On Being a Doctor
Empty Pockets
M any of the experiences in our work we smooth and
shape in the retelling like pebbles being polished by
the tides. Some are more valuable for their sharp edges and
the pain and lesson they bring by holding them tight.
I spent part of my residency training at a city Veterans
Hospital. Overnight call meant perpetual motion punctu-
ated by frantic episodes of critical care. On this night we
had done well, and by the time the first “code arrest”
sounded overhead we all had managed to keep our heads
above the tide. We arrived to the medical intensive care
unit, wearing the authority our white coats gave us, to a
bedside now ringed by staff. A trach collar had come loose
and the trach itself unseated, but all had been corrected.
Sorry about the run.
A curtain separated beds in this area of the intensive
care unit, and each curtain had been pulled when the code
was called. I lingered to one side, planning to stay long
enough to see the collar retied. I was jostled by some move-
ment at the adjacent bedside. The next time, it was fol-
lowed by an arm. My name was shouted, and then I was
pulled by my coat sleeve through the curtain to the next
bed. The patient, a young woman of 36, had been admit-
ted by one of the teams earlier that day. Chest pain, they
said. The bedside monitor began to bleat and flash. Her
blood pressure was falling with each systole, and her car-
diac tracing was taking on the jagged, wide, rugged con-
tour that meant it would be a difficult trip.
Her husband and two young daughters, 8 and 3, were
led away from the bedside as the intubation tray was being
opened. Quickly intubated, compressions made obtaining
central access more difficult, but I placed an internal jug-
ular line hoping things would go well enough that it might
be used for a Swan–Ganz catheter. Compressions, fluids,
advanced cardiac life support protocols . . . all the while
cardiac tracing into dysrhythmia. Occasionally, the moni-
tor would only stare blankly asystole, across its screen. And
the blood pressure. Boluses and drips and fluid, nothing
would move the blood pressure. She was only 36. I reached
deeper into algorithms, knowing the next vial off the code
cart would run the answer into her collapsing circulation.
The answer that would also push away the pain growing in
my own stomach. I believe I tried everything, and trusted
each new intervention would be the one. None of it ever
changed the course. Boluses, drips, compressions, bagged
breaths, time, and her heart finally stopped. She was only
36. I silently asked her why. A nurse touched my arm and
said the two words whose weight made my next breath
difficult and whose grip was tight around the pain in my
stomach. “The family.”
They had been taken to the waiting room. It was pale
blue and the row of lights indicated the soda machine was
still empty. My throat was dry. The youngest daughter sat
on Dad’s lap looking at pictures in an outdoors magazine.
The older sat watching her hands rest in her lap. Her
husband’s eyes lifted to me and met mine. I didn’t,
couldn’t, say a word. I took in the breath to begin, and he
knew. The words never meant quite enough, “All we could
. . .” They seemed small, like a string of toy boats against a
stormy sea, “ . . . her heart . . .” I only had to say them,
they would have to live them, “So sorry . . .”
He turned back toward his daughters, a single father,
and they lifted their eyes to his. As he drew the breath to
begin, his eldest daughter knew. Suddenly all alone, she
stood and ran toward us standing at the door. Dad bent
toward her, but she got past him to me. Tears an unbroken
line down her face, she took hold of my coat pocket. She
said words that made 6 years of medical school, residency,
and late nights too numerous wither. “Give mommy more
medicine. She’ll get better, but you have to give her more
medicine, please.” I couldn’t breathe. I had no words, no
gesture. Her dad bent to her, but she wouldn’t let go of my
pocket. He nodded to me, indicating I should go, and as I
did the pocket she held tore.
I drove home, tears making the road focus and unfo-
cus, replaying it all to find the why or how. Ruptured
ventricular wall? Aneurysm? Pulmonary embolus? I
stopped when I realized it didn’t matter. I went home to
my wife, then 33 years old. I took off my coat as she stood
silently watching and put it in the trash. I needed some
time to explain, all I could say was, “That one doesn’t work
anymore.”
Kevan Pickrel, MD
Phoenix, AZ 85020-2450
Requests for Single Reprints: Kevan Pickrel, MD, 9100 N. Second
Street, Suite 221, Phoenix, AZ 85020-2450; e-mail, kpickrel@cox.net.
Ann Intern Med. 2003;139:525.
© 2003 American College of Physicians 525