This story is drawn from real experiences. Protecting my patients’ confidentiality is of utmost importance to me; names, details, and timelines have been changed to honor their privacy, and any similarities to actual persons or events are purely coincidental. The emotional truth remains intact.

“You killed our son.”

They didn’t actually say that, of course, but that’s what they meant.

Dear Dr. Dael;

Please be advised that this firm represents the parents of Jonathan M., deceased. This letter serves as formal notice of our client’s intent to pursue a claim for medical malpractice arising out of the medical care and treatment you provided to Jonathan M., which resulted in serious injury and death.

We request that you place your professional liability carrier on notice immediately and preserve all records, notes, and materials related to the care and treatment of Jonathan M. Further communication regarding this matter should be directed to our office.

The echo of those words will be with me forever.

During my Pediatric ICU rotation as a senior resident, I was called to the floor one afternoon for a consult on a gravely ill patient. Jonathan was a young man in his early teens who had recently been diagnosed with leukemia. He’d had a central line placed and had been started on the appropriate chemotherapy regimen. The hematology/oncology team did everything right. Then, just weeks into his treatment, Jonathan began to feel off. Within a couple of hours, his parents became concerned when he developed a high fever and felt woozy.

Jonathan was admitted to a floor dedicated primarily to kids with cancer. His admitting team had asked all the right questions and entered all the right orders. I don’t think anything prepared them for how quickly the afternoon would turn to chaos as a young man’s defenses became overwhelmed by the infection snaking through his blood. Very soon, it all became too clear, and the call went out for the ICU team.

When we arrived, the room was filled with thick darkness. The floor team was already executing a choreographed but uncomfortably urgent dance that, when I saw it, raised the hairs on my neck. Jonathan was already unconscious and in terrible shape when we received report. They got us up to speed—during a fairly routine admitting process for a fever and neutropenia, Jonathan quickly moved from feeling miserable to crashing in front of the ward team. They immediately began aggressive supportive measures to stabilize his blood pressure, which was plummeting in real time. He was receiving fluids and medications to support his cardiovascular system, and the team was preparing to intubate him so they could support his breathing mechanically. Such was the gravity of his condition.

As the ICU team, we took over care from the ward team and quickly decided to move him to the ICU, where we had more resources and a dedicated critical care team. Everything attached was piled onto his bed, and we moved, fast Even as we transported him between floors, he began to worsen. By the time we reached the ICU, some 3 minutes away, it was clear that Jonathan was a very sick little guy.

Alarms rang, lights flashed, and the rumble of many quiet voices filled the space and left no room for anything else. We were a full team. The PICU attending, several PICU fellows, respiratory therapists, and several ICU nurses were all working methodically to save Jonathan. My job as a resident in a room full of ICU specialists was pretty simple: jump in and help with CPR whenever needed and report any noted change in status immediately to the attending and fellows. All these things I did, and with round after round of CPR, the crunching of ribs and the squeak of a hospital bed frame with every compression created a dismal rhythm in my mind.

I wasn’t completely green. The team knew me from a previous rotation, so 20 minutes into the resuscitation, the attending physician asked me if I would go out to the waiting area to update the parents. This wasn’t new to me. Several years into a pediatric residency, I’d already had too many of these conversations with terrified parents. So I agreed, grudgingly.

My memory is vague at this point. I remember how young they looked to have a teenage child. They held hands, fingers interlocked and white from squeezing. I remember too that they were leaning forward on adjacent chairs, but more than that, they leaned on each other, head touching head. Now I think families are witnesses to the efforts undertaken to save their child, but back then, it wasn’t so common. They were alone, in a sterile family room, wondering. Knowing this, I tried to paint a picture of what was happening for their son. I began by explaining that Jonathan was in grave condition. I explained that his heart had stopped beating and that we were providing him chest compressions to help move oxygen to his brain, and to hopefully restart it. I talked about the breathing tube that we’d inserted into his airway to provide him with oxygen and to allow us to breathe for him. I explained that it appeared that Jonathan had developed a sudden, overwhelming infection and that it, and his body’s response, was causing his blood pressure to fall to dangerously low levels, and that we were treating that with antibiotics, supportive meds, and special fluids. Everything that I could think of, I tried to describe. I also told them that we were doing everything that we could do to help him, but his condition was so severe that we weren’t sure we could save him. It was all so…clinical.

After answering a couple of questions and sitting with them for a little bit. I excused myself and went back to the ICU. Jonathan’s picture was not improving at all. I jumped in for another round of chest compressions, and the team worked on him for another 15 or 20 minutes. It was becoming heartbreakingly clear that we would not be able to save Jonathan. The attending asked me to speak to the family again, so I left to find them.

