Medical students occupy an emotionally vulnerable position, caught between the healthcare team and the public. While we observe and assist the team, the limitations of our role means that we sometimes feel like we inhabit an in-between space, not completely outsiders, but not in the treatment team.  But that space does not mean we are disconnected from the patients and their outcomes, sometimes we are closer to the patients than the team can be. 

As we are thrust into positions of high emotion we need the tools to deal with experiences that can be overwhelming, especially the first time. I wrote this reflection as my own way of processing my time on Intensive Care, I hope it helps you when you encounter similar situations. 

I also recommend this article by Atul Gawande, who writes eloquently on his perspective of embracing death as part of the natural order of medicine and the health worker’s role.

I saw someone die tonight. I watched their final moments as their heart rate slowed, their blood pressure fell until it was no longer perfuming their brain, their organs or their heart. They kept breathing, they were on a ventilator and the machine whirred on, oblivious.

I am in the ICU and this is the first time I have been party to someone’s final moments of life. I feel like an invader. I met the patient’s mother and fiancée just hours ago, laughed with them and held their hands. I only truly know the patient as the man in bed 3, with the interesting pathology and comorbidities that have complicated his care for weeks now. I feel ashamed to be standing here with his family, feeling my own grief for this man. I don’t feel like I deserve to grieve him, but in sharing these moments with him and his family, I feel such keen loss.

I have spent most of the last 14 hours with Stephen* or his mother and her best friend. They have waited for much of the day while we ran tests and imaging to try determine why his illness was resistant to all of our treatments. 

Stephen had been a patient for weeks in the ICU before I arrived, being the sickest patient there, I developed a keen interest in his care. As a medical student, the nurses and doctors don’t expect me to stay long into the afternoon - I have study to do. But today, something didn’t seem right and I wanted to see what Stephen’s testing would reveal, so I decided to stay a bit later while his scans were reported and test results came in. 

The results come back - Stephen has a massive pulmonary embolism. The consultant discussed treatment options with the family, he was already at high risk of bleeding, we could try to prevent the clot from growing or we could attempt to bust the clot into tiny pieces. Together they decide that the more conservative option is better. I do my best to be helpful, I ask the family if I can explain anything about what’s going on? I tell them about the vital signs and some of the drugs Stephen is being given. Their eyes flick back and forth from his face to his vital signs on the monitor. The numbers are displayed in aggressive colours, which usually I appreciate to help me distinguish between them quickly but tonight it all seems garish.

The day team handover and leave, the night registrar begins, again I decide to stay a bit longer. I help with procedures on some other patients but can’t help coming back to Stephen and his family in every quieter moment. Sometimes a new family member arrives and I am able to explain something or point out the right person to ask.

The conservative treatment isn’t working, his body requires more and more drugs to support his blood pressure and heart. The family discusses and decides that in this case the risk is worth it, we should try to bust the clot and remove the obstruction.

The first half of the dose is delivered, we wait 10 minutes to see any effect on his vital signs but they just don’t budge. They continue to grow weaker. The second half is given and we watch patiently together. I find myself cheering for Stephen and his heart to find the strength, to beat the thrombus and battle on. His family hold both hands and whisper quietly and shout out to him, that he just needs to hold on a few moments more. But he doesn’t. His vitals continue to weaken and the consultant agrees with the family that anything more is simply punishment. We stop increasing his blood pressure medications to maintain perfusion. His family continues to watch his blood pressure, disbelieving as there is no movie moment, no miraculous jump. Over the next half hour Stephen becomes more pale until finally he is completely devoid of colour.

There is a pause. The monitors all say nothing. His family are stunned. Somehow we all believed that Stephen, who had survived the last month of ICU, was going to turn the corner at any moment. Then they all started crying and I found myself caught. I felt this terrible connection to him and his family and party to this moment, but I wasn’t part of it. I didn’t feel like I was truly part of the healthcare team, so I didn’t have the tough outer shell the staff all seemed to have with professional distance. I was simply a stranger who had become caught up in the final moments of their loved one, but had been trusted to share these moments.

I help Stephen’s night nurse with removing the most obvious IV lines, breathing tubes and straighten his body on the bed and put a nice clean sheet over his legs and chest. Together we have made him appear far more relaxed and comfortable. In reality, the sedatives and other pain relief in his bloodstream mean he was always comfortable.

I excuse myself and let the staff know I am finally heading home for the night. It is 11pm, I have been here for 15 hours.

I was simply a stranger who had become caught up in the final moments of their loved one - 

Harry Copeland

I return to the ICU the next morning, the night registrar sees me and asks how I am. I’ve only been away for 8 hours. The resident enters at the same time as me and asks where Stephen is (he has been a fixture of the ward for weeks now). The night registrar simply says “he died last night.” The resident looks disappointed and sad, he might really have believed Stephen could pull through. The registrar adds, “Harry was there for it all, left around 11pm.” Then he paused, looked over at me and said, “oh shit, have you ever seen someone die before? Do you want to talk about it? There are lots of other people too if you don’t want to talk to me.”

I have seen patients who have died recently, but I have never seen anyone die in front of me. I tell him I am ok and I don’t need to talk about it, that I am better for having been there through the whole process rather than discovering the death of Stephen this morning as the resident did. The registrar is reassured and seems at least a little relieved I don’t need a long debrief or good cry. While I think it is true that I was better off for having stayed with Stephen the night before, as I look back I certainly could have benefited from debriefing with the night registrar. I would have liked to ask them what they thought of his death and how it affected them or what they did when a patient they had bonded with didn’t progress as hoped.  

We begin the handover of his other patients and their progress through the night. Then I round with the day team. Barely anyone mentions Stephen. At one point someone asks what happened. “Pulmonary embolism” is the answer. It seems woefully inadequate to describe yesterday to me.

Four days later, I am doing a simulated patient case and am running a code. The patient is a plastic manikin, although it is highly advanced and can make heart and lung sounds and can have drips inserted. It represents a 75 year old man with a massive GI bleed. I am in the zone, trying my best to coordinate my team of five other final year students to save this manikin’s plastic life while our supervisor throws curveballs at us.

Her curveball is that he has made no end of life plans. Just now his plastic wife has arrived in the corridor outside and I do my best to explain the situation and ask her what she thinks her husband would have wanted. Immediately I am back in the ICU, talking with Stephen’s mother and fiancée about what Stephen would want. I look back over at my team and for a moment I swear that instead of all working on a plastic manikin they are putting drips into and performing CPR on Stephen. I lose my train of thought and the fake wife looks at me while I try to shake this off and get back into the scenario.

I struggle through and several more times I find myself unable to divorce the simulation from the events of this week. To seperate myself from Stephen’s death.

Before this week, I had believed that it didn’t matter so much that medical students barely ever discuss death or receive coaching on how to deal with it. I believed that as a medical student I wasn’t responsible for the treatment decisions, I didn’t have to talk to the family before or afterward— I believed that because of this I wouldn’t be affected.

But I think I might be more vulnerable than the healthcare team I will eventually join. Right now I haven’t developed any of their experience with death. I don’t have any professional distance. I am simply a stranger who has been allowed into the room as an entire family grieves. But I cannot grieve with them. 

*Name of patient changed for privacy

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