First Time

Tonight Sari will die. The little bit of child left in me hopes that she will hold on until morning. When it won't be quiet and dark. When someone who knows what to do will be here. Not me.

One by one, the other interns sign out and leave. They look hard at me, telegraph sympathy with taps to my arm and say, "See you in the morning, Mark." Relief propels them down the hall away from me, from Sari. Some time, some night, it will be their turn. But not yet. Tonight it is mine.

The ER calls with admissions, one after the next. Pelvic inflammatory disease. Asthma. Osteomyelitis. Workups I know by heart, thank God, because my legs and my brain are soggy and slow. Every hour, I circle back to the Intermediate Care Unit where Sari's parents stroke her hands and try to memorize her. Sari's vital signs are duly recorded in her chart, as if they are still relevant. I check them frequently because I don't know what else to do.

At eight o'clock, Bartlett, the weary pulmonologist, pushes himself out of the chair at the nursing station where he has kept vigil since mid-afternoon. He tells me he is leaving. Don't go! I shout with my eyes. Don't leave me here alone. My heart races with pure panic.

"I'll be home all night," he says in a voice so tired I have to lean closer to hear. "Call me when it's time." He has gentle brown eyes in a pudgy face, a thick moustache in need of a trim. He has known Sari for 15 of her 16 years. How can you do this, I don't ask him, how can you keep doing this? Do you carry these children around forever? Will the weight of all those bodies someday pull me down so far that I won't be able to get up? Will there be so many after a time that I'll forget names, faces, voices? I really do want answers, but these are questions one must never ask. They're all going to die. Most of them before they're old enough to wave a learner's permit triumphantly in one fist. We all know that David will be next. That before the summer is over, the World Cup soccer posters will be peeled from the walls of his room, rolled up and handed to his parents. And then, probably Marcie, wizened and depleted at only 18. You can see her readiness, sense as you walk by that she would cut to the head of the line if she could. She's ready to stop hurting and watching the weather from behind windows that don't open. And before even a few days have passed, new children will come and make those rooms theirs. I watch Bartlett's lowered head, his heavy steps as he walks away. I follow him with my gaze until he disappears around the corner. He never turns back.

I make rounds on my other patients, executing smaller and smaller circuits centered on Sari's room in the Unit. At 12:30, they page me. Sari's heart rate is dropping, they say. Mine takes off at a gallop. Her respiratory rate is down, they say. I suck in a painful amount of air and hold it, turn myself in her direction.

I have to walk the length of the Adolescent Floor. I pass the treatment room where Sari and I faced off during those wretched battles to insert IV's into her skinny veinless arms. The first time was the worst, before she knew she could trust me, trust my hands. Her scratchy voice, shrill in anticipation of the pain to come, somehow drifts out to me through the open door.

"You get one stick." Her lower lip is pushed out as far as a lip can go, both hands fisted.

"Hi, Sari," I say as gently as I can while a hot coating of dread and self-doubt covers my body, seeps out through my armpits.

"You get one shot and then you call the third-year resident," she commands. Her eyes are narrowed and dark. "I'm sick of having you fucking interns practice on me every fucking July."

"Okay." I place a tourniquet around her left upper arm, start running my fingers lightly over the skin inside her elbow. It is the thin, see-through skin of an 80 year old. Not a teenage girl who right now wears a mask of fear that makes her look years younger than the 16 she is. There are no veins to be seen or felt. They have all been used, scarred up by 1,000 needles, 100 interns who've been here before me. I snap off the rubber tourniquet and move it to her right arm. Sari's eyes follow my hands.

"You can't even find a vein," she taunts.

I trace along the crease of her arm. Let my fingers try to see what is invisible to my eyes. "I worked as a phlebotomist all through med school," I tell her, trying to keep my voice even. This is true. "If anybody can find a vein, I can." This is not entirely true, but it is what I am trying to tell myself right now. Maybe it will reassure Sari too. She says nothing.

Finally, I find my only hope, a hard, inch-long thread that I can sense under the tip of my index finger. Maybe. Sari watches as I wipe the spot with alcohol, slide the needle out of the plastic cover. I hear her suck in a breath and see, just at the edge of my vision, her jaw muscles clamp down hard.

I stab through her skin. She says nothing. She knows what comes next.

I push the IV needle in deeper. Pull back. Aim it a hair's breadth to the left. Push again. Pull back. In again.

Her voice starts low, "Fuck, fuck, fuck."

I struggle to keep my hands steady. Fight the rising urge to tell her to shut up. Hate myself. Hate this goddamn job.

"Fuck you, mother-fucker. Take it out! Stop, you asshole! Stop!"