My second, and later third, conversations with the family went about the same as the first. I was somber and truthful; the situation was grave. Each time, I tried to gently warn them that things were not going well and that the outcome would likely not be a good one. I said all the things I needed to say, but none of the things I should have.

The attending called an end to the resuscitation and documented the time of death, a little more than an hour after we met Jonathan. Mom and Dad were invited in to see him and the evidence of our efforts to save him. Typically, the rooms were left largely as they were during the resuscitation efforts so that the parents could see the efforts taken to save their son, but the nurses lovingly cleaned any visible blood from Jonathan to avoid any undue trauma. Everything about this was undue trauma.

As is always the case, with other patients to tend to, and perhaps a need to not think too much about what just transpired, we moved on to other tasks, Soon thoughts of Jonathan were stowed into that memory box every physician opens quickly to store the caustic memories, but tries desperately to close quickly, lest any old ghosts sneak out.

I was forced to open that box nearly a year later when a letter arrived for me in the resident’s office. It was a nondescript-looking envelope, but inside was the message every physician dreads. Jonathan’s parents intended to sue me for the death of their child. I wanted to throw up as the world and the words spun around me.

I read and re-read the letter, sure it was intended for someone else. Realizing it wasn’t a mistake, I quickly moved from shock to anger. How could they blame me? I’d been so kind and supportive to them in their darkest hours. None of it made sense, and I grew to resent them deeply.

I spoke with our risk manager, and she reassured me that letters like this were meant to extend the time to file a lawsuit. She explained that they’d work hard to protect me and deflect any malpractice accusations away from me and toward the hospital. Still, my anger, likely fueled by the deep anxiety of it all, continued to simmer. How could they think I hurt their son? I was part of the team that tried desperately to save him! I didn’t give him his cancer, or his chemo that lowered his immune cells while it tried to fight the bad cells, or the infection that ravaged his young body. Poor me.

While no lawsuit was ever filed against me or the hospital, some 30 years later, thinking of Jonathan and the events of that afternoon still stirs high emotion in me, but it’s a very different feeling. Long gone are feelings of anger at Jonathan’s parents. As a dad, sitting in a coffee shop thinking about that experience, I’m simply filled with deep sadness for Jonathan’s parents. How often do thoughts of their little boy come to mind? Are they mostly happy memories now, or is it just more pain, perhaps dulled by the years?

Three decades later, I’m left with some tough new questions. What do you do with the knowledge that someone probably thinks you’re responsible for the death of their child? How do you manage the realization that somewhere, two parents, when they think of you, likely taste bile? I don’t know if I’ve found the right way to manage that knowledge. I don’t know if there is a “right” way.

Mostly, though, I think about missed opportunities to be a true physician in that moment. Sure, I said all the necessary words, but there were so many words that went unsaid. Words that maybe would have changed that moment from pure terror and absolute grief, into something that truly communicated how much we cared about the boy, and these two young parents. I don’t remember asking a single thing about Jonathan, the kid. Why didn’t I take a moment to ask what his favorite thing in the world was? Did he love to play soccer? Or baseball? Who was his best friend? What did they love to do together as a family before cancer made the world go dark? Why didn’t I try to heal them, even a little bit?

--

Dear Jonathan,

We never met, really. You were already so sick when I first saw you. We tried everything we could to make you better, and I tried hard to make sure your mom and dad knew that. But I wish I’d done more to learn about you, to see the look in their eyes when they talk about you, their precious boy.

I’m sorry I wasn’t brave or present enough back then to know how important that would be for them, and for me. I want you to know, though, how much your parents love you. I could see in their eyes that they’d have given anything in the world to trade places with you that day. I’m certain that not a day goes by for them that they don’t think about you and feel nothing but pure love.

I know now that I could have done so much more, not with the practice of medicine, but as a human being for your mom and dad. What I wouldn’t give for the opportunity to go back in time and just give them a touch, or a hug, or even a word of genuine kindness. I’m so deeply sorry for this.

I hope more than anything, in spite of my human failings that day and the words unsaid, that their memories of you are by far the best ones, and that they bring more smiles than sadness.

Yours,

Dr. Chris

This story is drawn from real experiences. Protecting my patients’ confidentiality is of utmost importance to me; names, details, and timelines have been changed to honor their privacy, and any similarities to actual persons or events are purely coincidental. The emotional truth remains intact.

In pediatrics, you have to be willing to give a lot of yourself to the people you care for. When parents face the fear of the unknown and the stress that comes with that, we want to help. We understand the helplessness they feel when their child is sick. We see their furrowed brows, their silent tears, or hear an edge in their voice; we try our best to help them feel anything other than fear, sometimes with unintended hilarious consequences.

