Grief, Interrupted

Internship presented me with countless opportunities to worry. The spectrum of concern varied widely, but rest assured there was always something for me to lose sleep about. Looking back, it was often a rather simple question, involving medication doses or routes of administration, but to a newly minted medical graduate everything feels substantial. Of all the dilemmas I faced though, these medication questions soon came to be my favorites. After all, there was usually a concrete answer, and it could be found in a drug database. Just 1 week into my postgraduate training I began to master many of these quandaries, having become quite adept at interpreting drug monographs and searching databases. I began to enter orders with ease and confidence, the latter not nearly justified at that time, but at least I knew how to renally dose antibiotics and make intravenous to oral conversions of many common medications. Despite this rapid growth, however, my worries hardly abated. There was always another terrifying experience looming around the corner, and at this point in my training even the seemingly ‘‘simple’’ things were horrifying. Shortness of breath became the bane of my existence one night, as I froze in terror, heart pounding in my chest, upon seeing an older patient wearing a facemask, perched in a classic ‘‘tripod’’ position to facilitate his respirations. Thankfully, the nurse knew what to do. ‘‘He just received some blood products but did not get any pre-meds. Should I give some Benadryl for a possible transfusion reaction?’’ she asked. Sure, that sounded good to me . . . but what did I know? I had never seen a transfusion reaction before. I ordered up some Benadryl , and sure enough the man got better! What a relief that was, although I felt like I needed an anxiolytic myself, if not a b-blocker for my internship-related situational tachycardia. I had survived what felt like another disaster, a defining moment, and had even learned something new . . . such is all in a typical day’s work as an intern, though I could hardly take credit for it. Still, the proverbial elephant in the room remained: I had yet to see someone die. And of all the horrifying thoughts and worries that being an intern provoked within me, this was by far the worst. Not a day went by that I didn’t think about it, especially since I was rounding on the solid tumor oncology service during that first month. It was inevitable, yet I knew not the day nor the hour. I remember how they tried to teach us about death and dying in medical school. We learned how to facilitate end-oflife conversations by watching a role-play in the auditorium, and then practiced this difficult skill by talking with standardized patient actors. These were paid actors who pretended they had a serious illness, with whom we had to deliver a terminal diagnosis and discuss goals of care. To make matters worse, this was done in front of several of our peers, or was videotaped and later critiqued by them. Much like internship, these exercises were frightening in many ways, but they were also incredibly helpful. Still, they were lacking in a very significant, albeit unavoidable way. Namely, no one could recreate the experience of watching a patient die. There’s no patient simulator for this. Fast-forward to week 2 of internship. It was only my third call night, and I was still terrified each time my pager beeped. Signout time came around, and one by one the other interns stopped by to drop off their patient lists. My anxiety increased with each successive handoff, as I silently counted the number of patients that would be under my care that night. In the end, I was covering nearly the entire floor of the hospital, upwards of 40–50 patients. This alone was enough to make me worry quite a bit, but not nearly as much as what another intern said next. ‘‘Mrs. G is not doing well, and just might die tonight. She’s DNR=DNI,’’ he said, circling this notation in large, black type on the signout sheet. My stomach suddenly sank. I knew this time would come eventually, but this hardly helped me feel any more prepared to face the reality. Even the logistics of ‘‘diagnosing’’ death seemed mysterious to me. Believe it or not, no one ever taught me how to actually ‘‘pronounce’’ a patient dead, and I had certainly never seen it done. So much for the old adage of ‘‘see one, do one, teach one.’’ For me it was more like, ‘‘do one and hope you don’t screw it up.’’ And sure enough, a few hours later I received the dreaded page: ‘‘Doctor, the patient in room 9 looks much worse. I don’t think there’s much time left.’’ A wave of terror rolled over me, and I felt nauseated. The business of the wards came to a standstill, as I contemplated how to face this challenge. ‘‘Thank you, I’ll be there soon,’’ I said, trying to hide the fear in my voice. As a student, I was not only allowed, but mostly expected to ‘‘pass the buck’’ on these difficult issues. It was not my responsibility to be the point person, to communicate with families, or to sign anything official. Now things were different. I was an intern, a ‘‘real doctor.’’ I still felt like an impostor, but was given a great deal of responsibility nonetheless.