Midnight Breakfast

Issue 10


Notes on That Space in Your Chest

by Eric Tran

No one knew the first man I saw die. Revision: No one knew his name, but many of us had seen him before. While he was rushed into a room for CPR and epinephrine, those of us who couldn’t help or fit into the crowded room gathered in the main computer hub. A nurse yelled, “What’s his name?” The patient was unconscious, and multiple nurses attested to having seen him before, a few times actually, but no one remembered his name. Usually, in spite of HIPAA, someone would mention something about a patient’s last visit to the Emergency Department, but no one even knew that.

I had just turned twenty and was a volunteer at the Emergency Department in my hometown, twenty minutes from where I went to college. My duties were ostensibly to improve patients’ comfort in whatever way I could, which was usually limited to blankets or Styrofoam cups of water if they were allowed it. I got the position through my school’s pre-med organization, which aimed to give aspiring doctors clinical experience before we applied to medical school, to show us how we could make real changes in people’s lives. But even those of us in the program saw that the mission was as thin as gauze; when we asked patients what made them more comfortable, the answer was never a blanket. Even when I went rogue on the volunteering guidelines by interpreting small bouts of Vietnamese, my presence hardly seemed worth the real estate.

That night of the patient’s death, I was shadowing John, the ED’s intern. He was closer to my age than the usual attending physicians and was more forthright about his experience with the training process—how much sleep he was getting, what useless extracurricular activities he felt like he had to add to his CV. When the paramedics rushed the patient in on a stretcher, John handed me his stethoscope so he could jump onto the side of the gurney and start CPR. I wrapped the stethoscope around my neck as I watched him, surprised both at how proud I felt of him and how comforted I was by the stethoscope’s plastic on the skin of my neck, how its slight weight held me down.

It took less than a handful of minutes for the action in the patient’s room to end. Then the horde of nurses and the attending physician filed out of the room, leaving behind a police officer, who snapped pictures of the patient like a paparazzo; a nurse’s assistant, who pushed a cart out of the room; and John, who waved me over to the bedside.

“So what’s next with this patient?” I asked.

John’s smile slid off his face. “Eric,” he said. His voice was softer than I had ever heard used in the ED. “He’s dead.”

I knew that I should have felt something then, but I didn’t know what—this wasn’t a situation anyone had prepared me for. I didn’t know what to look at. It seemed rude to look directly at the patient like he was some museum exhibit, but I knew there was something I was supposed to see. Was it the way his tan skin still looked alive and warm? The wiry hair on his neck? I settled on his wrist, where someone had attached a white paper ID, blank where the name was supposed to be. I didn’t have any particular feeling, but I had a space in my chest, a cavity where one belonged.

John must have understood something, because he spoke up after a few moments. “Let’s go.” He pulled at my arm unnecessarily. As we left the room, two nurses re-entered.

“I still can’t remember his name,” one of them said to the other.

“I know,” the other replied. “He’s come in so often. He was always so nice, so sweet.”

The volunteer organization was run entirely by its own members, most of us barely old enough to vote and hardly any of us old enough to drink. Fewer still understood the professional medical world, much less how to talk about it. Our med-student advisor would chime in with tips about studying for the MCATs or taking a year off to “explore ourselves” before med school, and an advising physician came in once in a while to give us speeches meant to scare us off the med-school track. For the most part, the program felt like a group of near-sighted people trying to describe to other myopics what trees in the distance looked like, what path to take through the woods.

Maybe to compensate for our lack of expertise or insight, we imposed strict and arbitrary rules on ourselves. We spoke of professionalism using flaccid definitions clipped from the dictionary: clean scrubs, conservative hair, no fragrances—things that were no-brainers. But also other things for which we had no empirical or logical proof of usefulness, just blind hope that it’d help us get by in the ED: be unassuming, be quiet, take up as little space as possible. Ask questions if they come to you, but not so many that it disrupts anyone’s work.

