I stood at the edge of the room, my body caught halfway between the sliding glass doors that separated patient from healer. From the computer speakers, the lyrics of Dreams by Fleetwood Mac filled the room: “Now, here you go again. You say, you want your freedom. Well, who am I to keep you down?” The song infallibly reflected the moment occurring at the patient’s bedside.
It was my first day back on the wards since we had been pulled from the clinical environment in response to the COVID-19 pandemic. I feared I had made the wrong decision to make the MICU my first rotation back. But the time between residency applications and now was narrowing and as we all were, I was in a rush to demonstrate my clinical knowledge and skills at an intern level before graduation. So, when it came time to start the rotation, I tied my hair into a ponytail, stocked up on ceil blue scrubs and with my N95 mask clipped to my hip, charged forward confidently onto the wards ready and eager to learn.
Richard was 55-years-old, younger than my own parents. He had been a prisoner to his body for 80-plus days, floating between the MICU and general hospital floors. He had been admitted after a biking accident with his son – broken ribs leading to a hemopneumothorax, spinal cord damage resulting in neurological deficits, and sequelae of a complicated hospital course, including pneumonia, countless intubation and extubation trials, PEG tube placements for nutrition. The list could go on. For the majority of his hospitalization, he had been unable to articulate his wishes. The team relied on his two daughters, not more than a year older than me, and his wife to make decisions. Naturally, when asked to read up on Richard, I was terrified of assuming care of this medically and emotionally complex case.
It was only day two of caring for Richard when a care conference was called to update the family and align as a team about next steps. It had become clear to us as a medical team that Richard’s condition was worsening and that he was unable to extubate safely. Even if he was able to breathe on his own, the prognosis was poor. I began to guide the conversation, trying to focus on lacing my words together coherently. It was challenging to speak.
I watched as the faces of his wife and daughters shifted, first challenging that we had tried all the possible treatments and then becoming peaceful as they started to accept the likely outcome of their loved one. His daughter shared that being dependent on others was the exact opposite of what her father would have wanted. He was a man of freedom. Her bravery with her admission that the best step to take for her father was to extubate to compassionate cares, gave confidence to her sister and step-mother to also accept that aggressive interventions were not what Richard would have wanted.
The next day, the plan was to extubate at 11AM. COVID had caused many changes to patient care since the last time I had walked the halls of the hospital, but the toughest for me was the limitation on visitors. Richard had 6 sisters and 1 friend he considered a brother. I mourned with Richard’s family that his loved ones would not be present at his bedside. Richard’s two daughters and wife sat at his side, holding tightly to his hand. As the extubation process began, Richard’s body began to fight in discomfort. The Chaplin asked the family if Richard had a favorite musician. His daughter said, “Fleetwood Mac”.
The lyrics that followed brought tears to my eyes. I had never cried in a patient room or been unable to keep a professional demeanor in front of family. Maybe it was that Richard’s family structure was so similar to mine or maybe it was the feeling that Richard was telling his family that he was okay with dying through the lyrics that flooded the room. Regardless of the reason, I couldn’t hold back my tears. I remember telling myself in that moment, I hope I never misplace this feeling of empathy for others. I fear the day that I am unable to relate to another human’s experience. It took 30 minutes for Richard’s blood pressure to drop into the 40s, for his soul to leave this earth, for him to find his freedom.
As I head into intern year, I reflect on the impact we as physicians have on our patients. We have the privilege to impact patient’s lives at deeply personal moments; even guide them in their transition to death. I found this to be particularly true of the MICU, where life and death meet each other every day. Richard’s siblings had known him his whole life. And yet, in his final moments of life on earth it was me, someone with only a glimpse into his life, in the room with him and not his family. Somehow I was given this badge of admission, and I wonder if I deserved to be in this position. I question, did we make the right call as a medical team? What if we just completely altered the outcome of someone’s life and were wrong to do so? Would I have made the same choice as Richard’s daughters?
The privilege of a physician runs deep. It allows one access to knowledge and higher education that is, to the general public, inaccessible, securely locked behind large, ivory towers. In the midst of a global pandemic, it grants me access to a vaccine before members of my own community, who have no choice but to go and serve on the frontlines in the form of grocery store clerks, home health aides, schoolteachers. The first step is recognizing the rite of passage into this world of access that my professional path has afforded me. To me, however, the most important step is the one that follows; finding a meaningful way to equalize this access for others, for my communities, and for my patients that I will serve in the most challenging moments.