It came flooding back to me this spring, as I walked under cherry trees laden with bloom. The word florid — as in “overly ornate, flowery in style or covered in flowers” — popped into my head, but the other meaning, one I hadn’t contemplated for years, crowded in to fill me with dread.

Florid means something sinister in medicine, and something else in nature.

Florid pulmonary edema, lungs filled with fluid, florid sepsis, overwhelming infection. What physician co-opted this poetic word for such horror? Although it has been a long time since the day I encountered back-to-back catastrophes, I still wonder if they took me out of medicine. 

To work at a hospital is to be steeped in tragedy. Nowadays, it’s the sickest, most injured or impaired people who occupy hospital beds, everyone else is an outpatient. There are also grieving loved ones, unacknowledged patients who need care and support too. Doctors and nurses receive little training in how to deal with the emotions that come from life’s saddest moments, particularly their own. I’d argue that repeated exposure to severe illness and raw grief plays a role in what some are calling an epidemic of burnout among our nation’s healthcare providers.

I left my specialty, Emergency Medicine, nine years ago, but I thought of it as more of a pivot than a hard stop. In 2008, I opened a patient advocacy practice to help people navigate serious illness and avoid landing in the emergency room without a plan. For a time, I continued to work ER shifts as well. It might have been too much.

Shortly after opening my consulting practice, I got a frantic call from a woman whose son was in a coma. A man I’ll call Adam had been admitted to the intensive care unit with encephalitis, a brain infection. The ICU nurse whispered to me,  “He’s got florid AIDS too.”

The day we met, Adam’s mother told me their story in one sitting. She admitted it had been a struggle to raise Adam and his sister as a single mother but well worth it. She bragged of Adam’s success in the television industry — he was her pride and joy.

Encephalitis rips through the brain like wildfire, burning vital connections in its wake. For days, Adam thrashed about in a feverish state, not opening his eyes or responding to any commands. His mother stood vigil. If he had awoken, he’d have noticed a photo of the two of them at an award show on the bedside table. He, in a tux with a bright yellow bowtie. She, in a designer gown with an expensive hairdo. They are beaming.

Even though the brain can sometimes regenerate if given a chance, the neurologists began to say out loud that even if he survived, Adam would not be the same after this infection. I obtained a second opinion from an outside neurologist who left the bedside whispering to me, “I don’t think this is going to have a good outcome.”

Grief can take many forms, but for Adam’s mother, it was an unbridled furor. She screamed at the nurses, doctors, and aides who helped turn Adam every hour so he wouldn’t develop bedsores. I also found myself in her crosshairs. She seethed, “Why have I hired you if you can’t fix this?” Since I was also working as an attending physician in the emergency department of our city’s trauma center and had a few shifts the next week, I had an excuse to take a break from the sad scene.

During one shift that week, I was working the trauma rooms when the ambulance came screaming in with a twelve-year-old girl. She was still in her Catholic School uniform, her brown skin unmarred by acne or any other scars of adulthood. Her long, curly hair neatly parted and braided. Her eyes swollen black and blue, with blood pouring from an ear and both nostrils.

“She was hit by a minivan going 35 mph outside her school,” they said while unstrapping her from the stretcher and untangling her IV lines. Nurses began hooking up her breathing tube to a ventilator, a machine like the one keeping Adam alive a few miles to the northwest.

I hear they are doing debriefings now for the doctors, nurses, and trainees after traumatic deaths. We didn’t do those back then.

“Can you squeeze my hand?” I shouted. There was no response. I circled her body, testing reflexes; they were absent. I saw that her blood pressure was sky high 250/160, her pulse, a laconic 54 — all of the symptoms of severe brain swelling.

Before we could finish the CT scan of her brain, her heart rate slowed, and suddenly, her blood pressure dropped. We started CPR in the hallway on the way back to the trauma room. The barrage of medication, chest compressions, and blood products lasted for 30 minutes or more, but it was for nothing. Her pupils widened and fixed in place, a signal that the brain had fired its last impulse. I made the call to stop.

