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On Being a Doctor

Empty Pockets
M any of the experiences in our work we smooth and
shape in the retelling like pebbles being polished by
the tides. Some are more valuable for their sharp edges and
breaths, time, and her heart finally stopped. She was only
36. I silently asked her why. A nurse touched my arm and
said the two words whose weight made my next breath
the pain and lesson they bring by holding them tight. difficult and whose grip was tight around the pain in my
I spent part of my residency training at a city Veterans stomach. “The family.”
Hospital. Overnight call meant perpetual motion punctu- They had been taken to the waiting room. It was pale
ated by frantic episodes of critical care. On this night we blue and the row of lights indicated the soda machine was
had done well, and by the time the first “code arrest” still empty. My throat was dry. The youngest daughter sat
sounded overhead we all had managed to keep our heads on Dad’s lap looking at pictures in an outdoors magazine.
above the tide. We arrived to the medical intensive care The older sat watching her hands rest in her lap. Her
unit, wearing the authority our white coats gave us, to a husband’s eyes lifted to me and met mine. I didn’t,
bedside now ringed by staff. A trach collar had come loose couldn’t, say a word. I took in the breath to begin, and he
and the trach itself unseated, but all had been corrected. knew. The words never meant quite enough, “All we could
Sorry about the run. . . .” They seemed small, like a string of toy boats against a
A curtain separated beds in this area of the intensive stormy sea, “ . . . her heart . . .” I only had to say them,
care unit, and each curtain had been pulled when the code they would have to live them, “So sorry . . .”
was called. I lingered to one side, planning to stay long He turned back toward his daughters, a single father,
enough to see the collar retied. I was jostled by some move- and they lifted their eyes to his. As he drew the breath to
ment at the adjacent bedside. The next time, it was fol- begin, his eldest daughter knew. Suddenly all alone, she
lowed by an arm. My name was shouted, and then I was stood and ran toward us standing at the door. Dad bent
pulled by my coat sleeve through the curtain to the next toward her, but she got past him to me. Tears an unbroken
bed. The patient, a young woman of 36, had been admit- line down her face, she took hold of my coat pocket. She
ted by one of the teams earlier that day. Chest pain, they said words that made 6 years of medical school, residency,
said. The bedside monitor began to bleat and flash. Her and late nights too numerous wither. “Give mommy more
blood pressure was falling with each systole, and her car- medicine. She’ll get better, but you have to give her more
diac tracing was taking on the jagged, wide, rugged con- medicine, please.” I couldn’t breathe. I had no words, no
tour that meant it would be a difficult trip. gesture. Her dad bent to her, but she wouldn’t let go of my
Her husband and two young daughters, 8 and 3, were pocket. He nodded to me, indicating I should go, and as I
led away from the bedside as the intubation tray was being did the pocket she held tore.
opened. Quickly intubated, compressions made obtaining I drove home, tears making the road focus and unfo-
central access more difficult, but I placed an internal jug- cus, replaying it all to find the why or how. Ruptured
ular line hoping things would go well enough that it might ventricular wall? Aneurysm? Pulmonary embolus? I
be used for a Swan–Ganz catheter. Compressions, fluids, stopped when I realized it didn’t matter. I went home to
advanced cardiac life support protocols . . . all the while my wife, then 33 years old. I took off my coat as she stood
cardiac tracing into dysrhythmia. Occasionally, the moni- silently watching and put it in the trash. I needed some
tor would only stare blankly asystole, across its screen. And time to explain, all I could say was, “That one doesn’t work
the blood pressure. Boluses and drips and fluid, nothing anymore.”
would move the blood pressure. She was only 36. I reached
Kevan Pickrel, MD
deeper into algorithms, knowing the next vial off the code Phoenix, AZ 85020-2450
cart would run the answer into her collapsing circulation.
The answer that would also push away the pain growing in Requests for Single Reprints: Kevan Pickrel, MD, 9100 N. Second
my own stomach. I believe I tried everything, and trusted Street, Suite 221, Phoenix, AZ 85020-2450; e-mail, kpickrel@cox.net.
each new intervention would be the one. None of it ever
changed the course. Boluses, drips, compressions, bagged Ann Intern Med. 2003;139:525.

© 2003 American College of Physicians 525