Years ago, I was on service and had completed rounds with the residents when a friend of mine on the surgical team asked if I could give him a hand with a procedure. We chatted about the case as I walked with him to our patient’s room. Baby Elizabeth was around a week old, and she’d been admitted to rule out a condition called Hirschsprung’s Disease. Hirschsprung’s is an abnormality of the nerve cells at the bottom of the intestines. Babies with the condition are missing the nerves that help move poop out of the rectum and through the anus.

In normal humans, when stool enters the bottom part of the rectum, the anus is relaxed by those nerve cells we were hunting for. This allows poop to exit the body. For babies with Hirschsprung’s Disease, the absence of those nerve cells keeps the area right around the anus tight and unable to pass any stool. Over the first few days or weeks of life, these babies retain more and more stool and become increasingly fussy and bloated. It’s a medical emergency and can lead to life-threatening outcomes if left untreated.

My friend needed help with the suction rectal biopsy, a procedure we use to determine whether babies like Elizabeth are missing these essential nerve cells. Suction rectal biopsy is a bedside procedure, but it is often helpful to have an assistant hold the baby, assist with suction control, and serve as a “third hand” for the trickier parts.

We arrived in Baby Elizabeth’s room to find her being held by her mom. Baby Elizabeth had a significantly distended abdomen and was pretty miserably fussy. Mom was similarly distressed. The first week of having a new baby is a tough enough adjustment to life; add an ill baby and sleepless nights, and you’ve got a perfect recipe for high levels of worry. Elizabeth’s mom was wearing all of that stress. You could see it in the tightness of her shoulders as she rocked her baby, and you could hear it in her voice. Between the words, she was pleading for help, for some relief from the burden of it all.

While I moved Elizabeth to the crib, my friend chatted with her mom about the procedure ahead, what the risks and benefits were, and gave her clear expectations for when we’d have the results. He answered all her questions and was kind and reassuring. She was appreciative, but you could tell that she bore the weight of the world on her shoulders and nothing short of a healthy baby would lift it.

Having answered all her questions, we began the procedure. It’s a quick and relatively simple procedure. A small suction tube attached to a gun-like device is inserted through the anus and a few centimeters into the rectum to the area likely to be missing the nerve cells. Once positioned, this special tube uses suction to draw a small amount of rectal lining into its lumen. Then, a small blade integrated into the device can be engaged by the gun’s trigger to slice off a tiny amount of mucosa. With the sample now secured in the device tip, the entire tube is retracted and, voila, you have your specimen—easy peasy.

At one tricky point during our procedure, my friend asked me to move a touch to improve his angle on the device. I shifted around toward the foot of the crib to make room for him.

That’s when it happened.

Remember that tight area of the rectum we talked about? It’s the one causing all of these problems. So here’s the thing: if you insert a device like a suction tube, past the blocked portion, there is no longer a physical barrier to the passage of poo. Nothing is now holding back days’ worth of pressurized, liquid waste.

We knew our mistake even before we felt its consequences. The moment I stepped around the foot of the crib, but before my brain could scream “hit the deck!”, an explosion of poo accompanied by a thunderous slapping fart shot forth from little Elizabeth, and I had no way to escape. Little Elizabeth had become a giant, wet-fart cannon. A jet of liquid baby poo traveling faster than a human can react left her body with such force that it flew six feet in an ever-expanding cone of destruction emanating from innocent little Elizabeth. In pediatrics, it’s called the “Blast Sign,” and on that day, it left nothing but a crime-scene outline of this pediatrician on the wall.

There I stood, covered from head to waist, in, well, waste. It dripped off of me. I slowly removed my poo-covered glasses to see the wide eyes of my friend. They tracked from him over to where Elizabeth’s mom sat. Slowly, her expression shifted from shock and awe toward what can only be described as the beginnings of delight, and then shortly after, pure hysterical laughter. While clumsily apologizing, my buddy started laughing too. All I could do was laugh. I’m not sure, but I think one of the nearby nurses may have said, “Um, doc, you’ve got a little something…” while gesturing her hand in a large circle encompassing pretty much all of me.

Baby Elizabeth did well. She underwent a surgical correction of her abnormal rectal segment. I can only assume she went on with life, perhaps amused by a story her mom still tells about the day she spray-painted her doctor with poo. But can we take a second to recognize my selfless contribution to this family’s well-being? In one moment, I was able to take all the building stress and worry Elizabeth’s mom had been bearing for days and take them away from her. I think her laugh may have been the purest I’ve ever heard.

