3 Philadelphia doctors reflect on the patients they’ve lost and the moments that stay with them

This year, in the first Temple Health Writing Contest, 14 doctors and medical students from Temple University Hospital, Fox Chase Cancer Center, and the Lewis Katz School of Medicine submitted entries on this theme: “Moments That Stay With You.” Entries were all reviewed and ranked by Larry R. Kaiser, dean; Douglas R. Reifler, associate dean for student affairs and medical humanities; Naomi Rosenberg, emergency medicine physician; William Greenfield, Board of Visitors member; Dianne Butera, student affairs director; Michael Vitez, narrative medicine director; and Charlotte Sutton, Inquirer health and science editor. Here are the first, second, and third-place essays.

This year is my 10th year at Temple Hospital, where I’m now a pulmonary and critical-care physician. I know every hidden passageway, where to find everything you never knew you’d need, and the code to almost every lock. I’ve spent more time here than I’ve spent in any building in my life. My memories are overlaid upon the curtained patient beds, hushed meeting rooms, and darkened stairwells of every floor.

Much has stayed with me over my time here, the pull of some events still palpable as I walk past the site. Shadows of patients inhabit empty beds, shades only visible to me. Room 620, ICU Room 227, ED Room 11, Procedure Suite 1; these places have ghosts. I remember many of them now only in images that flash by for a few seconds; some sad, some joyous, others terrifying, distracting me for a moment from the task at hand. ICU Room 201 though, is haunted so thoroughly that I often remark to residents as I pass by on rounds, “I remember a patient who died there.” Of course they just stare at me blankly.

>> READ MORE: Temple medical students chronicle 24 hours in Philadelphia’s opioid epidemic at Episcopal Hospital

Eight years ago, when I was a recent graduate of medical school and overconfident in my skills, Room 201 contained a man who looked too well to need intensive care. He was in his early 40s, muscular, and well-groomed. His daughter knocked on his door at home and heard silence behind it, her 911 call saved his life. First responders found him fully dressed and lying on the floor of his kitchen, the remnants of breakfast still on the countertop.

I was tempted by hubris to crack my knuckles as I began the workup of his case. Most ICU patients are older and burdened by serious chronic illness, but this man was young and well, and his diagnosis was simple: pneumonia causing septic shock. The ICU was designed for this: a man who could receive advanced care, recover fully, and walk out the door to go on with a life otherwise cut short. I went to work deploying my skills. To his daughter I expressed my confidence, “I promise you’ll be taking your dad home soon.”

Three days later I rang the bell to the only part of the hospital with a lock for which I don’t know a code, the morgue. My back and shoulders were sore from the day prior, when the man in room 201, for whom I harbored so much confidence, died despite 45 minutes of CPR and every heroic measure available. I needed to know why and I needed to see it for myself. I needed to know what I’d missed, how I had failed this man for whom all seemed assured. Twenty minutes later, the soreness of my muscles was forgotten for the weakness of my knees as his autopsy began.

The pathology team, used to this space, was efficient and upbeat. They joked with me, happy to have a visitor from “upstairs.” To them, he was a corpse. To me, he was a person, a family man whose hand I’d held and whose fever I’d calmed. The images were hard to process. I rooted myself to the floor. What would they find? What had I missed? As the procedure went on, my mind turned over the elements of his care yet again, searching for an answer, a flaw, a mistake. I held back my emotions as they churned upward, threatening tears.

“Goodness.” The pathologist’s comment drew me out of myself and back into the room. I watched as a pair of bright steel forceps withdrew an eight-inch blob of black, coagulated clot from the arteries between the patient’s heart and lungs. “A big pulmonary embolism, I think we found your problem,” he said, with the same tone as a mechanic removing a charred spark plug from under the hood of a car.

I walked in a daze to the patient’s chart, preserved there next to the autopsy table, terrified of what I might find — a record not of what I did, but of what I failed to do. I flipped through the reams of paper, anxiously, but there it was: a clear record of the administration of medication to prevent clots, medicine I’d ordered.

I shambled back to the ICU. I hadn’t failed medically. I’d failed as a doctor. I was guilty of hubris. I believed in my skills, the technology, the team. I believed that I possessed a power no doctor ever has.

Room 201 and its lesson are now tattooed upon my psyche and upon my empathic heart — no weight of prevention undoes uncertainty. I can’t make promises. To this day I feel no relief after this bitter lesson. It weighs on me as I walk by again and again. “I remember a patient who died in 201,” I murmur. I feel the unmoored nausea of this memory, and move on.

Erin Narewski, DO, FCCP, is an assistant professor of pulmonary and critical care medicine at the Lewis Katz School of Medicine at Temple University. Her essay won first prize.

―

I could not shake the feeling that I had stolen Joe’s last words.

I became a zombie to survive my ICU rotation, donning a suit of numb armor to endure and ignore the suffering all around. If I let in just a fraction of that suffering, surely my heart would shatter.

I shuddered to see bodies violated, minds scrambled. These were the necessary indignities we wrought to sustain life in the most critically ill patients. But I also raged at the indignity to me, the junior resident. I had signed up to minister to the sick. I had not understood I would inflict pain on my patients, battling death in room after room. Physically strong unlike my patients, the survival of my psyche felt uncertain.

Joe was not one of the frail, seemingly hopeless patients languishing in our ICU. Earlier that very day, he had been walking to work when he realized something was catastrophically wrong. His detour to the hospital landed him in the ICU in septic shock. Joe’s Achilles’ heel: his gigantic, grotesque legs the size of tree trunks. Verrucous elephantiasis covered every inch of those legs with tiny wart-like projections, providing a nearly infinite surface area, each and every wart a hiding place, a portal of entry for bacteria.

