“Do you have a stethoscope I can borrow?” the intern asked me.
“Yes!” I said emphatically, reaching for the stethoscope in my white coat pocket that had been untouched during my surgery rotation. Finally, it was my time to shine as a medical student. The prospect of being both helpful and prepared was an exhilarating yet unfamiliar feeling during my third year.
I was a few weeks into my first rotation of medical school and had just started night shifts on the trauma surgery team. Despite my growing aversion to surgery, the desire to see and do as much as possible was still flowing strong. I sought every opportunity to dip my toe in patient care, enlivened by the surfacing feeling of being a physician.
A patient on the trauma floor had died, and they needed a doctor to officially declare his death.
“Have you ever done this before?” the intern asked.
I shook my head, feeling a sense of eagerness to be included.
“Me neither. Why don’t we go together?” He said, already getting up to leave. The attending thanked him for doing this, as it would greatly help the busy team.
As we trekked to the patient’s room through the hollow hospital halls, I started to feel hyper-aware of my heartbeat against my chest. My legs were racing to keep up with the intern, while my brain was processing what would happen. I had not touched a dead body since the cadaver lab during my first few weeks of medical school.
The elevator doors slid open, and a group of nurses hovered around the patient’s room, waiting for us. We stayed just out of sight, hiding behind the curve of the hallway, to prepare ourselves. We pulled up the patient’s information on the computer, and the intern typed a shortcut that created a note template, which laid out everything we needed to check.
“Heartbeat, pulses, pupillary response. Heartbeat, pulses, pupillary response,” the intern repeated under his breath.
He then opened Google and typed into the search bar, ‘How to declare someone dead?’ He scanned the page, looking for a template of what to say while in the room.
‘After performing the assessment, the physician pronounces the time of death.’ As medical students, we have practiced dialogue for countless patient encounters, from disclosing a cancer diagnosis to debunking diet fads. However, we were never taught what to say when we declare a person dead.
We headed into the crowd of nurses, and as I handed the intern my stethoscope, I did not feel so excited to be helpful anymore. I could not look away from the man in the bed, appearing as though he was having an afternoon nap.
‘He is not alive. He is not alive.’ I recited internally as I tried to convince myself of this fact.
“F***, he’s still warm,” the intern muttered to himself. There was comfort in knowing that even the resident shared a similar feeling of disbelief.
After he listened to his heart, we both placed two fingers on either side of the patient’s neck. I looked over at the blank wall, trying to hone my senses to feel any movement under my fingertips. I was trained to identify pulses as a clue toward a patient’s diagnosis — regular or irregular, bounding or thready, normal or delayed. However, I was not prepared to feel no pulse. I was not prepared for the uncanny feeling of stillness under my fingers.
The intern was right; I could still feel the warmth of his neck, wrinkled from age, radiating through the latex gloves. I swept my fingers up, down, left, right and back up. Maybe I was just palpating the wrong location. The intern had moved on to look at the pupils, and I retracted my hand back, accepting the stillness.
“Time of death: 2:03 a.m.”
As we headed back to the computers, the intern asked me to confirm I had not felt a pulse.
“Definitely no pulse,” I responded, trying to reassure him in his new responsibility. As we walked away, I sensed a twinge of discomfort in my stomach. This moment was a vital learning opportunity for me to learn how to approach patient death in the sensitive and compassionate manner it deserves – medically, how to properly check for vital signs and reflexes, empathically, how to pronounce death and inform family members and emotionally, how to process the experience. However, this guidance was lost in the fleeting flow of medicine.
He dialed the phone number of a family member, glancing at the chart to remind himself of the patient’s name. I imagined the sinking feeling of the family member receiving a call from the hospital in the early hours of the morning. The intern introduced himself. He used the empathic statements we learned throughout medical school to deliver bad news. Listening to this, all I could imagine was the family member having to hear the news of her loved one’s death from a stranger, from the resident who happened to be available at his time of death and was asked to complete a task between writing notes to help his team stay afloat.
Was I supposed to grieve?
Was I supposed to feel sad?
Was I supposed to feel nothing?
I never expected my first patient death would be someone who I did not know their name, their condition, or their story. I did not expect to feel nothing.
The intern worked his way down the death note, the same word repeating on the screen, “absent.” From around the corner, I watched the nurses who were crowded near the room start to head in, preparing the patient for when his family came to say goodbye.
We returned to the emergency department, the late-night to early-morning wave of exhaustion hitting. I wanted to fill the silence in the elevator, tell the intern I thought he did a good job and ask him if he was processing the same things I was processing. However, I didn’t know how. The burying of emotions and compartmentalization of challenging patient experiences seem to be the status quo and may even be necessary in the fast-paced environment of the hospital. The need for an efficient healthcare system can be suffocating. A patient’s death becomes a checkbox on a list of duties for the overworked trauma team. There was little room for me to grieve, reflect or feel. In the end, I felt the moment called for silence.
On that brief elevator ride, I became afraid the grueling years of training may cause me to lose sight of the humanism in medicine. I decided to constantly check in with myself to ensure I continue to put human beings and their experiences at the center of my care. I also decided then that, as I move forward in my training, we must create the space for learners to process and decompress their experiences within such an emotionally demanding field.
When we returned to the team room, I slipped the stethoscope back into my white coat pocket, sat down at my computer and continued with my note.
Image credit: Custom artwork provided by the author for this Mosaic in Medicine piece.
Medical Student Contributing Writer
Case Western Reserve University School of Medicine
Shannon Fang is a third-year medical student at Case Western Reserve University School of Medicine and received her undergraduate degree from Duke University. Shannon is interested in pursuing a career in medical education, health humanities, and healthcare advocacy. Outside the hospital, she enjoys playing with her cats, crocheting, and watching college basketball.Shannon Fang is a third-year medical student at Case Western Reserve University School of Medicine and received her undergraduate degree from Duke University. Shannon is interested in pursuing a career in medical education, health humanities, and healthcare advocacy. Outside the hospital, she enjoys playing with her cats, crocheting, and watching college basketball.