Not all heroes wear capes, they say. Sometimes they wear poo from head to toe. I set out to help a friend take care of a baby. In the process, I delivered a moment of peace to a mom who deeply deserved a respite. I’m a giver; what can I say?

You’re welcome.

This story is drawn from real experiences. Protecting my patients’ confidentiality is of utmost importance to me; names, details, and timelines have been changed to honor their privacy, and any similarities to actual persons or events are purely coincidental. The emotional truth remains intact.

I think our seafaring ancestors’ hearts must have warmed at the sight of crepuscular rays—the sun bursting through the darkness of the storm clouds to illuminate the horizon ahead. It’s a message from our star to earthly explorers, “I’m still here, brave souls. Keep sailing. Ahead is the life you seek.”

Medical residencies are hard. The hours are long, the stress intolerable, and the stories, especially in pediatrics, sometimes crushing. But it’s not all terrible. There are plenty of joyful moments, and from time to time, a memory of one of those precious moments will flit into my mind like a warming ray of light.

As a young intern, I took care of Nadia, a firecracker of a teenager. Nadia had cystic fibrosis. For kids with CF, secretions become an immovable thick sludge. This, of course, is particularly devastating in the lungs. Over time, the sludge becomes worse, and infections take hold—bad ones—ever more resistant to the antibiotics we have. Back when I trained, kids with cystic fibrosis often didn’t survive the teen years.

Nadia’s disease made her an old soul. In her late teens, she had already been through more and had outlived many of her peers and friends. It’s not surprising, then, that Nadia had an edge to her. She knew her disease well and didn’t suffer fools. Such was I when I met her. My first day on service, I went into Nadia’s room and introduced myself. She wasn’t very talkative, but let me ask the same questions she’d answered a million times before. I asked if I could examine her, and after she consented, I began. When I got to her lung exam, I expected to hear a cacophony of copious crackles, but what I got was far more disturbing: nothing. Each time she took those “deep breaths” that we always ask for, I got absolutely no air movement.

I panicked.

This was not good, and I needed help. I clumsily excused myself and nearly sprinted to find my senior resident. Breathlessly, I explained what I’d heard, or rather hadn’t heard. I feared that Nadia would slip unconscious at any moment. He hastily followed me back to the room. When we arrived, we saw Nadia and her roommate nearly crying with laughter. At my expense, it turns out, Nadia had faked chest movement while holding her breath during my exam. A nineteen-year-old with gallows humor? Why not, I guess. My resident patted me on the back and said, “Welcome to the teen ward.” Finally able to control herself, Nadia let me finish my exam but mentioned my red face several times and wondered aloud whether I was sicker than she was.

We lost Nadia about a year after that: her wit, her crankiness, her ball-busting, and her sheer grit, all gone. But I’m left forever with that tiny moment she gave me, a ray of light streaming through the darkness of the years.

Over time, I became a wiser pediatric resident than that blushing intern. Eventually, as a senior resident, I was the one interns were running to for help. It’s always a bit of a crapshoot when you’re assigned your team during your month as senior on the ward. You can get the local talent show quartet, or you can get the Beatles. The latter was my fortune one month as a senior resident on 3 East, a floor primarily for small kids. That month, my interns and medical students were rock stars.

One night, we had been working hard all evening, but things finally slowed down around 11:00 PM. Karla, one of my stellar interns, was “tucking in the kids”, a euphemism for night rounds, when she appeared at the door with one of our cutest patients, little Javier. He was, for reasons unknown, having a bad night. He probably awoke to realize Mama wasn’t there, and he didn’t like it at all. Karla was bouncing him a bit on her hip and comforting him as best she could. We all tried to soothe him with a mix of baby talk and funny faces, but nothing was working. Then I heard the little radio in our call room start playing “I Can See Clearly Now” by Jimmy Cliff. I turned it up, and Karla started dancing with Javy. Soon, I was dancing; the medical student was dancing. A few nurses heard the ruckus and started dancing with us. And Javy? Almost immediately, he was all smiles, and not long after, back asleep, dreaming of rainbows and sunshine.

I don’t know what happened to Javier, and I haven’t kept up with most of the people in that tiny call room that night. But every so often, when I’m feeling a bit blue, I think about that evening with Javy, and our ragtag, scrub-wearing dance troupe.

Gone are the dark clouds that had me blind.
It’s gonna be a bright, bright sun-shining day.

And just like Javy, a smile lives where a frown once did.