As we worked on Joe, he stared at me with frightened, gentle eyes. Jolted alive with purpose, I was determined to fight for Joe’s life. We sent more tests to find the culprit, added more medicines to support his blood pressure, and more antibiotics to kill the swarming bacteria. All in the hopes he would soon turn the corner. Turn the corner, Joe. I had seen scraps of bodies bounce back from worse. Bodies riddled with cancer, made of nothing but grit, bone, a beating heart, slivers of soul.

It had only been a few short hours since Joe left his house, but the sepsis was ravaging his body, and we needed to decide whether to intubate. I explained to Joe that we could lessen his work of breathing to support his body. “Doc," he asked me, "Do you think this is for the best?” “Yes,” I said, hesitating. Then he turned to the nurse, “Alison, is this what I need now?” “I think so,” she replied. He turned to the respiratory therapist, “Dean, is this the right thing?” “This is what you need now, Joe.”

This is how we steal Joe’s last words.

The next minutes were a whirlwind. The nurse and respiratory therapist hurriedly gathered equipment while the anesthesiologists waltzed in. I urged Joe to call his sister to discuss this critical decision with someone who had known him more than a few hours. These may be the last words she hears you utter. He called to say his doc thought he needed the tube and hung up quickly, such a brief conversation. Isn’t there more you want to say, Joe? Goodbye? I love you?

As the anesthesiologists leaned Joe back for intubation, he and I locked eyes. I held his gaze as I tried to calm him. Somewhere buried in those moments were Joe’s last words. Was it a murmur of assent to the anesthesiologist? Was it a prayer to God?

The ventilator loud, Joe was quiet now. Marinating in multiple antibiotics and medicines to support his blood pressure, there was nothing to do but wait. I kept hoping he was about to swing one of those giant tree legs around the corner, but I knew he was slipping away.

Then it was time for me to leave. Staying past my shift, biting my metaphorical nails wouldn’t save Joe. I trudged home, flooded by the thought of losing this battle, yet aware that my capacity to care had not been extinguished.

When I returned to the ICU in the morning and learned Joe had died, I felt devastated, but not surprised. We cheated him out of some sacred last moment. I fantasized a return to the start of that fateful shift, when I could say plainly, “Joe, you’re dying. Would you like us to call your family so you can spend these last moments with them? Joe, do you have any last words?”

That was eight years and four institutions ago. I now work in palliative care to create opportunities for my patients to say their own last words. I gently nudge, to help others see that time is short and precious. I deeply respect the fear that facing our mortality can engender. Now I hope for a quiet held hand, whispers of love rather than sacred speeches in final moments. I am in awe every day at the human capacity for growth, strife, love, pain, reflection, suffering, grace, and connection at the end. Death dwells with me now, a welcome guest. It distills this, this life.

Molly Collins, M.D., is a palliative care physician at Fox Chase Cancer Center, part of Temple Health. She is the program director of the Hospice and Palliative Medicine Fellowship, training the next generation of palliative care specialists and leaders. She aims to integrate palliative care broadly in medicine. Her essay won second place.

―

To say her prenatal care was spotty would be generous. She had been seen once or twice during the pregnancy and was here in labor, with twins, somewhere in the ballpark of 35 weeks. The readings on the monitor were “non-reassuring.” One of the babies’ heart rate was dropping and it was clear that Mom needed an emergent cesarean section.

I was a third-year medical student in Tennessee and had been working closely with an upper-level ob/gyn resident that week. She was the one who pushed Mom’s stretcher to the operating room; calmly explaining the circumstances and preparing her for what was about to happen. A big part of my life as a medical student was watching how residents and attendings acted and figuring out who I wanted to be like when I would later practice on my own. This resident was one worth emulating.

Once in the operating room, it didn’t take her but a couple minutes to cut the first baby out. She worked calmly but quickly. Baby B, the first one out, looked healthy and responded well for the NICU team working in the corner of the operating room. Baby A didn’t fare as well. As he came out, his chest looked a little off — almost a tad concave if you looked from the right angle. And he was not breathing. The neonatologist quickly left Baby B to focus his attention on Baby A. The resident, well-aware of the fight for life taking place a few steps behind her, continued with the task at hand. She would calmly ask for updates on Baby A without taking her eyes off of Mom. But it wasn’t long before the writing was on the wall.

Baby A wasn’t going to make it. Mom wasn’t conscious since this was an emergency surgery so Dad was left to absorb the news first. The resident finished closing Mom’s abdomen and I watched her, always stoic, calmly take off her surgical attire and exit the operating room. I watched through a window in the door as she dropped to a knee and broke down in tears. This moment was tough to watch but it was special. It was messy and sad but it was so real. I was watching a doctor’s heart break for the injustice, for the unknowable potential, and most of all, for a fellow mom who just lost a child. Then I watched through that little window as the attending lifted up the resident, physically and emotionally, and within a minute or two she regained her composure and the shift went on. She had family to update, notes to write, other patients to see, and worst of all, to tell Mom what happened whenever she woke up from the anesthesia.

Unfortunately, that moment wasn’t entirely unfamiliar to me. I have been there before. Four years earlier my twin boys were born but neither of them made it. When I watched that dad in the operating room receive the news, I stumbled back in time. I knew what he felt in that moment and, maybe worse, I knew what lay ahead for him and his wife. Thankfully we had people step up and walk beside us through our mourning. I don’t know why it matters when others cry with us when we’re broken; I just know that it does. So when I see a doctor mourn the loss of their patient it means a lot to me. Those moments make me feel proud of my profession and thankful for my calling. Everyone wants to celebrate the miracle cases and they should. But I don’t think you deserve to if you’re not willing to hold a hand in the heartbreaks. And, in my experience, holding the hand is more important anyway.

Shane Coughlin is an emergency medicine resident physician at Temple University Hospital. His essay won third place.