“I did not know how to reach him, how to catch up with him…The land of tears is so mysterious.”

-Antoine de Saint-Exupery, The Little Prince

 

The scene will be familiar. It will fit into what you’ve already seen in movies: the medical team’s mad hurtle down the long corridor with the patient’s bed, the clinical sharpness of fluorescent lights, the shouting and jerking movements in the name of speed. All of this will signal serious. “He was already coding when he came in” they will say.  “A 15-year-old whose heart stopped at school.” Pay attention to the familiar undertones. Catch a glimpse as he rolls by. The patient is huge, you notice, his body floating in impossible folds. Realize what you thought you read as “lbs.” is actually “kgs.” Try to do the math as the nurses scamper by to grab drugs and supplies.

Everyone around you knows you’re a medical student. For the last two years, you’ve inched your way on the tightrope towards white-coated authority.  For now, you are a diligently reproduced sham. What you lack in clinical knowledge, you compensate for with appropriate attire. Be meticulous. Put on your requisite pressed white coat. Hang your stethoscope around your neck. Cram your pockets full of notes until they sag. Ignore the inconvenient facts: you’re not a doctor but you look like one. You want to help patients, but will settle for watching.

The patient is already in the ICU, attached to a mechanized jungle of tubes, electrodes and sensors.  You ask the physician next to you whether or not they will shock his heart. No, you don’t shock a heart when it’s in asystole, she will say.  This isn’t TV. You feel exposed, and wish to become invisible. You stare into the distance, pretending to be lost in your thoughts.

You have felt like this many times since you started training–like a cardboard marionette dancing to a peculiar tune: acting competent and acting ignorant of your acting.  You’ve accepted this dance as normal. Performance permeates the entire profession. Like all social groups, doctors gain legitimacy from enacting “ritual social dramas.” This ritualization of role – “learning by doing,” a bowtied professor called it during orientation – is both a pedagogical tool and a form of professional affiliation.  You perform the experience of whom you want to become. You try not fight it; you “fake it till you make it.” Find odd jobs to do. Offer pens to higher-ups. Smile. Don’t be so self-conscious, irony won’t help you here. You can ridicule the dance, you tell yourself, but the pull of performance – the tug of the strings, the inexorable drum of theatre – continues.  Sure, you can identify the rhythm. But knowing the rhythm won’t extinguish the pulse.

Back in the ICU you watch the cardiac monitor, oscillating in what you will learn is called “pulseless electrical activity.”  Erratic excitations of signal with no beat. The white noise of the heart. Watch as the team performs CPR – a surrogate pump supplying blood to the boy’s organs. See them sweat; CPR is labor intensive.  Remind yourself that this is real as the nurses transfer their weight through locked elbows, sending ripples through the boy’s flesh. The boy’s chin bobs in almost respectful recognition, yes, yes, yes.  This is real.

With nothing to do, you reflect on your training, on the way you’ve experienced patients’ problems through a cinematic glaze.  You remember how the reels of these stories have unspooled around you, how the scripts have jumbled in your mind. The pageant of standardized empathy –  “how does that make you feel? I’m so sorry;” the scandal of televised medical drama – “the patient was a GOMER.” This is real, remind yourself again, mouthing words like “making a difference” and “human suffering.”  But even these reminders sound mechanical – plot lines handed to you, still detached, not yet yours. You can’t shake the double-consciousness, the simultaneous view from both the stage and the audience.  

Until, suddenly, it’s your turn for compressions.  You feel surprised – “who, me?” – but you try not to show it.  You need to be useful, a part of the team. In waning seconds you comb your memory for a template, a script for CPR, and recall the Bee Gees’ Stayin’ Alive –  a synthesized background music for an artificial heartbeat. Ah, ah, ah, ah. Speculate how many times the song –  the irony of the title only now realized – has played in the heads of med students like you.  Get ready to take your turn. Feel the ribs fracture beneath your fingers. Question your technique.  Listen as the nurse say “good compressions,” and feel proud: you’re doing a good job. Step to the back of the line.  Wonder when you will feel the vicarious PTSD that, you’ve heard, accompanies code blue rib fractures inflicted by ambitious young trainees– a traumatic rite of passage buried in the collective medical unconscious.  Wonder when you’ve joined the club.