One of our biggest rules was to never touch patients. Our hospital volunteer coordinator emphasized this, right after she taught us how to disinfect our hands—two rounds of singing “Happy Birthday” in an operatic style. The rule started because the hospital couldn’t insure us, but it morphed into a noli me tangere situation: do not touch the patient, do not even breathe the patient’s air, for you will cause harm.

The physical distance inevitably morphed into an emotional one—from the patients, whom we spied from behind the attending or whose facsimiles we reconstructed from medical records, but also from the experience of being there at all. We were required to keep journals to track our thoughts about working in the ED, but sample topics focused on how the shift had informed our understanding of the profession, what skills we learned from our physicians, in what ways patients were helped by the system—nothing that ever felt representative of seeing skin split open or sewn back together. The process felt like the writing equivalent of the way we were to stand while shadowing: unassuming, inoffensive, hands clasped behind our backs. The result was the same: a practice in seeing and not understanding.

At first, I swore to approach the journals as a serious writing project outside of the prompts, a chance to practice an art I never seemed to have time for. But entries sat unfinished in favor of finishing required shifts each month, and to catch up, more and more of them relied heavily on the neutral, inauthentic reverence I knew was expected and easily palatable. The leaders of the organization were supposed to read our journals and provide feedback, but as students, they kept the same schedule as the rest of us and were too busy to do much. Mostly it felt like sending my thoughts and questions into a void.

The few notes I got back over the years struck the same tone regardless of the entry’s content—Yes, it is important to consider office environment for future employment or maybe just Thank you for sharing. A small part of me felt snubbed, but mostly I accepted the compromise on both of our sides, the role we each played in that clumsy choreography, how we each committed to the steps to convince the other that we cared.

I didn’t tell John about the volunteering organization. For all he knew, I was just an independent volunteer. For all he knew, there were no strange extra-hospital rules that I was supposed to follow, no twisted sense of how I was supposed to feel.

During a late-night lunch break—which the organization rather sternly discouraged—John asked me if I was okay. “I don’t know,” I said. Watching medical students and residents being quizzed by the attendings—once I was asked the signs of a heart attack and stumbled until the attending sighed, “Chest pain”—I had learned that it was important to admit what you didn’t know, rather than trying to come up with something that sounded right.

With the other doctors, I would have let the matter drop and hoped they wouldn’t ask me follow-up questions. But with John, I felt comfortable enough to ask a question of my own: How did he feel about it?

He pursed his lips and went quiet, like he hadn’t considered his stance on the issue before. It wouldn’t surprise me if he hadn’t had the time. Interns’ schedules are brutal; they clock over a hundred hours a week in some fields. It would make sense that to work through all the tasks, much less the emotionally taxing ones, you would have to just barrel forward without pausing to reflect, that you would have to reserve all energy for keeping your skin thick and focusing on the next immediate problem.

“I think of it as my job,” he said, as the elevator rose to the cafeteria floor. My shifts in the ED had never involved such confined, private spaces, away from hustle or someone else asking for something. “When I leave the hospital, I go back to my wife and kid.”

I had never considered that John might have a family or even an identity outside the hospital. Until that moment, he and all the hospital staff only existed to me in the hospital, an absurd belief buoyed in part by rules that implied that I shouldn’t ask about the staff’s personal life.

In some ways, the divide between personal and professional made sense. John wanted to protect what parts of his life he could from the scalloped wounds he saw each day, the stress and worry of was this meningitis or was it not, the frustration of seeing a family without insurance resort to the hours-long wait in the ED for cough medicine. It was a practice of sustainability.

But as the word practice implies, the technique is never perfected, never achieves what we know it can and should. John could shield himself from the repercussions of this man’s death, but there were other things that slipped through the cracks, which he may have taken care to avoid mentioning. “You should ask the nurses and other doctors about what they feel,” he said.

This didn’t feel like a brush-off, a sly request to take my badgering elsewhere. It was a sincere direction toward more resources. I had never asked any of the staff what bothered them about working where they did—it seemed unfair to ask people to struggle with moral issues when they were struggling with work already. But after John suggested it, I realized the invincible, unshakable ED staff sometimes unintentionally revealed their vulnerabilities.