In the sudden quiet, we looked her over with quivering limbs. As we began to clean up after ourselves, a social worker popped her head in to say, “Her parents are in the waiting room.”

The girl’s father, in his work shirt and dirty boots, was texting when we appeared at the doorway. Her mother was on the phone with a relative. She said, “Let me call you back. The doctors are here.” Her husband put his phone in his pocket in slow motion as his eyes scanned our bloody scrubs.  Her mother locked eyes on me, the woman doctor — could she tell I was a mother too?

We said, “Her injuries were too severe, we couldn’t save her.”  Her father exploded from his chair, and his wife let out a primal sound, grabbing the edge of her husband’s shirt and moaning into it. Florid grief. I remember shepherding them toward the trauma room, feeling sick about what they would see, that battered body, only hours from being in a growth spurt — a facsimile of my daughters who were close to her age.

As we huddled around her, someone came in with her CT scan and hung it on a light board. There it was, the soft grey brain with many patches of blood, showing up white on the scan.  Her father looked over at it and rushed over to the gurney to bury his head in the middle of her still-warm body and weep. I glanced at the images and recognized the pattern — a florid intracerebral hemorrhage.

I hear they are doing debriefings now for the doctors, nurses, and trainees after traumatic deaths. We didn’t do those back then.

On my drive home that day, I got an unexpected call from Adam’s mother, she said, “I need you to come back. They’re telling me we have decisions to make.”

When I found her in the Family Room, Adam’s mother looked haggard. Her anger vibrated the air like electrons before a lightning storm.  Before my lips could even form words, she cut me off at the pass, “Do not tell me he’s dying! He’s my everything!”

She let out a sob, her first.

I reviewed Adam’s record, staring unblinkingly at the computer screen image of his chest X-ray.  His lungs were white like a blizzard — no room for air — florid respiratory distress syndrome. When the supervising doctor pronounced a dim outlook, she screamed,  “Do not talk to me about stopping treatment. I will sue this hospital!” 

I’m not proud of it, but I remember thinking, “At least he wasn’t killed by a car at twelve.”

I walked Adam’s mother outside the unit, away from the perked ears of the doctors and nurses.  “Would it help to have a priest come?” I asked. She didn’t answer me; her eyes focused on something I couldn’t see.  A change came over her, and she cried, “I need my daughter here.”

Two days later, under the care of the intensivists, Adam’s ventilator was turned off. He made no attempt to breathe on his own, so his oxygen level plummeted, and his heart rate followed suit. He was gone in twenty minutes. His mother hurried outside to let out a sob.

I stopped taking shifts in the emergency department within the year. I told myself I needed to focus on advocacy and consulting, that I was filling an important niche. Some of the work was emotionally draining, Adam wasn’t the last dying patient on my consulting roster, but at least I wasn’t making the decisions. I told myself I could always go back, and although I passed a once-a-decade recertification test last year and continue to keep my state medical license active, I have not returned.

Lately,  my daughters laugh at my expanding ardor for nature. I’ve taken to walking in the forest behind my house and swimming in the ocean a few days a week. At 53, I’m too young to retire, but I feel too vulnerable to return to the clinical fray. I read about burnout on social media, electronic health records, corporate medicine and societal inequality are blamed. But— I think there’s something more. The other day, a nurse tweeted: “Drinking a bottle of wine for breakfast. I am not coping well with losing a patient last night. I can still hear the screams of the parents, begging us to do more…”

The distance between me and direct patient care is growing, and I feel sad about it. On the other hand, I can’t remember a fruit blossom season like this one. Plums, with perfect white petals and dark wine stamens, laced some streets in my neighborhood with an elaborate fringe. Then came the pomposity of pink cherry trees, so magnificently…florid.

Posted by Jennifer Brokaw

Dr. Jennifer Brokaw worked for fourteen years as a board-certified emergency physician before becoming a private consultant, patient advocate, writer, and speaker on the topics of end-of-life planning, medical decision-making and medical advocacy.

One Comment

  1. I love this post Jen,
    Brings back strong emotional memories from pre-retired days…

    Reply

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