But then it comes. The tiny flash of blood into the hub of the catheter. And Sari sees it too. She freezes as I attach the syringe and draw back. She knows not to move. She is more an expert at this than any doctor with 20 years experience. I remove the syringe, release the tourniquet, and hook up the IV tubing. She seems not to breathe until I have anchored everything to her flesh with strips of adhesive tape. With twice as many pieces as are actually needed. I step away, look at her, and know that she needs to gather herself back from this violation, to be private with her pain and relief and anger. I turn my attention to collecting empty paper wrappers and used gauze.

"You're good," I hear through the quiet, in a new, lower voice.

I look up at her. "Thank you."

She nods once and her lips soften, get fuller as one lonely tear finds its way from the corner of her eye. I reach out, put my hand over hers, now lying loose and curled in her lap. She squeezes it.

Without realizing it, I have stopped walking. I shake my head, force myself to walk on. I must leave the voices in the treatment room behind. Will they stay there after Sari's gone?

I stop in Sari's old room, hear her giggle with Jill as they use me for flirting practice. I move on. The teen playroom is dark and empty. In each room along the hallway, a silent adolescent stares at a TV screen, eyes flicking in my direction as I pass. They know. They know where I am going. They know tonight is Sari's turn. And sometime soon, it will be theirs. They don't know that, right now, it is mine.

"Hi. How are you two doing?" is all I can come up with as I enter Sari's room. It has been more than 24 hours since Sari last opened her eyes, and longer since either of her parents closed theirs. They nod at me with weary tolerance. I can't look at them for more than the few seconds it takes to force those words from my mouth. They know. They know why I am here. They have been in this hospital on other nights like this. Watched as other parents left for the last time. Now it is their turn. They don't know it is mine.

Sari is storybook beautiful. Long blond curls trail down to graceful shoulders; her nose is upturned and finely chiseled. She would have been one of the popular girls, one of the girls who always got asked out by the senior boys. If only they hadn't been frightened of those purplish, oxygen-deprived lips. They visited her once, those ironed, glossy kids she used to go to school with. A girl in a crewneck sweater and a boy with combed-back dirty blond hair. I lingered outside her doorway, an audience of one, riveted to the beauty of the teenage drama playing before me. The girl sat behind Sari on the bed, mutely brushing and braiding and then hastily unbraiding Sari's hair. A determined frown stayed on her face. Why was she so dissatisfied with her handiwork, I wondered. Did she think if she got the braid exactly right she could fix Sari's lungs? If her hair looked good enough could Sari go out with them that night? The boy shuffled from chair to window to bedside and back, hands in pockets, in a deranged solo square dance. I watched Sari watch him. Was she wondering what it would be like to dance with a boy? Hold his hand? Kiss him? Her eyes followed him the whole time and he never looked back. The girl stayed quiet too, kept her hands moving at the back of Sari's head. Look at her. Talk to her, just talk to her, I transmitted urgently to both of them. No one was receiving messages, apparently.

I saw the two of them huddled together at the elevator a half hour later, glancing at each other, then back at their feet. Two sets of arms were crossed over two chests, the only armor at hand to protect them from the dangers of this place. I felt a softness roll through my chest. They were children too. Fifteen, 16 is too young to look death in the face, but at least they had tried. For Sari.

The only sound is the bleep of the cardiac monitor and it calls me back to here, this room, this night. To Sari. Something isn't right. Fingers of unease tickle the back of my neck. Ah, I realize. She isn't breathing. Her chest is motionless.

Before I can take the one step to her bedside, a loud rough sucking noise arises from the bed and Sari's chest wall lifts straight up. It sinks back down accompanied by a coarse huffing sound. And then there is stillness as the heart monitor chirps on. Understanding settles over me. Agonal respirations. That's what these are. I learned about this, but have never seen it before. This is the way a person breathes before she dies.

I want to run away.

Instead, I wait with Sari's parents for the next breath. When it comes and then comes again, we breathe with her.

We stand around Sari for a long timeless amount of time, each of us silently willing her to take one more breath. One more. Time stretches, elongates. The room is an enclosed orb, the only lit place in the world right now. Dust particles hang, unmoving in the empty space, the unfilled air above Sari's bed. Waiting. No breath. Waiting. Still no breath. Wait, just wait a little longer.

A nurse steps into the room, breaking the spell. She looks at me and wordlessly reminds me of what I must do.