You mark time on vital sign monitors as the chest compressions continue – crude, mechanical, anticlimactic.  Wonder, after twenty minutes, if there’s anything else the team can do. It seems primitive, you think, this business of circulating blood with manual labor, and the storyline bizarre. A boy comes to the hospital and is given CPR indefinitely.  Is this the story? Where are the escalations or complications, the foiled solutions and retooled plans? You ask a nurse in pink scrubs if there are more advanced treatments. She explains that outside of CPR and “pressors” – drugs that raise the dangerously low blood pressure – there really isn’t anything else modern medicine can do for a stopped heart. Sometimes, she says, that’s all we have.  

Then you hear a voice – Someone get the parents! – and you sense the plot beginning to shift.

You ask the nurse if this means death is certain, the end close.  She shrugs: if a patient is deemed “high risk,” she says, we often let the family watch. This strikes you as sadistic but she cites studies showing that watching a loved one “get coded” helps the family with long-term closure. It’s preferable to the alternative, she says, and you imagine it: the quiet vigil in the waiting room, the physician’s icy words. Bad news: “We did everything we could,” the doctor will say.  But for some families, seeing is believing.

Listen to them now, in the hallway, coming undone.  You know them by their lines: the mother’s oh my god; the aunt’s wailing on her knees, on her back, bargaining on the floor; the uncle, silent, burly arms crossed, holding his muffled breath. We have been giving CPR for 45 minutes, the senior physician gently explains, and this is when the team would normally discontinue care.  Note that he does not say “give up.” Watch him pause, as if asking permission. The family remains silent. But we can continue for five more minutes at the family’s request.

Five more minutes at the family’s request.  You wonder about this form of medicine – critical care as performance. If this begins long term closure, then the closure is a violent one.  Hear the family’s words grow wetter, their moans longer, almost synchronized. Watch them repeat questions to which which they know the answers.  “There must be something.” They demand treatment, demand that the doctors shock their boy’s heart. Them too! Wonder whether you and the family are reciting the same lines of the same play, finding comfort in resolvable arcs of fiction: the life-threatening experience, the lifeline of skilled hands, the climactic uncertainty, and finally – a life saved, a collective sigh.  A commercial. Don’t chide yourself for your cynicism: your turn is up for CPR.

Five more minutes at the family’s request: a different, smaller performance whose meaning eludes you.  Coarse smoke-and-mirrors: a group of medical professionals thudding on a dead body for show? A symbol of medical exhaustion?  A therapeutic crescendo, a curtain call of everything we could? All of the above? Is this too a form of care– a necessary violence?  If so, then when does it stop? When does a boy turn into a body turn into remains, sanctified, an object of reverence, unfit for continuing care? Not yet. Not merely after the death, but after the family’s ritual.

Watch now as the script shifts, the camera pans, the music slows.  Watch as the narrative of the rescued boy fades into the narrative of the grieving family.   Adapt accordingly. You will find it difficult, not only because of their pain but because their struggle to express it – this perhaps another layer of pain.  Watch them clutch at language. Oh my god and I can’t believe it and how could this happen. They will strain to not repeat themselves but will do it anyway. The uncle will bang his head into the wall, punching his hands. The nurses will help the aunt and mother to their feet, and they will plummet back down.  

You will find yourself, despite yourself, finding these expressions worn out – showy even – like soap opera parts played too vigorously by B-rated actors. As though they are playing the role of a wounded family when that is exactly what they are. You remember reading somewhere that representation not only precedes reality but produces our very perceptions of it. For the parents, this means that grief and the borrowed language of grief run counterpoint.  But what does it mean for you, the would-be healer and spectator of pain? You have no answers, just a painful awareness of your defense mechanisms: comparing life to fiction, demanding eloquence of the grieving. Watch the family restate their grief, stammering repetitions.  Ask why you demand eloquence of the grieving, insist that they transcend the fiction of their own grief with original expressions and authenticating details. Remind yourself that they don’t know how to grieve a lost son any more than you know how to do CPR. Neither of you has done it before.

