“She’s not alive,” I said woodenly.

“You can write the death note,” the resident told me.

Just then, Mrs. Grassini’s daughters hurried into the room. Guilt flooded my mind as I watched their stricken faces.

“I’m so sorry for your loss,” I said mechanically — and then I burst into tears. Not quiet, discreet sobs, but loud, noisy heaves that filled the room.

“Oh, honey, don’t cry,” one of the daughters said, putting her arm around my shoulders. “She was old and very sick. You made her last days comfortable and pleasant, and we’re so grateful.”

Nodding through tear-filled eyes, I said something inane, and stumbled out of the room. She was my first patient to die, and I’ll never forget her.

Since then, I’ve seen many patients die, for many different reasons. They mostly blur in my mind because death becomes familiar when you see it so often — but not completely; we still need to retain our humanity.

Mrs. Grassini, limp and still, flashes through my mind as we wait for the ambulance to bring in a two-year-old toddler. It’s only been 30 seconds since the call, and we’re scrambling frantically to make the room ready.

“It’s a potential drowning,” the attending says tersely. “Page anesthesiology for someone to intubate, and we’ll begin with chest compressions.”

When the patient comes in, there’s no time to think. It’s all swift and automatic. One of the techs begins chest compressions with his thumbs as I put an oxygen mask on the toddler and begin bagging him, compressing a football-shaped bag to force air into the lungs.

“His oxygen levels are dropping,” the attending says grimly, after the pulse and rhythm check.

The anesthesiologist quickly intubates the tiny form and one of the nurses is calling the ICU.

“I think we have a pulse!” cries the attending, hand pressed firmly on the toddler’s neck over the carotid artery. “No, we’re losing it….”

I take over from the nurse and speak to the staff at the ICU, explaining the situation.

“There was some brief cardiac activity, but the patient keeps coding,” I say. “Do you have any ideas? Anything else we can try?”

“You’re doing all the right things,” I’m told. When the attending sees my face and glances at the monitors, he knows. We all know. We can’t save him.

“I’m going to speak to the parents,” the attending says. “They’ll need to be here.”

The frantic, shell-shocked parents enter the room while we continue our medical care.

“We’ll stop when you’re ready,” the attending says softly to the parents, showing them the numbers on the cardiac monitor, and I know that he’s told them the truth.

Finally, the devastated father looks at us and whispers hoarsely: “Okay, you can stop now.”

We stop, and I step into the hallway, feeling curiously frozen. The other resident, the anesthesiologist, three nurses, and two EMTs crowd nearby. We’re all immobile, just looking at each other, panting from the frantic efforts of the last few minutes, and trying not to listen to the sounds coming from the room we’ve just vacated.

The attending emerges from the room and sees us standing in the hallway.

“Let’s find an empty space and have a debriefing,” he says, and starts searching.

We follow, dazed, until he flings open a door at the end of the corridor. Everyone squeezes into the unoccupied room, sitting on any available surface, as the attending looks at each of us. He doesn’t say it, but we know we need this. A debriefing is usually called by someone in charge after a particularly traumatic episode in the ER. We ensure we made the best decisions, give suggestions for what we could have done better — and also share our thoughts and feelings, to process what we’ve been though.

There’s no real break between patients in the ER, and a particularly tough experience can be distracting. To fully focus on the next patient, sometimes we need to take these moments.

“Does anyone have any thoughts to share?” the attending asks. “I think we did everything we could for that little boy, but I want to hear what you have to say.”

“We really tried,” one of the nurses adds as a tear lands on her scrubs.

“I have three kids,” the other resident tells us, his voice shaking. “It was hard to see that….”

We sit and talk for a little longer, and some of the ice inside begins to melt.

“All right, everyone,” the attending finally says, standing up. “It’s time to get back to work.”

I walk outside, ready for my next case. If there’s one thing I’ve learned here, it’s that a heart can break an infinite number of times, and still be perfectly whole. The pain is there, but the living always comes first.

The characters in this series are composites; all the stories are true.

(Originally featured in Family First, Issue 891)