that needed to be addressed, he was a complex case. Realizing he did not understand the gravity of his disease, I made it a point to stop by each day and speak with him about lifestyle change and dietary habits. I anticipated that by continually emphasizing the importance of his need to change with positive support, he would slowly be more accustomed to the idea of making lifestyle changes following his discharge from the hospital. I hoped to never see him again in such a poor condition.

Unfortunately I did meet him again. This time it was different. I was rounding one morning with my surgery team, seeing patients in one of the critical units, when I realized that someone we were talking about seemed extremely familiar. Thinking that it could be him, I opened his curtain to find him lying in bed. While staring at him in disbelief, I could hear my team in the background say that he was going to die in the coming days.. He had suffered an acute brain bleed that brought him right back into the hospital. I felt sick. I felt disappointed. Despite my best efforts, he was back here lying in a bed with a machine breathing for him. My surgery team proceeded to check on the next patient, as there was nothing else we could medically do for him. I decided to step in, hold his hand and say goodbye. It was painful to see someone who you spent time with to treat slip away.

Numbness.
Death has made me numb. Within our school’s surgery rotation, you are required to work several extended nights on the trauma team. If the night was busy, it involved many hours spent down in the trauma bay of the emergency department. Patients would be quickly wheeled into one of the two rooms of the bay with a team waiting to stabilize, analyze, and treat any emergency. I have witnessed everything from motorcycle accident victims to gunshot victims. After so many traumas, I have developed a sense of detachment from the absurdity of the situation in order to objectively address and treat the patient in my own mind. However, I will never forget seeing my first dead-on-arrival patient.

The man had committed suicide. One bullet to the head.

After realizing that there was nothing to do for the man, my attending called off the trauma assessment. He stated that he was dead and unable to be treated. As another trauma came through the doors of the emergency department, our team quickly changed their focus to the next patient who was rolled into the room right next door. Following initial stabilization, the new patient was sent to the CT scanner for full body imaging. I found myself alone in the trauma bay with our dead man.

I don’t know why I did it, but I felt like I had to. I went up to his body and looked at his head. I saw where the bullet had penetrated into one side and came out the other. I even put my hands on either side of his head to touch what a gunshot wound felt like on the skull. I could not help but look into his eyes and see him staring right back at me. I felt numb. I realized that he must have suffered greatly in his life to come to such a point that he felt the need to take his own. I will never know why he had to do such a thing, but I felt severely grief stricken that he would not wake up the next morning like I would. Before I left his bedside, I did not know what to do. So, I prayed for peace, and I prayed for forgiveness.

Sorrow.
Cancer is awful. It can affect all walks of life – from the very wealthy to the very poor. It does not discriminate. Despite our current advancements in treatment, patients continue to die. I will never forget the connection I made with one of my cancer patients while I was on my internal medicine rotation.

I helped admit a woman in the emergency department one evening. She had been sent to the hospital by her primary care physician for further evaluation of a mass found in her lungs. She was a spunky and upbeat woman, and I immediately made a connection with her, but after hearing the reason for her visit, I anticipated that it had to be something serious.

Her family physician had found a large mass in her lungs on imaging. Her doctor wanted her to be admitted quickly to the hospital to ascertain the seriousness of her mass and to provide the opportunity of initiating any necessary treatment. Before the oncologists came up with a final diagnosis and plan for her, I got to know her very well. I found myself spending twenty to thirty minutes in the room with her and her cousin each morning and evening. They enjoyed making jokes and finding ways to make each other smile, including me. I would sit down next to her bedside and listen to her stories, but I also made a point to listen to her worries and concerns. She brought up her faith, her family and the importance both of those had in her life. I felt her nervousness and anxiety about what the oncologists would tell her, and she eagerly wanted to know if it was going to be OK. I did not have an answer for her.

I will never forget the day we broke the news to her. After reading the results of her scans and notes from the oncologist, she was diagnosed with stage four metastatic lung cancer. It had spread all over her body, with multiple lesions throughout her liver and several darkened spots across her brain. It was the reason why she was having trouble with her vision and feeling unsteady—the cancer was slowly destroying her. I felt deeply saddened when I saw the results and listened to my attending. Though I was on a large teaching service, my attending only allowed the upper level resident and me into the room. Her entire family had arrived that morning to hear the results. I stood in the back of the room as her cousin looked at me with concern while sitting up on the windowsill in the corner. My attending addressed my patient with great empathy and explained to her the results and the gravity of the situation. She began to tear up and then cried for the duration of our time in the room. I glanced over at her cousin, who was crying too. It was extremely difficult to remain strong for this woman and her family. As providers, we have a duty to compassionately serve our patients and remain steadfast in their care. But this time, it was hard.

After our conversation we walked out of the room. I was the last one to leave, and as I turned my back to see her looking at me with tears in her eyes, she said, “Thank you.” With a tear running down my eye and with shaking hands, I responded, “You are welcome. I will be thinking of you, and you will be in my prayers.” I quickly wiped away the tear running down my cheek as I closed the door, and I was grateful that my team had already walked halfway down the hall to see the next patient. I did not want them to see me cry. That was the last time I ever saw that woman.

Peace.
Despite the deaths I have encountered early in my medical career and inevitably the many patients that I will see die in the future, I will never forget those patients. I will always remember those moments as special times that I was given the privilege to be there during their final minutes. I had the lucky opportunity to hold their hand or “say a line” that enabled me to be part of their final chapter. In medicine you experience every aspect of the human condition—love , grief, sorrow, pain, suffering, joy, gratitude, friendship—every day with patients. I have not once regretted my decision to enter into such a vocation. Though I have seen death, I have also seen life.

Currently on my OB/GYN rotation, I delivered my first baby the other day. I can proudly say that I was the one who first placed their hands on new life, brought someone into a new world, and witnessed the beginning of a new family. With everything in medicine, there is always something more than death. There is a life and a peace that can never be taken away from every one of us. Whether that is a newborn baby girl or the smile of a dying cancer patient, they both will live forever in the pages of my life’s chapters.

I was born and raised in Nashville, Tennessee before heading to Furman University for my undergraduate studies. Football brought me to South Carolina, and I participated on the varsity team for a little over a year before deciding to focus more of my time on my studies and community involvement. I graduated Furman in May 2014 with a degree in Religion, and I believe that my background allows for a unique perspective into the lives of patients. I have been wanting to practice medicine since my youth, and I am grateful for the opportunity given to me by the USC School of Medicine Greenville to pursue that dream.