Creative Writing in Medicine – Eve

By Tanima Arora

It was the second time I was rotating through our neonatal intensive care unit, now used to the constant beeping of monitors, weak cries of infants and having to use more math than I ever have since graduating high school. It was Christmas Day and “Santa Claus” had visited the afternoon before taking photos with the babies’ isolettes and wishful parents that were around. I peered through the isolette at one of our new admissions the day before: a 24-week micro-preemie, a mere 600g, thin tangled tubes connecting her umbilical vessels to numerous drips and an endotracheal tube secured to her frail mouth connected to a heaving oscillator. Her isolette had a photo of Santa Claus standing next to her, but there was no parent in the picture. And how could there be, the whole family having suffered a tragic accident on Christmas Eve.

This family of three: father, pregnant mother 24 Weeks of Gestation (WOG) and three-year-old girl, had planned to visit their grandmother on Christmas Eve, when a drunk driver collided into their vehicle after running a stop sign. This tragic accident had landed all the family members in the hospital. The three-year-old was admitted to the PICU, suffering from cervical spine fractures and a concussion. The father was the most stable of the lot, admitted to the internal medicine floor with bilateral rib fractures and a minor splenic contusion. The mother was impacted the most, her left lung completed transected, intubated on a propofol drip, and via emergent C-section, birthed a beautiful angel into the world. “Eve” is what I named her.

I had nine babies that day, five of which were in level four, all connected to ventilators and some of which were TPN dependent. I spent half of my morning calculating their calories and interpreting their arterial blood gases, playing the game of vent setting adjustment vs blood gas results. I wanted to reserve half my pre-rounding for Eve. As I quickly jotted down the rates of her drips, making note of what was flowing through what line, our respiratory therapist (RT) tapped my shoulder and presented Eve’s 8 am blood gas. Her pH was down to 6.9, her respiratory acidosis worse. I sent the results in our group chat for the day, asking my fellow if it was okay for me to bump up her amplitude. He agreed, and I let the respiratory therapist know, who gave me a look of hesitation but made the change. I looked back down at my notes, resuming my calculations when my fellow appeared at the bedside. He had been there with her overnight, and told me that her gases had been becoming exponentially worse. “Can we change the frequency?” I asked, remembering that in some cases, frequency adjustments have a greater impact. “We can try,” he responded and called the attending. I went back to my workstation, getting my ducks in order before my attending arrived for rounds. Eve will be okay, she is in good hands, I promised myself.

My attending decided to round on Eve first, the typical order for our day would be sickest to relatively healthiest infants. Our team, complete with the attending, fellow, pharmacist, nutritionist, three residents, respiratory therapist, two bedside nurses and mob of COWS (computer on wheels) huddled by her bedside. I peered through the isolette one last time at Eve to say hello, a tradition I started from my first day of the rotation and turned back to the crowd to start my presentation. As I strategically went through my presentation, detailing the overnight events, current vent settings, most recent gas and proposing my respiratory system plan, one of Eve’s nurses appeared at my side. “I’m sorry to interrupt, but her Mean Arterial Pressure (MAPs) is dropping.” I whipped around, the eyes of the team following, and saw her monitor reading a MAP of 10. The next thing I know, my attending was at her bedside, talking silently with the nurse and calling another provider (the one carrying her overnight). He peered over at me “Thank you, Tanima. The team may continue with rounds, I will join in a bit.”

Our fellow led the team onto different bays, rounding on the other babies, and even as I presented my other patients for the day, my eyes kept wandering over to Eve’s bay. There was some commotion and I was desperate to step away and help in any way I could. And that’s when I saw the door to the NICU open, a man being wheeled into the ICU, his head hanging low, and an old lady accompanying him. I immediately knew this was Eve’s father and possibly grandmother. I held my breath. They were ushered over to Eve’s isollete, and the next few minutes were a blur. I could hear muffled sobs, drowned by my co-resident presenting the last patient of the day. As soon as rounds finished, I walked over to the bay. My attending had authorized her morphine drip to be increased as much as it could, the time was close, the decision made by a grieving father. Another fellow had made her way over to the Medicine Intensive Care Unit (MICU), where Eve’s mother was housed, intubated and heavily sedated, in an attempt to allow her to see her baby, the only and last time, before her surgery. My heart was aching, my throat starting to close and I blinked rapidly attempting to dissolve the tears that would soon be streaming down my face. Could I cry? Is it even appropriate, for the provider to cry in front of the family? I didn’t know, but what I did know was that I was feeling helpless and wanted to help in any way that I could. So, I stepped up to the isolette and asked Eve’s nurse if I could hold the iPad, and assist with the Facetime. I hovered over Eve, taking in her fragility and beauty, and after a few minutes received an incoming call from my fellow.

Eve’s mother was in her ICU bed, a large endotracheal tube obscuring her significantly edematous face. She could not speak, she could not see, but I would like to believe, that just being there in this virtual presence of her baby, that she could feel, and that was something.

I stepped away after the Facetime ended, walking as quickly as I could out of the NICU to catch a breath by the windows overlooking our garden. It wasn’t fair. Eve and this entire family did not deserve so much heart ache. Tears were streaming down my face, collecting below my mask. After a few deep breaths, I made my way back to Eve’s bay. Her ventilator had been disconnected, her ET tube removed, her umbilical arterial and venous catheter removed and her skin was being cleaned from residual blood. Her nurses dressed her in a pink onesie, with a matching cap and mittens, while her father and grandmother prepared to hold her in her last breaths. I sat at the workstation directly in front of her bay, catching glances at these precious moments of Eve with her father and grandmother. They talked to her, they prayed to her, they sang to her, they held her close, and they cherished every single second they had with her. A few hours later, they took Eve up to the “Butterfly Suite” (our department’s palliative care room where family can room in with their babies privately and comfort care is provided). That was the last I saw of Eve.

Mortality in the NICU is not uncommon, and one can argue that no matter how many deaths you’ve witnessed in the world of medicine, one can never really be completely prepared. Eve was not the first death I have witnessed during my medical training, nor will she be the last. Working in any intensive care unit, where all your patients are critical and require constant monitoring can become very overwhelming, but each instance of death is a learning opportunity. An opportunity to broaden our skillset outside the world of medicine and clinical knowledge, by refining our compassion, empathy, human connection and coping mechanisms. I feel fortunate enough to have been supported well by my attendings, fellows and co-residents through de-briefing sessions and I feel fortunate enough to have been a part, albeit maybe a small one, of this patient’s and family’s journey. I will always remember Eve, on happy days and sad days, in good times and bad times, for she made my education and my empathy stronger.

Eve had passed away by the following morning when I returned to work, a small box left at her bay ready to be shipped to her home. It was a memorial box, with pictures of her being held and loved by her family, a notebook and her pink onesie, cap and mittens. I peered at the bottom of the box, and the last few lines of a poem from Eve to her mother caught my eye and I smiled with a heavy heart. Goodbye, Eve.

I know that in Heaven there is no marriage, but surely there can be some acknowledgement of Motherhood, Because there’s one thing I don’t only wonder about, It is something that I really hope for When I