11/11

2014
Cuberovic, Nick

Late internship.  I was ready to throw in the towel after years of adversity.  The hallway clock above the ICU door showed eleven minutes before the eleventh hour on the eleventh day of the eleventh month.  Remembrance Day.  I would rather have been standing at attention at a cenotaph.  

I thought anything else was better than what I was doing.  One-year prior I had worked a seventy-two hour stretch of neurosurgical assists with a half hour sleep.  Things got better, like one night in three on call.  And off nights, I would get home around seven or eight and then get up at five in the morning and start all over.  All I could think about in my free time was sleep.  Stop!  Selfish!  I would not trade places with that angel in the ICU.

It was my first rotation when I met her in the emergency room.  She looked so pretty, even if ghostly white.  Her blood pressure was fine, then not fine, then fine again.  She felt exhausted each time the pressure fell.   Examination and diagnostics came back with; nothing much. 

I approached my supervisor, able to give four of five of the most probable differential diagnoses.  I felt so stupid that I could not remember the fifth!  Neither could the staff man.  We called the internist.  This happened to be our hematologist and he did not hesitate. 

He said, “The fifth cause is cardiac tamponade”.

 He arrived and performed a pericardiocentesis.  Her blood pressure normalized.  I was in awe.  Then the answer in that fluid ruined it all.  Leukemia.  The worst kind. So, back I went to the next emergency case, and the next, and the next three weeks.

My next rotation was hematology.  There she was!  So too was the haematologist.  What a great opportunity for continuity of care, I thought.  The patient was my age, so pleasant, and so brave in the face of her diagnosis.  I devoted a longer than usual time with her on my daily rounds.  No, not because of her beauty, but because I knew, we both knew, that things looked grim.  Her leukemia was not responding to standard treatment. 

One fine and early sleep deprived morning, I joined the entourage of our hematology holy man on rounds.  Our patient had awoken and smiled a weak smile at me.  My hero turned to me and said to give our lady a bolus of calcium.  I was taken aback.  By necessity, I had to be familiar with the numbers in the morning blood work. 

“Sir, I shouldn’t do that.  Her potassium is low”, I said in sheepish fashion.

He slowly turned to face me.  In the corner of my eye I saw the glare from the charge nurse.  The others stood with mouths agape.  The message was clear.

“Just do it!” 

They turned on their heels and bolted out the door, satisfied that my scarlet cheeks betrayed obedience.  How had my logic failed?  Was I so tired that I had forgotten my physiology?  A hematologist of renown just gave me an order.  I was wrong.  That had to be the conclusion.

A medical school legal course flashed in my mind.  If I knew I was right, and still followed orders, I was about to commit gross negligence.  If I refused the order, I felt my career was in jeopardy.   I wasn’t ready to throw in the towel, not yet.  I had to believe in the experience of an expert.  I had to believe in something! 

A nurse returned with an amp of calcium in hand.  The patient looked up at me with puppy dog eyes.

Do or die.

I did. 

Intravenous.  Slow. 

There was no way I was going to leave her side.

Done.

Nothing,

until the second minute.

Her eyes rolled back.  She arched.  She gasped.  Everything stopped.  Code Blue.  

We resuscitated her so that she could face her death sentence.  I was tortured with guilt.

Thereafter, the service staff, the rotation, and the hematologist, were warm and gentle on me.  The specialist and I never, ever, talked about that day.  We should have.  We had both been in error, and we knew it.

Those days passed in a flash. 

I dropped my gaze from the clock to the ICU door.  I thought it strange that the few free moments I had between surgical cases was spent walking down this hall.  She had been transferred to the ICU a couple of weeks ago.  In I went.

To my grief, a nurse informed me our patient had slipped into a coma a couple of days past.  Death was imminent.  Her one brother and two sisters were on vigil and invited me to join them at bedside.  It was a surprise to learn that she had talked to her family about me.  I had not asked and known that her sisters were nuns and her brother a priest!  Her brother, in his vestments, was giving last rights, his head immersed in the bible.  I looked at the monitor, which showed a tachycardia of one hundred twenty. 

“Yea, though I walk through the valley of the shadow of death…”

Her eyes sprang open.  He stopped reading mid-sentence.  We were all stunned.

His eyes returned to the book in haste.  “I shall fear no evil…”

One by one her gaze met us, rich in warmth and love.  Words cannot express the moment.  When she locked her eyes on mine, I could not escape her mental grip.  She was saying goodbye without words.  Her soul was content.  She did not want us to grieve.  Selfless! 

At last her eyes moved on and fixated on her brother.  We all shed silent tears and shuddered.  I could not comprehend what I was witnessing.  “… and I will dwell in the House of the Lord forever.”

 “Amen”.

The heart monitor with the QRS complexes of 120 beats per minute, flat lined as fast as though the plug had been pulled.  No more respiratory effort.  Her eyes closed.  No movement.  Peace at last.  And we cried.  The image is engraved in my head to this day.  I will leave this transition from life to death for the reader to ponder in all its wonder.  For me, I was again shown that there wassomething to believe in.

Thankfully, memories of many adversities faced as a physician fade in time, but they do help define me.  We carry on in our profession in a war against death.  We win many battles, but we do not win the war.  Not yet.  Today, twenty-five years later, one simple miraculous pill, once a day, could have saved this angel.

Bravery can be defined as the ability to function in spite of fear.  I salute those in the medical profession who are selfless and brave, such as those who were on the front lines of the SARS crisis.  This woman, cut down in the prime of her life, faced her killer with bravery and selflessness.  I can only hope to do honour to her memory by continuing the same good fight she taught me. 

This is the angel that visits me every year on every Remembrance Day.

Theme: Death and Dying | Décès et le mourir
Theme: Family | Famille
Theme: Health Care Delivery | Prestation des soins de santé
Theme: Patients | Patients
Theme: Physicians | Médecins
Theme: Teaching and Learning | Enseignement et apprentissage

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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