This was often the story. A group of people who love kids coming together to make them better and help them smile again. And always, to do it right, we leaned on each other. The weeks were long, the work exhausting in its complexity and importance, and the stories all too often were devastating. I think we tried to stay on the lookout for signs that it was all becoming too much for our friends. I remember one rainy morning after a brutal call, several residents asked if I wanted to join them for breakfast to regroup a bit. Nothing overt, just a small group giving me a chance to see a different world than the one I’d just survived. Exhausted as I was, I jumped at the opportunity.

We, at first, were complaining about how rough the night had been, but soon a few lighter stories started popping up in the conversation. We made fun of our attending and their various neuroses and compulsions. Then we made fun of our own. We saw people walking outside and guessed at their stories. We laughed enviously as we all wondered what it must be like to be them—to have a life.

I’m an old doc now, and my memories of those days have faded. But some moments are frozen in time, like that morning. How young we were to bear such weight. How delighted we were to be together, bonded by trials too much for young souls. But how much easier it was because we were facing it together. We were envious of those nameless faces with lives, walking outside in the rain. I know we didn’t realize it then, but every storm cloud and especially every ray of light, we were part of a bigger journey—our story. We were young explorers, sailing rough seas toward a horizon afire with crepuscular rays, and calmer seas. And a quiet voice reassured, “You’re still here, brave souls. Keep sailing. This is the life you seek.”

This story is drawn from real experiences. Protecting my patients’ confidentiality is of utmost importance to me; names, details, and timelines have been changed to honor their privacy, and any similarities to actual persons or events are purely coincidental. The emotional truth remains intact.

I am not the smartest doctor. I’m not even close. I’ve met doctors with brains so impressive that I walk away questioning the decision I made some fifty years ago to become a physician. Often they went to far more impressive medical schools than I did. They were members of mysterious societies with Greek names. After tests, talking with them was an exercise in heart-sinking reality as they rattled off with near-perfect memory, nearly every question on the test, many of which you then learn you got wrong. I’m not going to lie, it can suck being around them.

Let me be clear, they’re not assholes…well, most aren’t. They’re generally lovely people, with ginormous brains. They are usually giving and not at all cutthroat. Most don’t need to be. They, through a combination of hard work, discipline, and a ridiculously efficient brain, just plug along and do exceptionally well at almost everything. I wanted to be one of them so badly

My journey was fairly typical for a medical student. In high school and even college, I knocked it out of the park academically. I was a salutatorian in my small high school—my mom still holds that I was robbed of valedictorian—and was, generally, a superstar. College was similar. Classes came very easily to me, and it was there that my love of science really flourished. But more than that, it’s where I developed a deep love of writing and the arts. College made me explore areas foreign to me, and I found great joy in those spaces. I finished college, having completed the honors program, won academic awards in the field of biology, and graduated summa cum laude. I had already been accepted to medical school; I was ready, baby.

For a time, I held my own. I regularly ranked in the top 10 of the anonymized ranking list of freshmen students. Life was moving along pretty much as I’d imagined it. But the days wore on. The volume of information continued at a pace unrealistic for mere mortals. I moved into classes for which college had not really prepared me. Slowly, I saw my ranking drop. Nothing I tried changed that slow, depressing descent into the morass of the middle.

During my third year of medical school and during my clinical rotations with a cratered confidence, I dropped out. A feeling of not being enough for the responsibility of patient lives had been slowly growing, mostly superimposed on the same graph plotting my realization that I wasn’t nearly as smart as I thought I was. I felt continuously embarrassed publicly by unkind attendings, seemingly looking for weakness. I stressed about patients constantly, and if one died, I fully and completely knew in my heart that it was me, Christopher Dael MS3, who had killed her.

I just wasn’t smart enough.

On realizing this, I knew there was only one course of action. I went to the dean’s office, and from a bowed head said, “I need to quit.”

Our dean was one of my favorite people in all of medical school. He was fun, and brilliant, and kind, and, as it turns out, completely oblivious to my existence.

“What was your name again?”

It’s okay, I was part of a very big class, but it did sting a little. Once he had my name, he looked me up on the computer to see how I was doing in classes and rotations.

“You’re doing pretty well. Usually, I hear this from students who are really struggling.”

“I am struggling! I go to the hospital every day, terrified I won’t know something and will hurt someone. I’m constantly ashamed that I can’t answer questions that everyone else seems to know. I live in fear every single day of my life. I just don’t think I’m cut out for this.”

He paused and took me in for a bit. “Let’s do this. Why don’t you take a break?”

“You can’t give me a big enough break. I need a forever break.”

I think he smiled a bit, “Let’s start with a month. Come back to see me, and if you need another month, I’ll give you another month.”

