Practicing medicine is full of firsts: the first time someone calls you “doctor” and the first time a patient thanks you for saving their life. After those moments, you leave the hospital remembering why you went into medicine. You like to help people. Sometimes that means curing or easing someone’s suffering. Sometimes that means helping families cope with terminal conditions. You want to save the world 1 person at a time. And then, of course, there’s the first time you call time of death. I remember every moment leading up to the first time I called time of death. During sign-out that day at a children’s hospital, the senior resident discussed newly admitted patients with me. She breezed through the list and then told me about a patient whose family had requested “Accept Natural Death.” No chest compressions, no cardiac medications, no intubation. The senior resident never mentioned that this patient could die that night, and I did not think to ask. So, I was surprised to receive a call from my intern that this patient had hypoxemia with the maximum amount of oxygen flowing to his lungs. I knew he was going to die that night. I felt inadequate and underprepared. I entered the room as the nurse asked my intern, “Did you call your senior resident?” That “senior” was me. When the nurse saw the patient’s condition worsen, she had called the intern. When the intern saw this child developed cyanosis, she had called me. What I wanted to do was call my family—I needed a reminder to be strong. Instead, I entered the room and introduced myself to an anxious mother. The patient was unresponsive and gasping for air. His oxygen was low and not budging. His systolic blood pressure was 60 mm Hg, barely high enough to squeeze enough blood to his fingers, toes, and brain. The mother thought he was not responding because a new medication for sleep was started the night before. However, I knew this medication should not cause a child with a chronic illness to be unresponsive and have hypoxemia. I explained what each vital sign meant to his mother. I explained that his blood was not getting to his brain, and his body was holding on to dead air. I explained that he was gasping for clean air and that a little bit of morphine would help provide her child more comfort. Then she asked me a question that will haunt me forever: “Is my son going to die tonight?” Chills. Everyone silenced, and the beeping faded away. “It looks as though he may,” I replied. At that moment, the mother understood the severity of her son’s illness, and I felt like I became a physician. The child continued to reach decompensation, and within an hour, I was called to the bedside. I took a deep breath—for myself and for the child—and entered the room. I explained that I was going to do a physical examination. I listened to his empty chest for a full 2 minutes, felt no pulse for a full 2 minutes, attempted to constrict his pupils, and pinched his shoulder blades without eliciting a flinch. Then, I called time of death. I apologized for the family’s loss but could not fathom what they had been through. After that, I took a moment to cry and call my family to tell them I love them. I brought together the nursing staff, respiratory therapists, my intern, and the medical students who had been in the room that evening to debrief. I was deeply sad, and knew I was not alone in this. Together we discussed the patient and made a plan. I filled out the appropriate paperwork and wrote my first death note. Then I asked if the patient’s family wanted to have handprints and footprints of their beloved son. They said yes, so I searched the hospital for the kit. During the day, Child Life specialists take care of these requests, but there is no Child Life at 1:48 AM during the holiday season. I reentered the room with blue ink and paper and respectfully stamped the patient’s hands and feet. I gave this family back a piece of their son after so much had been taken away. As a physician, I felt humbled and disoriented because I did not go into medicine to pronounce people dead, much in the way parents do not have children to watch them die. And, as a person, it made me miss my family. The next day, I left the hospital in tears. I tried to sleep during the day, knowing I had to return later that night and be fully present yet again. My sleep was disrupted by my tears as I awoke from dreams of getting the call over and over from my intern. It also happened to be my birthday, which is just another day in life’s progression, but I felt like I became an adult that day. I continue to reflect on why I felt so underprepared in this situation. People die. This is something that will happen in every person’s life. I have hugged my own grandparents for the last time and brought flowers to freshly dug land and patches of earth that are weathered with time. In those moments, it is OK to feel and reflect on lives lost. After all, feeling is part of the human recipe. And just because we are physicians does not mean we are not human. We feel deeply, and, so we can continue caring for others, must stifle our feelings until there is time to reflect. But, what if we do not find that time, or push it away when it presents itself? Does this environment make us less human or, instead, instill a resilience that makes us better versions of ourselves?

