Emotional Triage

I was midway through a shift in the emergency department during my ultrasound rotation, two weeks away from a much-needed winter break. I waited for my patient suffering from back pain to return from a CT scan so I could perform a bedside echocardiogram. In the interim I refreshed my cardiac anatomy, but my attention strayed to the open electronic health record tab of our most recent patient. COVID-19 positive, worsening shortness of breath, and chest x-ray demonstrating diffuse, bilateral opacities. I scanned their problem list, developing a gestalt of their health and mentally checked off each comorbidity portending poor outcomes for a virus now resurging. My seasoned 3rd year emergency medicine resident prognosticated a succinct yet ominous disposition.

“They’re not going to make it out of this hospital.” I followed her gaze to the room behind me and saw a tortured soul fighting for air as the respiratory therapist increased the oxygen via high flow nasal cannula. I stared blankly for a moment, yet quickly my attention was averted. I caught a glimpse of my patient returning from CT. My resident was busy finishing notes, but our attending physician also noticed their return. He looked at me while pointing to the ultrasound machine.

“Ready?” He barely finished the word before darting toward the patient’s room. I’d quickly realized this was the only pace at which emergency medicine physicians worked. I eagerly rose from my chair and responded. “Let’s do it!”

My attending provided guidance as I felt the prominent rib contours through the ultrasound probe pressed against my patient’s frail frame. A textbook view of the heart appeared on screen, just as my attending was urgently called out of the room. I continued the procedure, awed by my patient’s abnormally large heart, with such poor contractility it bordered on asystole. As I finished up, I thanked my patient for the learning opportunity yet fumbled briefly having forgotten their name. This rare uncouth moment represented a sharp deviation from what is normally my penchant for quickly building authentic rapport with patients. Leaving the room, I recalled past evaluations by residents and staff that corroborated my intrinsic investment into patients’ lives. But immediately after closing the door, a cacophony of different colored scrubs in another patient’s room broke my internal reassurance. An all too familiar scene of organized chaos I recognized as a code.

Two medics, whom I’d worked with before medical school as an EMT, arrived with a patient in cardiac arrest. COVID-19 precautions barred students from assisting in these, so I watched from afar and reminisced with my former co-workers. Moments later, a nurse scurried from a small opening in the sliding door to hand the crew their LUCAS device. We exchanged farewells and as they departed, I heard the echoes of alarm tones emanating from their radios, followed by their dispatcher’s voice. She begrudgingly addressed the crew, provided them a street address, and gave them their next call: “Code 3 – cardiac arrest.”

My focus shifted back to the resuscitation. A fellow classmate and I talked as we gazed helplessly at the ongoing entropy beyond the plexiglass. We discussed potential etiologies of this patient’s stopped heart, as well as prudent investigations and treatments. When our view inside the room was obscured, our conversation detoured to life updates, postponed holiday plans, and the fraction of anatomy current first-year medical students had learned compared to our class. “They didn’t learn any of the pterygoid fossa?!” I exclaimed in disbelief.

“Can we get another amp of bicarb?” Another nurse exclaimed from behind a small opening in the door. I peered through this fleeting aperture to get a closer view of the turbulent exercise of restarting a heart I’d participated in countless times before.

The resuscitation was momentarily successful – a thready, tenuous, slowed heartbeat restored. My attending remained outside the room to console the family over the phone, tenderly informing them of the situation and the grim prognosis. Silence followed, then muted sobs from the other line. They’d made the decision to act in accordance with the patient’s newly discovered “Do Not Resuscitate” order. Barred from the hospital given COVID-19 precautions, the family listened over speakerphone while the hospital chaplain gave the patient’s last rites. A final ventricular depolarization flashed on the monitor before deafening stillness. There would be no compressions this time.

I was getting hungry as we neared shift change, and anxious to get home. I refreshed my patient’s chart from earlier and opened their CT scan images. I challenged myself to read the imaging before the radiologist’s report. But the pathology was clear even to my novice eyes. The vertebrae in my patient’s spine were peppered with a half dozen or so small, lucent circles representing erosion of bone. As if pierced maliciously by a hole puncher. The etiology of their back pain was clear. I reviewed the rest of their chart.

“Mets,” I said quietly, to no one. Metastatic cancer.

“I called medicine and palliative care,” my resident exclaimed to our attending as they discussed my patient before sign-out. I admired her astonishing efficiency, having already finished her note from the code. This patient, too, was likely not going to leave the hospital.

My stomach growled.

The oncoming night resident appeared at the workstation to relieve us, and I practiced delivering sign-out on my sole patient. I approached a nurse who’d helped me earlier in the shift with placing IVs to say thank you before heading home. My walk back to the workstation led me past our patient suffering COVID-19 pneumonia. Their battle for oxygen grew more intense as the respiratory therapist traded the nasal cannula for BiPAP.

Another growl from my belly. I found my resident and expressed gratitude for her teaching, solicited feedback, and we parted ways. I hazily remembered the mental map back to my car as midnight passed. I drove straight home – immediately falling asleep and forgetting to eat altogether. I was awoken peacefully by a late-rising December sun hours later. Feeling refreshed with sleep, coffee, and finally a meal, I began a process I’d routinized since starting clinical rotations that proved crucial to sustaining my humanity in medicine: Writing, reflecting, and learning from the previous shift.

As I began typing, however, the gravity of each encounter began weighing on my conscience. My refreshed energy quickly abated, supplanted by a gnawing grief as I recapitulated the suffering I’d borne witness to. My seeming indifference to this pain, then necessary to focus on my learning and catalyzed by hunger and fatigue, gave way to overwhelming guilt. I recoiled from the keyboard. My eyes closed. My thoughts quieted. I opened up space – to feel. A space to focus on that painful, yet necessary, expression of sorrow unconsciously triaged until now. I surrendered to those emotions, shedding tears concordant with suffering heretofore left unattended. The suffering of three patients and families whose mortality was now palpable. Undeniable. Eventually, my catharsis and tears rescinded, having rehydrated the clearly desiccated but still fertile soil that sprouts the compassion and empathy from which my motivation to practice medicine harbors its roots. I finished my reflections, sobered and revitalized, ready to carry my replenished soul to my next shift.