Handoffs

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.