I touch my fingers to Sari's still-warm wrist, wait patiently to feel for the pulse that never comes. I reach slowly to the softness of her neck, acutely aware that Sari's parents are watching. No carotid pulse. I pull the stethoscope from around my neck and place the earpieces into my ears. I warm the metal disk in my hand as I always do. Keeping my movements small and low, I fold down the very top of Sari's hospital gown. I place the stethoscope first on the right side of her chest and then on the left. No whisper of air. Finally, I rest the circle of silver just to the inner corner of her left breast. Nothing. I replace the top of her gown carefully and straighten up before removing the stethoscope from my ears.

What will happen now? Will her parents scream? Collapse? How does a person bear this and not die? How do they take the next breath? How does a heart keep beating? And what am I to do? What will I be called upon now to save, to cure, to repair? I have no equipment for this, no diagnostic tools to help me figure out what to do next. They didn't teach me how to do a physical exam on the human soul. I don't know how to splint a fractured human heart. I watch this man and this woman. How will they put one foot out and take the first step into a life that no longer contains their child? I watch and I wait, thoughts ricocheting off the inner walls of my skull.

Sari's mother's eyes are on me, holding a silent question. "Her heart isn't beating anymore," I answer, reaching toward the still-beeping cardiac monitor. "The electrical impulses continue for a while after the heart stops pumping." Sari's mother looks away. I turn off the machine. "I'm sorry," I say.

The room fills then with a small burst of activity. The pulmonologist arrives, nurses bustle through, forcing Sari's parents into chairs. I back out through the door, open my eyes wide to the unfamiliar world outside of Sari's room. I slump into a chair at the deserted nurses' station, rub my hands hard over my face. Footsteps come from behind me and a nurse-voice calls out, "Time of death?"

"What?" I can't make myself turn to see who is speaking to me.

"Time of death," the voice insists.

"Oh." I fumble with my sleeve and strain to read my watch in the half-light. It is 4:35. But I realize I have no idea how long I have been sitting here, how long it took Sari to die. I mumble something to make the voice go away. But it won't.

". . . And don't forget to fill out the death certificate," leaks into my murky consciousness.

"Death certificate," I repeat in a dulled voice I don't recognize as my own. A rectangle of paper slides onto the desk in front of me. There it is. "Certificate of Death" is written in knife-sharp print across the top. It looks just like a high school diploma, I think.

I lift myself out of the chair, placing both hands on the desktop to support my still-living body. I expand my lungs slowly, deliberately, taking in a huge volume of air. Then I force myself to breathe in just a little more. I can feel my heart pump blood into my legs as I begin to walk.

There are other patients. Other children with names I don't know yet, waiting for me in the ER. I am fine, I think, fine. I mentally check myself all over, feeling gingerly for injuries the way I did 15 years ago each time my skateboard flew out from under my feet and landed me on the pavement. No, nothing broken. Whew, I'm Okay. There is only one first time and there will never be another. I have survived my turn and now my turn is over. So this is how it's done. You just go on.

An hour later I can see daylight through one smudgy window. I am in a corner of the ER supply room gathering supplies for my new admission. Fourteen-year-old boy, newly diagnosed diabetic in ketoacidosis. What is his name? Sean? Scott? I gaze at the ceiling, can't remember right now. I look down at the collection of plastic, glass, metal, and paper in front of me, comforted by the undemanding familiarity. I know what to do here. I select a 14-gauge IV catheter, a 10cc syringe, red-top and purple-top test tubes. Easy. Simple. I head for the door. Stop, mid-stride.

Something tells my legs I can't go out there. Where did this come from?

I turn back and drop my handfuls of supplies on the countertop, lean into it and try to take a deep breath. One deep breath and I will be all right. I'm just tired, haven't eaten since yesterday, I tell myself. I close my eyes. Something is holding me here. Won't let go.

I open my eyes slowly and look down. My right hand clenches itself, four fingers rolled hard under my thumb. Suddenly, my fist shoots away from me faster than any punch I have ever thrown before. I watch it disappear into the wall up to my forearm. Jagged, broken plaster encircles my arm and I can feel my fist still clasped tight, though it is hidden from me inside the hole I have driven in the wall. I leave it there and slowly extend each finger, think about the sensory neurons carrying their strangely unhurried signals to my brain. Yes, there it is. Hand hurts. I pull it slowly back out through the hole, scraping against the sharp edges. My knuckles are red, the thumb and back of my hand smeared with blood. I see my hand tremble, feel it throb, watch it bleed. My vision clouds, gets wavy as something moves on my face. It feels like a fingertip lightly tracing a line from the top of my cheek to my jaw. I touch the back of my uninjured hand to it and ponder the wet mark left there when I pull it away. It is then that I notice the quiet come into me. An unbearable pressure I am only now aware of releases and subsides. Something opens wide inside me and I breathe.

Copyright © 2003 The President and Fellows of Harvard College.
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