Circle cut, white gold, solitaire

A 26-year-old female graduate student.

I was recording everything happening in the trauma bay, but my eyes kept wandering from the trauma team to the patient’s left hand. Her engagement ring looked just like mine.

I wrote another line: Pupils fixed and dilated.

Back at the ring. Circle cut, white gold, solitaire.

Abdomen soft and nondistended.

Her hair was the same colour as mine, same texture, same length. We could have been sisters.

FAST* negative.

Who was her fiancé? What was he doing right now? I thought of my own fiancé. Both going about their days, unaware that anything out of the ordinary was going on. Both undeniably real to me.

Extremities cool and mottled. Distal pulses absent bilaterally.

Circle cut, white gold, solitaire.

Time of death: 10:02 am.

My fiancé picked me up from the hospital. I sat in the car and wept for a long time after he went inside the house. My eyes were fixed on the cat in the yard in front of me, but my mind dwelled on the image of the young woman’s left hand.

Circle cut, white gold, solitaire.

I have no idea who she is. I imagine she had a radiant personality, maybe outgoing and inquisitive, someone I would get along with—all my own conjectures because really, I never even saw her conscious. I know nothing of her past, but the ring is something I can latch onto as a window into who she was. Her ring symbolizes the same things as mine: joy, hope, and plans for a future with people she loved.

I question why this case affected me more than others. I think back to a code from the day before, an elderly man who had not survived. I felt anxious during the code, mostly about whether my compressions would be up to scratch. At the beginning of clerkship, that experience would have had a significant emotional effect on me. Now, I efficiently compartmentalized it alongside memories of previous codes and I did not think much about it after leaving the hospital. This skill of compartmentalizing (or perhaps numbing myself to the scenes of human suffering I now routinely witness) that clerkship training imparted to me seems to be selective. Why am I unable to compartmentalize the death of this young woman?

Though medical training seems to teach us to bury our emotions, the automaticity of emotion may make it the greatest source of insight into the unconscious biases guiding our interactions. I think of other patients who lingered in my mind: a woman my mother’s age who passed suddenly with her daughter at the bedside; a resident physician struggling with infertility. I realize now that these people resembled me enough to signify that I, too, am vulnerable to unthinkable tragedy. Not much separated my circumstances from theirs apart from sheer luck.

Looking at this patient’s ring, not only did I imagine myself in her shoes, but I sensed the ripple effects of this patient’s death would be incalculable, like a network of inscrutable tree roots. My unconscious emotions were driven by both how much I saw myself in this patient and how much I perceived her death as a loss to others and to the world, and the ring was a symbol of both. Correspondingly, I observed that the effort and compassion the medical team poured into this young woman seemed to supersede the regular standard of care—an unacknowledged, likely unintentional, emotionally driven disparity.

A ring symbolizes love, togetherness, and hope for the future; it also represents illusory notions of what makes a human being “successful” and “valuable.” I overheard the attending saying, “She’s engaged!” when negotiating an operating room slot. Should that have made a difference?

Perhaps seeing myself in a patient brings to light my own values. It is impossible not to appreciate the incalculable loss of a single life when it so closely resembles my own, the value of which is infinite to me. Seeing features of myself in this patient forced me to confront the magnitude of the loss of her life and prevented me from neatly tucking it away in a memory compartment as I have done so often before.

Any reader who has practised medicine surely knows the feeling of a case hitting too close to home. It is worthwhile to use these moments as opportunities to acknowledge the gravity of the things we experience so regularly and to check in with one another. I am grateful for the resident who pulled me aside after we left the trauma bay to ask if I was okay, and to share that she, too, was struggling. She gave me permission to experience what were normal feelings of shock, grief, and empathy.

I wrestle with the guilt of having variability in my emotions, but I believe that it is not necessarily a moral failing to have different internal responses to patients. Although I cannot always control my emotions, I do have agency over what I do with these feelings, and the strong emotions elicited by certain patients can be used to fuel compassion in all the care I provide.

I am sure the image of this patient’s ring, and the feelings it evoked within me, will stay with me as a reminder for many years to come; a reminder to practice empathy with all patients, to acknowledge and learn from the emotions that arise, and to support my colleagues in doing the same.

Circle cut, white gold, solitaire.

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