When the Healer Needs to be Healed by Juan Rivera, MD, TAIM Associate Member, UT Southwestern, Irving

Immediately upon laying eyes on Mr. R, I knew he was deathly ill. But, he was smiling ... After carefully examining him and reviewing labs, it was clear to me that he was in full-blown sepsis. He was supposed to be admitted to the MICU, but the unit resident called me, the on-call CCU resident, for assistance with his atrial fibrillation with rapid ventricular response. In retrospect, I am glad she called. He was admitted to the CCU and started on broad-spectrum antibiotics, aggressive fluid resuscitation, and rate control therapy. As the infection took over his body, the blood pressure continued to drop steadily. I started to get nervous. I stepped out of the unit and spoke to his wife. "Mr. R is doing poorly. I don't think ... " She interrupted me and said: "Doctor, I can't lose my husband; He is all I have." I felt an overwhelming sense of pressure and responsibility, but kept my composure. I went back to work on Mr. R, but this time with a heavier load on my shoulders. I whispered under my breath: "You are a third year resident; you can handle this." With restored confidence, I attacked again with IV fluids, inotropes, and finally shocked him out of the abnormal rhythm. Not once, did I think about death.

Despite all my interventions, Mr. R continued to deteriorate. As I stepped out of the room for a second, one of the nurses informed me that he had lost IV access. "I am going to try sticking him again" -- the nurse told me. I replied: "Since he has no visible veins, it will probably take me less time to place a central line." I was able to cannulate his internal jugular. The whole process took me 20 minutes.

Approximately an hour after the central line placement, his oxygen saturation began to drop. What I saw on his post procedure chest xray took me by surprise. His right lung was down. My first reaction was denial. This must be another patient's chest xray. But, Mr. R was almost in respiratory arrest. By the time I decompressed his lung and place a chest tube, he had received three rounds of epinephrine and atropine. It was a long code. Unfortunately after an hour, there was no sign of life. The cardiac arrest team started drifting out of the room one by one. I continued resuscitation efforts until I was almost the only one left in the room. I felt ill.

It was time to confront his wife. Immediately after I told her exactly what had happened, including the complication of the procedure, she threw her arms around me and stood in silence for at least a minute. She never cried. I experienced guilt, anger, disappointment, and powerlessness. That minute seemed like an hour. I didn't know what to say or do. So, I kept quiet. As she finished embracing me, she said "You know ... I knew this was going to happen. He was a very sick man. You did the best you could." But my mind was saying: "No, I didn't." I walked away and went into one of the rounding rooms where I could be alone. I cried. I tried to forgive myself.

I don't know how Mrs. R recognized and felt my anguish; even after my stoic performance. After composing myself, I walked to the CCU entrance. She was waiting for me. She grabbed my hands and closed her eyes. She was quiet for 45 seconds. When she opened her eyes, she was smiling. She told me that she had just prayed for me. She gave me her blessing and told me that she was glad that it was me who took care of her husband. She said "You are going to be a great doctor" She gave me a hug and left.

I tried hard to be the healer and ended up being healed. I still think about the things I didn't do or could have done differently for Mr. R. But, I don't feel sad anymore. Mrs. R reminded me that we, doctors, are human, and as such, we should judge ourselves. My guilt gradually disappeared as we both shared our sadness. My anger dissipated once I accepted my imperfection. The powerlessness vanished once understood that I was not the one making the last call. We are intermediaries between the patient and an entity far greater than all of us. A healer creates a sense of wholeness in another person. I believe Mrs. R did exactly that for me. Her words, even in the context of failure and death, represent the true joy of healing.

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