Earlier that month, the EMTs had wheeled a gurney into the ED. The nurses surrounded it as it entered the trauma-bay doors, and even my attending at the time, a calm but charismatic woman who gave me her personal password so I could work with patients’ charts, jumped out of her seat. I didn’t understand at first. The stretcher was completely empty. I couldn’t see even the patient’s head or feet in the mass of personnel.

But then, during a brief moment when someone ran off to get more equipment, it became clear. The patient was tiny, dwarfed by the size of the orange stretcher. A baby.

I didn’t position myself in the room behind the attending as I usually did. I gave the room a wide berth to accommodate all the people swarming in and out with various tubes and bags. I didn’t even know or understand what was wrong. All I saw was my physician placing a mask over the baby’s mouth and attaching a suction pump. She squeezed on the pump for a minute or two, until the baby started to aspirate thick white liquid. Milk. The baby had choked on milk.

The situation de-escalated quickly from there, and we soon sat back at the computer station. “Man,” the doctor said, slumping into her chair. “I can never get over the baby stuff.”

We never learned the baby’s name—all the nurses and physicians just referred to the patient as “the baby.” Sometimes it was meant affectionately, but it betrayed a fear, an obsession: a baby almost died.

It’s hard for me to admit that the baby didn’t shake me as much as it shook the other staff, nor had seeing my first death with John. Those moments should be the obvious ones where it’s acceptable to let the professional veneer crack, right? But the death that affected me most wasn’t even really a death. It was the preparation for one, a moment removed in time and space from the event itself.

It happened when I was called in to help interpret for one of my favorite attendings. I hadn’t seen the patient; he was asleep before I started my shift. To be honest, I hadn’t known he was there at all. I didn’t talk with him but with his son, who looked like my father: similar height and age, wisps of white hair at his temples, tan skin from working outside. The patient’s family—his daughter, his son, and the son’s wife, all middle-aged—only spoke Vietnamese. Though I didn’t know why the patient was there, the doctor told me what I needed to tell the family: their father was going to die soon.

My family didn’t talk a lot about death growing up. No one I knew well had ever died, and I never imagined that any of them would. So I never learned the words to frame the idea, to speak it into my life, much less in a delicate manner. I didn’t know how to say “pass away” or “it doesn’t look good” or even “I’m sorry for your loss”—only the clipped versions, the way my family talked about celebrity deaths or the detached, philosophical death that comes for us all.

But as inadequate as those words were, they were all I had. They tumbled out of my mouth like rocks—sharp, uneven. “He’s going to die, probably.”

“They’ve told us that before,” the son said. “But he always walked out of the hospital.”

I told this to the doctor, who just shrugged and repeated that the patient was very close to dying. He could have mentioned test results or physical exams, but I wouldn’t have understood the meaning of any of it in either Vietnamese or English, let alone known how to pass them on to someone else.

“Uncle,” I tried again, remembering to be polite, “he’s going to die.” I nodded, inexplicably, as if that lent my words authority.

“When?” he asked.

The doctor looked stony, told me that the timeline was unclear—it could be hours, that night, tomorrow. The attending was one of my favorites because he always schemed ways for me to get out early, to practice things like splinting and bandaging. He didn’t mean to be so curt or unreadable—none of us there did, really.

I didn’t know how to express uncertainty other than saying, “I don’t know,” which I did say, before correcting myself—“No, no, soon. Soon.” The son looked at me quietly, like he was deciding whether or not this was worth a fight, if he wanted to know why this time was different.

The man’s father didn’t pass during my shift, and I never found out whether he walked out of the department like he had allegedly done before. John was mostly right about having to leave your shift to continue your personal and professional life: I didn’t even think to ask about the patient during my next shift.

But mostly right isn’t completely right. For a while after, I looked at my dad and thought of the patient’s son. I wondered if I could ever tell my dad something of the same seriousness, if I could learn to be gentler.

