Dr. Rebecca Sullivan, PGY-2
It was my second call day in the MICU, and my first 24-hour call during my intern year. My pager went off, reporting a “CODE BLUE MEDICAL P9.” I started the long journey to P9, almost a quarter mile of meandering hallways from my current location. Thus, I was one of the last to arrive. I quickly walked into the room, crowded with over 20 people, ACLS being performed on the blood-splattered floor. Within moments, I realized that I was most useful outside rather than within the melee, because if this patient survived, I would be admitting her.
I asked if anyone knew the story, and someone related a brief description of the patient. Wait! A sudden thought flashed through my mind. I know this patient. She was in her late 20s, and I had transferred her from the MICU the preceding week, diagnosed with diabetic ketoacidosis. At that point, another colleague added that she was found in PEA arrest on the floor but with no clear idea how long she had been without a pulse. Ultimately, however, ROSC was achieved.
As we wheeled her into the ICU, I finally talked to my fellow who provided no more information than I already knew. After many lines, procedures, and multiple transfusions, we had finally resuscitated her. Nonetheless, during that previous hour, she had developed myoclonic jerks. I well understood that this symptom is a bad sign, likely indicating a hypoxic brain injury. After settling her in her room, I finally got a chance to confer with the family. Speaking first with her husband on the phone, I asked, “What is the most recent update you have received?” He responded, “I spoke to her this morning, and everything seemed fine. She should be going home soon, right?” A heaviness enveloped me as I realized that I must break this life-changing news to him. I summarized the events that had transpired throughout the day, then heard him begin to sob. Barely coherent, he choked out details of their lives: newlyweds, plans for their future, his fear of losing his great love. I did my best to comfort him, but I too had been married less than a year and could never imagine the position he was in. Finally, he asked me to call her mother to replay the entire conversation with her.
If I thought breaking the news to her husband had been daunting, informing a mother that her daughter had died then been resuscitated proved devastating. In contrast with her son-in-law’s confused ramblings, she focused on the hard questions: “Doctor, is she suffering now? Will she live through the night? If she were your daughter, what would you do?” As I talked with her mother during my 16th hour of work, I had no words to ease her pain. I told her that if she were my daughter, I would be at her bedside, holding her hand, and telling her how much I loved her, how proud I have always been of my beautiful child, because things did not look promising. As we concluded our conversation, she thanked me for being honest with her.
Days went by. I was on call again. She lay in status epilepticus, and we struggled to control her seizures. She had completed hypothermia protocol—time for her MRI scan to indicate if her brain had been affected. We all knew what the scan would reveal, but the moment I read “global hypoxic brain injury,” my heart sank. Sobbing in the corner of the work room, I knew this woman, only a year older than I, would never wake up.
I broke the news to her husband and mother, who had no more tears. Previously, our patient had told her family that she wanted to be an organ donor; thus, they were adamant to fulfil her final wish. The night before we were going to palliatively extubate her and donate her organs, I entered her room. Veteran’s Day. Her sister and mother anchored her bedside, a tableau of grief and exhaustion. Recognizing me as I entered, they began free associating happy memories of a life cut short: her quirks, her humor, her determination, and positivity, even after many hospitalizations and surgeries. As we spoke, I revealed to them how much she had touched my heart in the short time I had known her, how sorry I was that they were in this position. I longed to do something for them—anything to help ease the pain.
Fortunately, I have had practice in bedside ultrasound; I offered to ultrasound her heart so they would have a record of her heartbeat during her final hours. While I searched for the best window and audio quality, her mother raised the questions which had been haunting her, “Dr. Sullivan, what will happen tomorrow? Will she suffer?” As gently as I could, I explained the process and assured that I would be there to make her as comfortable as possible. We then recorded her heartbeat, quickly followed by their tears.
As I was leaving the room, after spending an hour with her and her family, fireworks exploded outside of her room in celebration of Veteran’s Day—a surreal moment. This young woman, who would die much too soon, who was so full of life, who has a husband and family who cherished her, would have loved to see the fiery display.
The next day we transferred her to the PACU to palliatively extubate her with her mother and husband by her side. I was terrified. I had never pronounced anyone. I had never palliatively extubated anyone. I had never assisted in organ transplantation on any level. I had never attempted any of these challenges. “I’m just an intern,” I thought to myself, “I’m not ready for this.” But I did it anyway. I had gone through the process multiple times with my attending, fellow, and the organ donation staff to ensure I was ready. The RT removed the endotracheal tube, and I wiped away the secretions so her family’s final viewing of their loved one would be the best one possible. I held my fingers on her carotid artery, watched the monitor, and waited. “Am I feeling her pulse, or my own? Surely her pulse can’t be 150—definitely feeling my own. Deep breathe, Rebecca; you can do this.” I palpated her weak pulse, and at 12:25, I called time of death as her family held her hand.
With the organ donation process, we have five minutes to transport the patient from PACU to the operating table and auscultate her heart one final time to ensure she does not have a heartbeat. The team literally ran down the hall so that we were within the 5-minute window. As we ran down the hall and family were escorted to the waiting room, her mother shouted, “Dr. Sullivan—thank you.” “Oh, geez—keep it together, Rebecca,” I admonished myself. Within minutes, she lay on the operating table, sterile and draped. There was an attending surgeon, two upper level surgery residents, the surgical staff, and the organ donation staff, all staring expectantly at me. “How much time do I have left?” I asked. The organ donation staff answered, “Thirty seconds ‘til the 5-minute mark.” Feeling all eyes riveted on me, I laid my stethoscope on the sterile towel draped across her chest. “Ten seconds,” the organ donation staff yelled. I heard no heartbeat. “Five minutes.” I announced, “There is no return of heart sounds.” Under two minutes thereafter, the liver was cannulated, and the organ donation process was launched.
I stayed to see her liver removed, then returned to the waiting room to talk with her family. That conversation was brief, but something her mother said will stay with me forever: “Dr. Sullivan, I was so scared when I walked into the PACU, but knowing that you were there made me feel at ease.” Although I felt nervous and incapable during the entire experience, I am thankful that I was able to provide her family with closure and peace. Two months later, I found a letter in my mailbox—both of her kidneys had been transplanted into two deserving patients.
Her name, her memory, will forever be in my heart. During that patient experience, I grew as a person and more importantly, as a physician. As interns, we constantly doubt ourselves, our decisions, and our abilities to be a physician—imposter syndrome at its finest. But we have these experiences that remind us of the impacts we have on our patients’ lives—on their family’s lives: the moments when we put on a brave face and tell the patient the news that no one wants to hear; the moments when we swallow our own fears and insecurities to provide the best care we can for our patients; the supreme moment when we realize that we are indeed, truly capable.