中文翻译：

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医学第一

行医充满了第一次：第一次有人称您为“医生”，患者第一次感谢您挽救了他们的生命。在那一刻之后，你离开医院，回想起你为什么进入医学领域。你喜欢帮助人。有时这意味着治愈或减轻某人的痛苦。有时这意味着帮助家庭应对绝症。你想一次拯救世界 1 个人。然后，当然，这是你第一次称死亡时间。我记得在我第一次调用死亡时间之前的每一刻。那天在儿童医院退房时，老住院医师和我讨论了新入院的病人。她轻而易举地浏览了清单，然后告诉我一位患者的家人要求“接受自然死亡”。没有胸外按压，没有心脏药物，没有插管。老住院医师从来没有提过这个病人当晚可能会死，我也没有想过要问。所以，我很惊讶地接到我的实习生的电话，说这名患者患有低氧血症，最大量的氧气流向他的肺部。我知道他那天晚上就要死了。我觉得自己不够好，准备不足。我走进房间，护士问我的实习生，“你给你的高级住院医生打电话了吗？” 那个“前辈”就是我。当护士看到病人的病情恶化时，她打电话给实习生。当实习生看到这个孩子出现紫绀时，她打电话给我。我想做的是给我的家人打电话——我需要提醒我要坚强。相反，我走进房间，向一位焦虑的母亲介绍了自己。患者反应迟钝，大口喘气。他的氧气很低，没有动静。他的收缩压为 60 毫米汞柱，几乎不足以将足够的血液挤到他的手指、脚趾和大脑。母亲认为他没有反应是因为前一天晚上开始服用一种新的睡眠药物。然而，我知道这种药物不应该导致患有慢性疾病的孩子反应迟钝和低氧血症。我解释了每个生命体征对他母亲的意义。我解释说他的血液没有进入他的大脑，他的身体一直在死气沉沉。我解释说他正在呼吸新鲜空气，一点点吗啡可以帮助她的孩子更加舒适。然后她问了我一个永远困扰我的问题：“我儿子今晚会死吗？” 发冷。所有人都安静了下来，嗡嗡声也渐渐消失了。“看起来他可以，”我回答道。那一刻，这位母亲了解她儿子病的严重性，我觉得自己成为了一名医生。孩子继续失代偿，不到一个小时，我就被叫到床边。我深深地吸了一口气——为我自己也为孩子——然后走进了房间。我解释说我要去体检。我听了他空荡荡的胸膛整整两分钟，整整两分钟都感觉不到脉搏，试图收缩他的瞳孔，捏住他的肩胛骨，没有引起任何退缩。然后，我称之为死亡时间。我为家人的损失道歉，但无法理解他们经历了什么。在那之后，我哭了一会儿，打电话给我的家人，告诉他们我爱他们。我召集了当天晚上在房间里的护理人员、呼吸治疗师、我的实习生和医学生进行汇报。我非常难过，知道我并不孤单。我们一起讨论了病人并制定了计划。我填写了适当的文书工作并写了我的第一个死亡笔记。然后我问病人的家人是否想要他们心爱的儿子的手印和脚印。他们说是的，所以我在医院搜索了试剂盒。白天，Child Life 专家会处理这些请求，但在假期期间的凌晨 1:48 没有 Child Life。我带着蓝墨水和纸重新进入房间，恭敬地在病人的手脚上盖章。在带走了这么多东西之后，我把他们儿子的一部分还给了这个家庭。作为一名医生，我感到谦卑和迷失方向，因为我没有进入医学界宣布人死亡，就像父母没有孩子看着他们死去一样。而且，作为一个人，这让我想念我的家人。第二天，我泪流满面地离开了医院。我试着在白天睡觉，知道我必须在那天晚上晚些时候回来并再次完全存在。当我从一次又一次接到实习生电话的梦中醒来时，我的睡眠被我的眼泪打乱了。也恰好是我的生日，这只是人生进程中的又一天，但那天我感觉自己已经长大了。我继续反思为什么我在这种情况下感到准备不足。人死了。这是每个人生活中都会发生的事情。我最后一次拥抱了自己的祖父母，并把鲜花带到了新开的土地和随时间风化的土地上。在那些时刻，感受和反思失去的生命是可以的。毕竟，感觉是人类食谱的一部分。仅仅因为我们是医生并不意味着我们不是人。我们感触很深，为了继续关心他人，我们必须压抑自己的感受，直到有时间反思。但是，如果我们没有找到那个时间，或者在它出现时将它推开怎么办？这种环境是否让我们变得不那么人性化，或者相反，灌输了一种使我们成为更好的自己的弹性？