I agreed and left, confident that medical school was over for me. And in an instant, I had no stress, no terror at the thought of humiliation, or worse, killing someone. It was an amazing feeling to have the crushing weight of all that responsibility and self-doubt suddenly lifted from my shoulders.

But a few days in, amid all the heady joy and freedom, a niggling sense of loss began to emerge. I was missing the process of figuring out what was hurting people, what was making them sick. I missed the patients themselves, too. I missed learning about the veteran of WWII sitting on the bed, more interested in telling me about his buddies in the trenches than how the tumor had taken the vision in his left eye. I missed the 63-year-old woman who, in spite of her failing liver, was so excited to be released from the hospital in time for her daughter’s wedding. I missed sharing moments of utter exhaustion with my classmates and laughing together at the bed-head that comes from two hours of nearly useless sleep. I missed it all.

I took my month, but it became one of reflection and self-examination. I realized a few things. I’m never going to be the smartest guy in the room. I will continue to get questions wrong when put on the spot by relentless attending physicians. I won’t be able to divine their personal niche areas of interest, or figure out, “What the hell are you even asking me?” But mainly, I realized I still very much wanted to be a doctor.

I went back to the dean at one month on the dot and, as I’m sure he suspected I would, asked to resume my studies. He was very happy but had one requirement. He wanted me to see one of the most respected faculty members in the department of psychiatry. My heart sank. What might a psychiatrist uncover deep within the murky confines of my mind?

We talked for about an hour. I told him my story, from start to finish. He listened, he asked questions, mainly about what I was feeling in those moments, and what I was feeling now. But he wanted to know so much more. What did I hate about medicine so far? What excited me? Where did I see myself within this great tradition of healers? They were big, meaty questions. And I loved it.

A few weeks later, the letter, which had been sent to the dean, was forwarded to me. I desperately wish I still had it, but I’ll never forget what it said.

“Christopher cares deeply about his patients and bears heavily the responsibilities that come with that. Sometimes these feelings can overwhelm him, much as they have for nearly every physician who came before him, and for those yet to come. But I believe it is this deep and genuine caring he feels for the people in his charge that will make him an outstanding physician, and one we will be proud to have representing this school of medicine for years to come.”

So deep in the grips of self-doubt, no part of me felt I might actually become something extraordinary in medicine. That was for those special few at the top rungs. I was aiming for pleasantly, benignly competent. But here, in a few thoughtful words immortalized in a letter, this old psychiatrist, and the dean before him, gave me an incredible gift, a way forward.

I returned to my training as a third-year medical student, but with a new sense of purpose. I embraced my limitations and crafted a strategy around them. I decided in that moment to focus all my energy on a truly deep understanding of human physiology. I spent all my energies trying to learn and understand how it all should work in this crazy amalgam of mostly water and carbon. I kept asking myself, “What does good look like?” I studied human physiology with a passion. I couldn’t do what the best and brightest around me could. I couldn’t know all the minutiae, so I accepted that I wasn’t always going to look good on rounds; I might even be mocked a bit. But something good started to happen. As my understanding of how the human body should function grew, I began to have increased confidence in speaking up when, by extension, it wasn’t behaving properly. I started to trust what I knew about the body, and speak up when I observed something askew.

This simple plan to focus on what my brain could handle, but always in the context of how the information applied to actual human patients, transformed my medical school experience and clinical rotations. I started to do better. Over time, attending physicians began using phrases like “insightful” and “good mind for medicine” in their evaluations at the end of rotations. I started doing better on exams as well, scoring some of the highest grades I’d ever achieved on standardized tests.

There are great benefits to brilliance, and I’ll always covet that gift. But there is a benefit in working from a place of disadvantage, too. To those of us without the unimaginable capacity to absorb and retain. When forced to do something very hard from within the confines of inescapable limitations, a purity of focus can develop, and from that, something very special in its own right. I spent a career aware of outliers but not obsessed with them. I focused instead on developing a keen, well-honed sense of when something didn’t make sense in the story, the physical exam, or the labs and studies, and I trusted that feeling, even if I didn’t fully understand why. It’s a subtle-sounding shift, but a giant leap psychologically, to take something that doesn’t make sense, and rather than assume the mystery lies in some fault in your knowledge, to instead confidently endeavor to figure out WHY it doesn’t make sense.

I made it through all of that, because a kind dean of students, and an old psychiatrist recognized that something special can be hewn from even the most mundane looking stones. The work may be harder, the approach different, but it may be all the more special because of it.

As I look back on a long career, I’m happy and proud of the work I’ve done and the people I’ve helped. And while it would have been nice to have rare gifts, I wouldn’t trade my journey for anyone else’s. The view I have from the middle of the pack, of a life fighting tooth and nail to become excellent, is pretty special.