I never asked John what his weak point was, what kept him up, what he could never unsee or think about again. And despite his encouragement, I never asked other physicians in that ED. In the end, it seemed a disservice to them, to have to think about what they didn’t want to think about while doing things so difficult to contend with. Why should we bring to light the things we need to keep in the shadows?

After John left his shift, just hours after the patient with no name died, I helped interpret for an elderly Vietnamese woman who was taken to the ED after a fall. She needed to consent to have a procedure done, but she insisted that her daughter come help her make a decision. The attending wanted to pressure her into agreeing, entirely out of benevolence: the consulting department was going to be switching to a small, slower shift soon, and she was less likely to get care in a timely manner if she waited. But in a rare fit of bravery, I stood by the patient and repeated that she needed her daughter.

I’d like to say I was acting as an advocate for fair patient care, but in truth, I took more care because the woman reminded me of my grandma. They had the same close-shaven white hair. When I spent the night at my grandma’s—a two-bedroom upstairs apartment that housed six of my family members at once—I would watch her buzz her hair every week until her hands grew too weak to hold the clippers steady.

When the attending felt he couldn’t say anything more, we turned to leave, but the patient reached for my wrist. She was frail, and her fingers were bony; I could have broken her grip at any point. But when she asked for help and called me son—a term of endearment that in Vietnamese connotes affection, that transcends relationships of blood in a way I don’t know how say in English—there was no option other than to be invested.

I’ve been writing about that night for six years, and each time the story ends at the hospital doors. There’s a description of the warmth of Californian summer air and a nod to returning home, but always with a look back to the ED or a thought toward the next shift, as if this story could only be contained within hospital walls. The story never felt finished at that place, and I could never stop picking at the details in drafts, hoping that some final pass at recreating the memory would lay the whole night to rest. But I didn’t need to talk more about what machines I learned to use or what medical lingo I scribbled in notebooks I never referred back to; repeatedly missing what I wanted or needed to say—purposefully and not—reopened a wound in my chest again and again, never let the edges heal or strengthen.

What I needed to say was this: When my shift ended on the day the nameless patient died, I drove home to my dorm. It was the part of early morning when the sky is slate gray, when it feels like the last bits of night could be pulled down like a spider web. My roommate had gone to bed hours before; a benefit and downside of working late shifts was that I was entirely alone immediately after coming home. But even if he had been awake, I’m not sure I would have told him much of anything that happened. My friends always looked at me blankly when I told them about the ED, probably unsure of how to express their pity or else how to ask me why I was sharing such sad news with them.

Neither did I directly tell anyone in the volunteer organization about the death that night, or the son of the dying man, or the woman who reminded me of my grandma, or any time I had gotten so close to the fire of a patient’s disease that I felt myself burned. The act risked institutional scrutiny for blurring the professional and personal, or worse, being rejected because and in spite of revealing the softest parts of myself.

Instead, I pulled open a new document and wrote. A little of it was about the elderly woman, but most of it was about my grandma, how she always put aside a part of her Social Security checks so I could buy books, the nights spent at her apartment, so small and crowded—we slept in sleeping bags that we rolled away during the day. One afternoon, I had spotted the neighborhood ice-cream truck from the porch. My grandma was the only adult home, and she hurried to get her money from a small black leather coin purse that seemed to only hold quarters. But even then she was too old to move quickly. By the time she got to the doorway, the truck was down the block. We both started to run, and she held up her hand to wave at the driver, but I saw how gently, gingerly she raised her shoulder, and we both stopped and watched him disappear into the distance.

I emailed the document to the volunteer group’s journal subcommittee, where I both knew and hoped it would never be read. I closed my computer and cried until traces of sunlight crept under the curtains.

Eric Tran is a resident physician in Asheville, NC. His work appears in DIAGRAM, The Shallow Ends, Best of the Net, and elsewhere. His chapbook of poetry, Revisions, is available from Sibling Rivalry Press.

Illustration by Mai Ly Degnan

Issue 10