Look away, avert your gaze.  Find distraction in the uncle’s tattoos: a six-inch eyeball on a hairy chest, a cartoon skeleton riding a red bull. You realize he must have been a teenager when he got them done, letting your mind drift to an image of his younger self, perhaps with cigarettes and a motorcycle. You find the tattoos foolish, and hole up in a guilty comfort – disdain as redirection.  Then you watch as the uncle cries, even with all those ugly tattoos. Listen as he promises the boy that if he comes back, they’ll play video games. He shouts each game they will play. You no longer think of his tattoos.

Watch as the mother asks what she will do with her son’s possessions– a question that has never occurred to you.   A room full of things, she asks, a question for no one, a question for everyone. You pause at this utterly practical question, this break from the script of wounded melodrama. This you’ve never seen before. It is not dramatic grief, or climactic grief, or grief that ends with a bang. Instead it is a pitter patter of anguish that comes on in waves. She starts and stops, stuttering awfully, unable to fathom the astounding transition of her son into merely a body on a table – a body that already, absurdly, has its own needs and requirements. Her son’s absence has not yet set in; but the body lays heavy with demands.  The clean-up, the forms to sign, the coroner to call and the family members to notify. Watch the unsparing responsibility that is already here. Listen to the awkward surprise of logistics that have come too soon.

You watch this family fumble with loss that cannot be scripted, an unraveling that resists repackaging into known quantities. You think of the word indescribable, how people point to their own inarticulateness as proxy. You watch the family’s movements slow, listen as they speak with their silence: wordless, looking downward, painting with negative space. They cannot trace the loss’s circumference or hem its dimensions. Instead, they whisper: a room full of things. Perhaps, you think, the words are provisional. Perhaps, like you, the grieving sometimes meet their words halfway– faking it till they make it.  If they mouth the script, chant the ritual, perhaps the feelings will come rushing out.

Join the mother’s audience, not as a critic but a witness.  Watch her lock her gaze down, down, down to some unknown point on the floor.  Listen to her grief expanding silently among the machines of the ICU, among the expanding and compressing bodies, filling the crevices with a pressure that makes everyone’s skin taut, rigid, until no one can move. No one dares.

Months later you stay awake at night, squeezing that memory for a drop of a lesson, a taste of some distilled moral.  You can’t sleep, can’t study, can’t go on with this doctoring act until you make sense of such barefaced loss. You turn the scenes in your mind – the puffy faces, the screaming – probing their sharp edges to see if you too can bleed. You recognize the vanity in this; this performance for yourself, this stroking thrill of summoning yourself for another’s pain. It is a flexing of a certain type of muscle. But a good muscle! you tell yourself.  You will walk again across some internal stage, throwing the weight of your emotions into some swelling pitch of a final scene. The team’s compressions, the boy’s ribs, the uncle’s video games…until finally, tears.

You will remember the nurse saying that the boy was playing the piccolo flute when his heart stopped. You will wonder why such a big boy chose the smallest instrument in the entire marching band. You will marvel at this triviality, how in any shipwreck only the lightest of remnants seem to float to the surface. You wonder how this remnant retains the power to unhinge you as it does.

You will think again of the family. You will wish to talk to them unmediated, outside of the story of your white coat and the story of their grief. You will wish the cameras had been off, the fictions gone, that you all could have built a shared communion between people who do not yet fully know their parts. You would have sat in the silence of understanding. You would  not have needed to explain how grief makes everyone de facto beginners. You would not have feared performance – that specter of inauthenticity that materializes only when we preemptively ward it off. You wouldn’t have needed to say what you’ve wanted to say ever since: that fiction does not have to mean false any more than scripted has to mean insincere. Sometimes that’s all we have.