This story is drawn from real experiences. Protecting my patients’ confidentiality is of utmost importance to me; names, details, and timelines have been changed to honor their privacy, and any similarities to actual persons or events are purely coincidental. The emotional truth remains intact.

I surveyed her small body clinging to life, and realized in that horrible moment that I had run out of ideas to beat back death. The team looked at me as if to ask, “What’s next, doc?” I had nothing. I was young, well-trained, and probably at the peak of my pediatric knowledge, but I didn’t have an answer for them —or, more importantly, for her.

It was the loneliest moment of my young life.

—

Lucy’s heart held a dark secret. Within one of its chambers, deep within the muscle of the pump itself, a menace was growing—silently. Everything about her childhood was moving just as any loving parent would hope. She was full of joy, loved playing with her best friend, and was obsessed with figure skating. Even at her young age, she showed real promise, and her coaches had high hopes that she might one day become an Olympian. Then one day, in the middle of a practice skate—her breath in the cold air, the turns, the jumps, the laughter—stopped. Her dark secret made its presence known, and Lucy slumped lifelessly to the ice.

Staff at the rink, and her family, immediately began CPR and called 911. Paramedics were mercifully close by and arrived on scene quickly. The actions of people at the rink and the advanced care from the paramedics were successful; Lucy’s heart began beating again. She was transported to the nearest hospital, where the emergency department team began their life-saving work.

--

There are two kinds of days when you’re a physician on call for medical transports. There are the lazy days where almost nothing happens; you spend your hours reading, studying, watching TV, or chatting with the team. Then there are days so terrible, you have a hard time scrubbing them from your mind for years to come. It was one of those days when I met Lucy.

Since her arrival at the ER, Lucy had been in a tug-of-war with death. Since her arrival, Lucy’s team has been battling to maintain a stable heart rate. No matter what they tried, she kept slipping into a fatal heart rhythm. They did everything right. A tube had been placed in Lucy’s airway so that a ventilator could breathe for her. Lines had been placed in her blood vessels so that medications could be administered quickly and with greater effect. They had tried multiple rounds of medications and electrical stimulation shocks. Nothing stuck, so they called our pediatric critical care transport team to pick her up.

We arrived amidst this controlled chaos. I introduced myself to the ER attending, and he gave me a rundown of all they’d tried and what they’d found on an ultrasound of Lucy’s heart. Within the walls, a tumor had been growing and had reached the size of a golf ball. Unimaginably, this tumor had not caused her any symptoms up until that very day when something about it was too much for her heart’s electrical system, and everything stopped. I thanked him, and he moved on to manage his busy ER.

There was no operating on this tumor, no taking it out and sewing her back up. No cocktail of chemotherapy and radiation would save her. Lucy needed to be transported to a hospital that could keep her alive on a complete bypass machine called extracorporeal membrane oxygenation, or ECMO, and hopefully then, find her a new heart.

Our job was simple in concept, but ever so challenging in reality. Stabilize Lucy long enough that we could put her in a helicopter and transport her 10 minutes to a tertiary hospital equipped to care for her. One of the tenets of transport medicine is: never start the transport until the patient can survive it. It might seem like scoop and run is the best thing to do when someone is critically ill, but when all hell breaks loose in an ambulance, or worse, air transport, your chances of saving that patient plummet.

Nothing was working. Everything I tried had the same effect. Lucy’s heart rhythm would stabilize for a few minutes, then return to chaos. We had provided multiple rounds of medications and cardioversion, an electrical stimulation of the heart through the chest wall, to no avail.

Stable...chaos…stable…chaos…stable…chaos…

She was dying.

—

He walked in around 45 minutes after I started working on Lucy. He smiled and introduced himself as Dr. Tanaka, a pediatric cardiologist. His day in the office was done, but as he was leaving, he heard there was a girl with cardiac issues in the local community hospital where he had privileges. So instead of heading for home, he went back to work.

I’d never been more grateful to see someone in my life.

We talked about her history and what I’d been trying up until then. He pursed his lips a bit and shook his head. He knew what I knew. This was going to be a long evening, and very possibly a tragic one. But, he glanced at the telemetry, took his stethoscope from around his neck, and gently placed it on her chest—the cardiologists’ equivalent of rolling up sleeves. After about 30 seconds of quiet listening and contemplation, he suggested a new medication combination. And we were off. We made headway, but the battle still raged. Just when we thought we’d found a stable beat for a tantalizing stretch of time, she’d slip into another fatal rhythm. And so the cycle continued.

