I awakened to death one morning in my life as an intern. I awoke and found myself standing next to my call bed in the hospital: an A code was called over the intercom and I reacted like reflex.  Where was it? I ran to the room and two residents had already arrived. The intern was giving chest compressions to a dying patient. The man was so brittle with his illness that his ribs broke with the first compression. I took over for the tiring intern, and as I pushed rhythmically, the patient passively vomited blood from his ruptured esophagus. The blood spilled from his mouth, onto the pillow, bed sheets, and floor. I noticed these details as though in a dream: what was real was my counting of the compressions, keeping the rhythm. Soon he was pronounced dead by the senior resident. I stopped pushing the broken chest, took off my gloves, and saw it was time to start rounds on the living patients. He was not one of mine, and in the rush of events, I did not catch his name. I put on my white coat over my scrubs to go and face the living.

Little did I understand, when I first received this physician’s costume, how it would usher me down to the underworld, onto a stage where sickness and death are main actors in the play. What I found within me during the descent was my mother-guilt. With the white coat comes an influence that presses you to provide good care to your patients. I call it mother-guilt,” for it is innate like one’s “mother-wit,” or common sense. It feels inherited, passed on through many generations, like the remembrance of my father in the features of my face.

I became a physician one day in May when, with all my classmates, I recited an ancient Greek oath by Hippocrates “to first do no harm” to my patients. On that sunny day, I did not feel the weight of the mother-guilt that grew heavier when in June I put on the long white coat at Yale-New Haven Hospital. The mother-guilt fears the harm done to patients in your care, even if not done by your hand. The death or decline of my patients began to feel my fault until proven otherwise–no American justice system at work here, but something akin to an ancient indictment for a crime long-forgotten.

My fellow interns have confessed to me this guilt in corners of hallways, when a patient under their care suffers complications. Sometimes it hits you first thing in the morning when you walk onto the floors. The nurse tells you that the patient was transferred to the intensive care unit overnight.  I have to remind myself that it was not due to my care, but because their body is failing them. I have to reason with myself, try talking away the guilt, but it lingers, whispers from hallway corners that you don’t know what you are doing, and are to blame.

The making of a medicine man

The pressure of guilt makes me as aggressive about my patients’ welfare as I’d be if my conscience, my livelihood were in the balance. In such a manner, the professional caregiver is driven to care. The days begin to merge and blur as I work the eighth hour, which becomes the fourteenth hour, which becomes the twenty-sixth hour, which becomes the thirty-fourth. Solace is found in the restroom for a few minutes, or writing patient notes, speaking with a fellow worn intern, or in an empty cafeteria. The distinction between this ancient guilt and the care of my patients–a haze of sleepless work, immersion in the infinity of details, the endless checking of doses and vital signs, and the constant moving of hands over the body–this distinction blurs into a near identification of their body with mine.

From one perspective, this approach is good medicine, for I am not only intellectually processing that the intravenous potassium I order for Mr. Baxter will burn his veins if given too quickly; I also feel my veins burning, and tell the nurse to administer the potassium slowly. Perhaps that is an empathy provoked by guilt and fear, but not sustained by it. It must be sustained by a greater motivation, otherwise short is my stay in medicine.

Certainly I am not alone in this guilt-induced empathy. I’ve had colleagues come to me in nausea, almost in tears, at the decline of their patients, or due to some small oversight.  They do not know how to contain their feelings; meanwhile the needs of other patients call to them.  Once during morning rounds, a patient passed by on a stretcher. A fellow resident clutched her throat. “I feel like my body mimics what my patients have,” she said. “You better not go into oncology,” I replied.

This guilt-empathy, like a fear of perdition, motivates you to get things done for the drug users, the alcoholics, the obstinate, the gluttonous, and the lascivious whose desires have brought on hepatitis, HIV, poorly managed diabetes, morbid obesity, and other consequences of bodily neglect.  That does not matter when they are your patients. You stay the extra hour, draw the blood, and check the chest X-ray before you sign their care over to another resident and leave the floors, satiating the flames that keep you in the hospital.

A story from within and release

Catherine was a heroine addict, prostitute, and a regular on the HIV wards. Rumor was, she’d told a fellow patient that she would milk this admission for all the time that she could. As the weeks passed, she lay in bed in a dark room save for when she would go outside for a smoke. I noticed her growing thinner in the early morning light when I examined her each day. We searched for the cause of her diffuse pains but found none.  Her T-cell count was low enough that something could be brewing, but during her second week we became convinced that she was using her hospital stay to evade the police. Then one morning I looked into her mouth and saw thick white yeast coating her throat. “It hurts to swallow so much I want to jump out of the window,” she whispered to me. In addition to the yeast infection, endoscopic examination diagnosed a herpes flare extending down her throat. We gave her medicated lollipops to suck on as she shambled along the hallway. The next time I took blood from her veins, my attitude was not of doubt or double- guessing. My intent was to get her better, her past be damned.

I emerge from the hospital and squint at the setting sun, and it seems foreign, this sunlight, for I have become accustomed to fluorescence. The last I saw the sun, it was rising on a Thursday, and now Friday is coming to an end. I walk out to my car, and on some days I am at peace. On others, I am swallowing all the small terrors and frustrations of the past ten or fourteen or thirty hours.  I want to sleep, but I also want to release the distillation of black bile collected under my rib cage; otherwise it comes up my throat and tastes metallic, like acid. I have smelled the iodine and the vomit, the shit and the latex gloves, the scent of the sick and the putrescence of infection. I feel deprived of the regeneration found in sitting at Rudy’s, my hole-in-a-wall second home, with a glass of Guinness and much talk around me.

Headed north, I pass East Rock, that traprock rise overlooking the city, and I spy its red heights, green crown, and the memorial tower. I breathe: my ribcage expands, loosening its anxious hold on the black bile in me. The seagulls circle near the sublime East Rock, and in that circling comes a gratefulness and freedom from this mother-guilt for a while–a rest, a simplicity in returning to a quiet home.”

In The Fray Contributor