Student Scene
 Alisa Land Photo by Graham Ramsay |
Learning to Grieve for Each Death
Leaning over him, I pressed my stethoscope to the arch of his curved back listening to the breath sounds I heard only faintly, interspersed with sighs. Paper-thin skin stretched over narrow ribs as he leaned forward on his knees, struggling for each breath. The muscles of his neck and chest stood out like bands, trembling and taut. I could see bruises and puncture marks, new blood over old staining the skin of his arms, legs, and abdomen deep shades of red and purple--the legacy of so many procedures after years of steroid use. Gaunt cheeks hung below the green rubber band that held an oxygen mask over his face. Yet, when he looked up at me, I was stunned to see his blue eyes sparkle and a faint smile play behind each misty breath.It was the end of my third year and I had finally arrived to the inpatient wards of adult medicine. In stark contrast to my patients from pediatrics or OB/GYN, these patients came with long histories of illness and even longer lists of medications. If the body represents a map of our checkered past, the bodies of these patients unfolded like a map, dog-eared, marked, opened and reopened through a long journey. I could imagine many stories behind so many scars, stretch marks, bruises, and deformities. I became familiar with the many intimate sights and smells of my patients--the scent of blood, sweat, tears, urine, and feces that permeate every room. One cannot escape the solid earthiness of our work, and finally one learns to celebrate rather than run from these humble reminders of our humanity. It is perhaps in these moments when our patient feels most naked and unlovely that our gentleness speaks more powerfully than all our knowledge combined.
Lionel Peters--though only in his 70s--seemed much older, and I feared for his life as he struggled with advanced pulmonary disease. He seemed extremely fragile over the next days as his condition deteriorated, and I agonized daily, wondering if he would live through the night. Like many with his condition, he experienced overwhelming panic when he became short of breath and would cry out and cling to my hand, asking me not to leave him during an attack. I shared his sense of helplessness as time went on, knowing we were doing all that could be done medically. Yet we were still unable to arrest the inexorable progression of disease.
I remember him telling me he couldn't go on and asking how much longer--and we both knew he was speaking of a final release from his suffering. I sought to comfort his wife and daughter, who visited daily trying to encourage him through each worsening attack. I remember spending time with his daughter when his condition was so poor that he and his family had been considering whether to change his code status. We both shed tears thinking about what his life meant to his family and how he would be remembered. Having lost my own father a year ago, I felt a deeper understanding for her situation than I ever could have before and tried to care for her father as carefully and tenderly as I would have wanted someone to care for my own.
Can I Go Home?
Down the hall, a Russian patient of mine with severe heart disease wandered the halls confused one night. Painstakingly, she had buttoned her coat over her hospital gown and slippers, the gown ties trailing behind her as she walked wide-legged and unsteady down the empty corridor. Clutching her old-fashioned black leather handbag, she found me at a computer and asked sadly "Why am I here? Can't I just go home now?" I tried to explain, but finally abandoned the attempt. I guided her gently back to bed while she cried and told me again that she could scarcely walk across the room with her terrible chest pain and how her husband and family just didn't need her anymore.Once I remember how an intern--perhaps the most enthusiastic supporter I had all year--sat quietly watching me talk to one of my patients who had had multiple strokes. Though the patient seemed to know only his name, I still spoke to him to explain what was happening. I realized that this doctor, rather than being impatient that I was wasting my time on an incoherent patient, seemed to appreciate my efforts. I am grateful for physicians like him who have encouraged me to find my own voice in caring for patients, even amid so many pressures to conform to others' images and opinions of what a doctor ought to be.
Last Good-byes
Another night when I was on call at 4 a.m., sitting hunched and bleary-eyed over the computer typing an admission note, the nurse's intercom beeped. A stark voice whispered across the crackling line, "My mother isn't breathing!" The nurses and I rushed down the hall to the room of a Brazilian woman with end stage renal disease, who looked pale and bloated, a motionless form with skin almost waxy under the fluorescent lights. Her family gathered around her bed as the intern and I tried to find a pulse on her limp wrist. Fumbling with the snaps on her gown, we pressed our stethoscopes to her chest searching for the faintest breath as the red second hand on the face of the clock slowly wound its way for one, two, now three minutes. The intern's eyes finally rose to meet mine and I saw her faintly shake her head and stand up to tell the family, "I am so sorry...." As we stepped back, her children pressed around her to say their good-byes, one last kiss to a cheek still warm though her spirit had gone.That familiar ache tightened my throat, and I blinked back my own tears as we turned to leave. It seemed impossible that in that narrow room just there, just then, this woman's life had ended so quietly--and a whole family's life was forever changed.
It seemed impossible that we as caregivers were expected to walk down the hall and continue our paperwork as though this extraordinary event had never happened. I know my own loss remains so fresh that each new one must brush painfully against this scarcely healed wound. Are we ever really finished grieving or does our own pain just become more familiar and bearable?
Somewhere we must tread this line between empathy and control, daring to care without burdening the family with our own pain; the tears we shed are not only for them but inevitably also for ourselves. Yet rather than hiding behind intellectual defenses and retreating from each loss, we can learn to grieve for each death without being destroyed. This process refines us into physicians who recognize that competence and compassion, never truly at odds, should provide the foundation for our work.
--Alisa Land, who is beginning her fourth year as a medical student at HMS
Patient names in this column are pseudonyms. The opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.