Sam Blackman -  In the Eye of the Beholden

 

 

I looked in the usual places. I looked in the lab, and the labor and delivery ward and the operating room. But for me, the images under the microscope were just mostly interesting. The birth of a child, if it's not your child, is not beautiful. Sorry. [audience laughter] In the operating room, I found more brutality than beauty. As a second-year pediatric resident, if there was beauty in medicine, I wasn't seeing it. 

 

After 100-hour work weeks, a kid could craft rose petals and I would just dutifully put some in a vial and note it in the chart. [audience laughter] Don't confuse cute with beauty. Sick kids, even really sick kids, can be cute, but disease is not beauty, and parents of sick kids are not beautiful. Parents of sick kids are terrified. 

 

When you feel that the life of your child is in danger, you want some element of control. What you don't want is a second-year pediatric resident, and you certainly didn't want me at that time. [audience laughter] Because between the crushing fatigue and the constant fear of screwing up and not knowing enough, not only was there no beauty in my life, but I was actually getting uglier, because I would let the frustration and the fear creep in, and sometimes my words would hurt the people that I was there to help. 

 

It turned out that there were moments where I was so ashamed, because for someone who so desperately wanted to be a doctor, I was not being the doctor that I wanted to be. I was not being my best self. Brianna's mother took this to a whole new level. The rage that she felt and that she made the team feel pervaded us on a daily basis. We all knew why. Her child was going to die, and there was nothing that we could do about it. She had the period, worst period, tumor period ever. 

 

She had a diffuse intrinsic pontine glioma, a bastard of a tumor that invades the brainstem. It's inoperable in all situations. You can't touch it with chemo or radiation. It's 100% fatal. And most children die within eight months of diagnosis. Her rage was compounded by the fact that she was a single mother and she was going through this alone. And so, she would wall herself off. She kept the glass door to her room closed, she kept the curtains drawn and the lights off and she wouldn't let us in at all for rounds. She wouldn't even let us to examine Brianna, because what was the point? 

 

And so, we would dutifully hover every morning outside of her room to go over the day's labs and to go over the plan and we would beg to come in, but she would not let us come in. She wouldn't even talk to us or want to hear the treatment plan, except for when she wanted us to use her treatment plan and then we would negotiate. “Substitute herbal tea for water?” “Sure.” “Skip the steroids and blood pressure medicines?” “No.” Coffee enemas? What about coffee enemas?” We had a week-long debate about coffee enemas. It's a thing. And my attending had never heard about coffee enemas. And so, he sent me to go research coffee enemas. 

 

When I came back, he said, “You go into the room and tell her why we can't do daily coffee enemas.” And so, I went into the room. But because I presented both sides of the issues to her, she actually started to let me in, literally let me in. I was the only doctor who could go into the room. Every day, I would sit outside and we'd round as a team, and then I would go into the room, and I would examine Brianna, and I would talk to her about the plan and then I'd come out and communicate with the team. And so, for a few weeks until I went off service, I was exclusively Brianna's doctor. But then, rotations end and teams rotate off and residents change and I went on to the next thing. 

 

About a month later, I was coming home from dinner with my wife on a Saturday night. My pager went off, and it was a nurse from the pavilion, which is the part of the hospital where the palliative care patients stay. The nurse said that she thought that Brianna was dying and wanted to know if I would come in. Now, I wasn't on call or on service, but something told me that I should go. 

 

So, I called my attending on service and I said, would you meet me there, because I've never attended a death before. And believe it or not, attending a death is a lot more complicated. You don't just stand there and wait for the person to die. One of the horrible things that they neglect to tell you at the start of your pediatric residency, is that children take a really long time to die, because they've got brand new hearts and brand-new lungs. Their bodies really try to cling to life. Think about that for a minute and think about what that looks like. 

 

So, it was 10 o'clock at night. And for the next four hours, we did our job. We gave medicines to help her agonal breathing and to alleviate any pain. When we couldn't do any more, we stood by the door and we bore witness. The nurse went in unchecked on her, and came out and said that she thought that Brianna had stopped breathing. The attending physician said to me that I should go and pronounce her dead, because the mom knew me and appeared to trust me. And I said, all right, but I've never done this before. I didn't know what to expect. 

 

So, I quietly went into the room and I said, I need to examine Brianna, one last time. And then, I performed the ritual. I felt for the absence of a pulse. I put my stethoscope on her chest and I listened for a full 60 seconds for the absence of a heartbeat. I said to her mother, “I'm so sorry for your loss,” and I noted silently the time of death. As I was getting ready to leave the room, I turned to her and I said, is there any I can do for you? She paused and said, “Could you pray with me?”

 

I hesitated, because I'm a lapsed Jew from New Jersey, and I don't really pray and I don't really believe in God. And frankly, pretending to pray in the face of a dead child seemed like the absolutely wrong thing to do. But then, there in that moment, it dawned on me that this wasn't about me. Brianna's mother needed me to be the doctor that she saw me as, and this was the opportunity for me to be the doctor that I wanted to be. And so, there in that room, lit just by silent, glowing monitors, I had the one truly beautiful moment for myself in medicine, where a stranger held my hands and we stood over the body of her daughter, and I closed my eyes when she did. 

 

When she started to speak words of a prayer that I had only heard a few times before, somehow came forth, “Our Father, Who art in Heaven, hallowed be Thy name, Thy Kingdom come, Thy will be done on earth as it is in Heaven.” Thank you.