Throughout all of this, I would slip away from time to time to update Lucy’s parents. I can’t imagine how hearing the words coming out of my mouth must have made them feel. I shiver to think of it. What I needed them to understand was pretty simple, but exceedingly awful: Lucy will die if she stays at this hospital. Her only hope is to get her to a more advanced children’s hospital. But if I put her on a helicopter now, she’ll likely die in transit. I have to get her to a point where she’s stable enough to fly, but not wait too long and have her die here. I didn’t have to imagine how hearing those words would make them feel—it was written all over their faces, and they screamed it in their sobs.

Dr. Tanaka and I worked on Lucy for two more hours. He was a consummate professional. It’s easy to use words like hero, but I think I have an even more profound respect for the true professional. The pro wakes up one day very early in their journey and realizes something critical: people are going to depend on me, and their very lives might be in my hands. Once that realization hits, the pro does something many won’t: they dedicate their lives to doing the backbreaking work of becoming excellent. They’re not running into a burning building, as admirable as that is, but each morning they’re getting up and striving to be the best they can be at what they do. Day after day after day, they sacrifice much to put in hours of extra learning and practicing and failing and growing, because someday, somewhere, a little girl in an emergency room will desperately need them to be the very best they can be at this thing. It’s a sacred responsibility, and that, goddammit, means something. That was Dr. Tanaka. He could have been home, but instead, he drove the opposite direction to help some guy he’d never met try to save a little girl.

Finally, we got what we needed to move. Lucy’s rhythm stayed stable for ten minutes, and we knew it was now or never. At my call, my fantastic team had Lucy on a gurney and on the move within 90 seconds. I had only a moment to turn to Dr. Tanaka and, with a half smile,

“Thank you for everything.”

He nodded grimly, “Good luck up there.”

We shook hands, and I was off. The helicopter had been in hot standby, and we loaded hot, rotors turning. I put on my headset, looked at the pilot, and said, “Fast.” I probably didn’t need to say anything; he knew, he could see it in our faces.

—

Three days after successfully transferring Lucy to a local children’s hospital, I called the cardiothoracic team to check on her. Despite everything they tried, Lucy had died forty-eight hours after we dropped her off. I could hear in her voice how heavy her heart was.

She broke the short silence, “I don’t know how you guys were able to get her here—it must have been insane.”

“It was, but I had some pretty remarkable people working on her.”

—

As I think back to that day, I have many different emotions. As a parent, I feel deep sadness for Lucy’s parents, who woke up one morning having no idea their lives would be so horribly changed forever—such grief. I also feel angry about a world that can, in a heartbeat, so cruelly steal a Lucy from us.

Perhaps it’s what my brain needs to continue functioning, but I also take a small measure of comfort from that day. In a horrible, terrifying, unthinkable moment, a small transport team and two strangers came together to fight for her. In the end, Lucy was by no means alone. An emergency room team, a transport crew, two air ambulance pilots, and two doctors who’d never met before, went to war for her. Her little life, in that moment, mattered. And for this old doc, Lucy, and the echoes of that day, make up a part of who I am.

One of the things that’s beautiful about life as a pediatrician, and in public health for that matter, is that it’s never challenging to find your purpose. Parents and health insurance and science foes and exhaustion may make you resent your purpose some days, but it’s always there, with a wry smile and a subtle nod.

“It’s the kids, dummy.”

Most will never know the myriad ways you helped keep them healthy and robust, but that’s okay —maybe even better. For some, though, they’ll jump with joy and smile ear-to-ear whenever they see you. They’ll remember the Halloween when they were ill and came to see you, but were met instead by Woody, or Sully, or Jesse, or Mr. Incredible, and they’ll instantly feel better. Some might even take those warm memories to school and think, “That’s what I want to do!” Oof, if you think your purpose makes you misty sometimes now, wait until that conversation happens.

As I wind down a career in pediatrics and public health, I wonder, what could ever replace that meaningful, ever-present companion on the journey? Where will I find my purpose when the career drifts away and I’m just an old guy with a lot of stories?

It occurs to me, maybe telling them is essential. Perhaps it’s a way to pay tribute to all of those tiny faces, staring boldly, defiantly up at me, or the ones timidly peeking at me from behind Mama. Some of those faces are grown now, and have their own kids, and bustling lives. Some have even taken the same steps as I, and found an incredible life caring for children. Some are gone; I remember them, and I still ache. Maybe telling their stories and mine, and the moments of intersection, can be healing?

And there, for a second, I’m pretty sure I see a familiar face looking at me—one with a wry smile, and a subtle nod.

“It’s the stories, dummy.”

—

Thanks for reading. I hope Strong at the Broken Places becomes a small, steady corner of calm and connection whenever you stop by