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t m c » p u l s e | a u g u s t 2 0 1 7 24 24 Genesis A first-year medical student loses his first patient A n e s s a y b y S r i h a r s h a K a m b a l a Y ou can scrub your hands with soap and water until the force of friction burns the face of your palms, but moments like these never leave you. They become a part of your identity, slivers of memory that become intertwined among the coils of your DNA. You try to wash away any feelings of liability, regret, sorrow, to cope with the pressure. But standing outside of the emergency room, how was I expected to clean away these stains when I could still hear the mother weep- ing from behind thin glass doors. I knew that I would have to face this moment, but I never expected to have to deal with my patient dying as a first-year medical student. I was simply supposed to be shadowing—follow- ing the ER doctor as she covered infants with colds and allayed the concerns of parents. Our biggest task before her shift ended was finding out if one of her patients had received a Holter monitor, a portable device that measures and records the heart's activ- ity. So I wasn't prepared for the complete change in atmosphere when the department received the call. A two-year-old girl was arriving in 10 minutes via ambu- lance. She was in cardiac arrest; her mother noticed her unresponsive and without a pulse in the car ride home from day care. The rapid response team was assembled and the emergency room set up. My preceptor told me I had to be part of this experience, and I was carried into the undercurrent of excitement and optimism that was exuded by the members of the team. Two minutes passed, then five. We were relaxed, laughing, ready. At eight minutes, the jokes died. The glass doors of the loading bay slid open and suddenly the whole floor was depressurized, unstable. I moved to the side, my back against the wall, subcon- sciously put in my place by the gravity of the men carting this small girl into the ER. I was frozen, hyper- aware of how underqualified I was to be in that room. This little girl deserved better. But there is no place for fear in a situation like this. While I was having an internal crisis, a true emergency was progressing before my eyes. She was given a respiratory mask, intubated, EEG leads were placed, and other measures that I didn't yet understand. This team was efficient, a cohesive unit of people who knew their exact roles. I was lost, but these were professionals, men and women made for this moment. They had a protocol and knew what to assess, and I tried my best to follow the commands and conversation of this theater. I picked out phrases: "No signs of life," "No pulse," "She needs her next dose of epinephrine," and "Hey, are you CPR certified?" They were speaking to me. "We need you on this rotation for compressions. Come here and check her axillary pulse, and start compress- ing the moment he stops." Thirty minutes on a CPR dummy didn't qualify me for this, but I had no choice. I stepped onto the stool and started pushing down. Someone had started a metronome on their phone. For the next two minutes that was the only sound I heard. I just tried to fixate on the backs of my hands, too scared to look at the girl's face. But I realized I couldn't even see it. She was turned away from me, her tiny features obscured by her respiratory mask. I followed the metronome beat, up and down, up and down, hoping her heart beat would join this metallic symphony. How could she not be okay? Every push I gave her, she gave back to me. I felt her force on my palms, telling me "I'm here," until my right hand sunk into her chest. The breath trapped in my throat escaped through a gate of clenched teeth. I could only gasp as I realized I had broken her ribs. There was blood on my gloves, her blood on my hands. "Okay we are switching." It was someone else's turn. I could feel sweat running down my back, chill- ing my spine. There was no change on the EEG. We went on and on, cycling, for 45 minutes, hoping that we might see a reflection of our movements on the monitor. Epinephrine, compressions, a quick, hope- ful glance at the screen. Nothing. They defibrillated her once. Epinephrine, compressions, bated breaths. Nothing. All the voices in the room dissipated at once. My shoulders were tired. I couldn't bear the weight of this silence. A pause where 10 people mourned. "Please bring the mother in. It's time to call it." How did they know there was nothing more to do? I don't know. I didn't know a lot of things that day. I didn't know how my legs kept me up when the mother collapsed onto the floor as we told her that her daughter was dead. I didn't know why she didn't blame me for being a failure, for not doing my job. I didn't know why I couldn't cry, my chest so tight I couldn't breathe. I didn't even know what the little girl looked like. I had lost my first patient and I would never recognize her face. I never knew how she smiled or what her voice sounded like. So maybe it was okay that I couldn't wash away this loss. Some moments deserve more dignity than to be cheaply discarded at the first instance of discomfort. The infancy of my medical career cannot become a reflection of this young life lost before her time. Throughout my career I need to keep scrubbing away at the hopelessness I felt in that room, the lack of knowledge and the guilt. To grow in her stead. Every injury healed, a year added to the memory of her life. Every family kept whole, a birthday in her honor. And every patient saved, a grad- uation, a wedding, a celebration of a short life she shared with me. Sriharsha Kambala is a student at Baylor College of Medicine. Credit: Courtesy photo