Chapter 5: M & M (Pauline Chen)

If you poke a hole from the belly into the diaphragm and
with your fingers, clear away the cobweblike tissues that
separate the heart from the spine, there will be just enough
space back there to fit your entire arm. And if you put a
small incision along the base of the neck, as you do when
you remove an esophagus, you might even see, if your fore
arm is long enough, the tips of your fingers poking
while your elbow remains enveloped by the soft, rubbery
stomach and a flap of liver.
It’s tempting to leave your arm in that warm, reassuring
space. On the back of the forearm, you can feel the
hardness of the vertebral bones, at the tips of the fingers,
the coolness of open air, and at the elbow, the slithering
contractions of the small bowel. But what you will marvel
at most, and what will make you keep your arm there for
just a few seconds longer than you probably should, is
the sensation you notice against the patch of skin on
the underside of your wrist, the most tender area where
mothers gauge the temperature of milk for their babies.

Against that small swath of skin, and squirming of its
own accord, you will feel the strong, twisting contractions
of the heart. And it will remind you as you look down at the
open belly and warm skin and bloodstained instruments
on the table that the person whose body embraces you is
very much alive.

Surgical residency is infamously difficult, so a month
before I graduated from medical school, I polled my
favorite surgery residents for advice.
“Sleep when you can, eat when you can,” said one.
“Let your fingers do the walking,” said another, pointing to the telephone.
“See a donut, eat a donut,” said yet another.
One resident told me to draw up a list of the five most
important things in my life and then cross out every one of
the first. “That’s all you’ll have time for during internship.”
he said, “and maybe even not much of it at that.”

I kept mental notes on these aphorisms, imagining
myself passing them on to others one day. But of all the
pithy observations, there was only one that I ever used.

Rob had completed his general surgery residency and
was in his last year of subspecialty training when I worked
with him. When not operating he displayed an array of
nervous, tic-like movements that ranged from machinegun-fire blinking to bouncing on his toes to passing his
hands through his brown bristle-brush hair.

Despite the never-ending display of frenetic movements,
Rob was the most even-keeled resident I had ever
worked with. It helped, too, that he managed to find humor
in situations that sent most residents screaming off the
edge. He was supremely confident and gave me more
responsibility and independence than I had ever experienced.
I showed my medical student gratitude by throwing
myself like a human shield into Rob’s less savory scut. I
made the calls to cranky radiology scheduling clerks, drew
blood from ornery patients, and regularly ran interfernence
with demanding attending surgeons. “Make sure to ask
Dr. Miller a question about amputations,” Rob would
whisper to me before rounds. “He loves that stuff and
will keep him out of my hair for a while.”
When I finally went to Rob for advice, I was hoping for
the secret of sanity in residency training.
I caught Rob as he was wheeling a patient back to the
ICU from the operating room. “Let me think about it a
second,” he said, grabbing his patient’s chart and walking
toward the nurses’ station.

It was quiet in the ICU. All the patients appeared
be sleeping, and some of the nurses were away on their
lunch break. The floor, freshly waxed, glistened under
fluorescent lights. Rob sat at the nurses’ station writing
postoperative note. I saw his knee jiggling underneath the
table and could not figure out how he kept his pen still
enough to write.
Rob closed the chart and motioned for me to move
closer to him. “All right, Pauline,” he said. ‘Here’s my
advice.” Not a single part of him was moving; I smiled,
thinking that this sudden seriousness might be part
playful game.

Rob looked straight at me. “Somewhere along the line,”
he said, “you are going to kill one of your patients.”

I shook my head, not sure I had heard him correctly. I knew
patients would die under my care, but my role was to save,
not kill, them.

Rob leaned back in his chair, still looking at me. “You
may not mean it, but it’s going to happen.” He sat there,
absolutely still. I could hear the breathy chorus of ventilators in the
background.
“Pauline.” he finally said. “This happens to all of us.
It’s part of the job if you’re in it for long enough. You’ll just ciome
to accept it as part of the learning process.”

Rob stood up. He put his hand up to his head,
removed his surgical cap, and began running his fingers
through his hair. The nervous movements had started up again
and I saw him anxiously looking in the direction of
the operating rooms.
“Listen,” he said, now walking to the ICU exit. “When it
happens to you, you call me and we’ll talk. You’ll understand then.
Really.”
As the doors closed behind him, I wondered if what he
to me was really true. For days afterward all I
could think about every time I saw one of my residents or
attending surgeons was “Whom did you kill?” While I
my duties as senior medical student and budding intern, I wanted to stop every one of them and ask
about that patient. How did it happen? Did you know you were doing
it? Or did you only realize it later after the fatal mistake?

Like some festering ulcer, Rob’s words gnawed away at my gut.
I remembered his promise to talk, but when it
happened to me during my second year of residency
I never talked about it with him or with any of my
colleagues or even with my family. Instead, all I
could wonder then as I watched other surgeons walk by
was “How do you ever get over it?”

In the early 1970s, Charles Bosk, then a sociology graduate
student at the University of Chicago, spent eighteen
months observing a surgical training program. At the
time Bosk was interested in how surgeons as a professional
group dealt with error. He rounded with them,
attended conferences, and went to the operating room. He
became, in essence, a full-fledged member of the surgical
service.

During that year and a half, Bosk discovered a professional
culture that demanded the highest level of competence
among its members: infallibility in a highly variable
world. He also noted that the surgeons’ group identity was
intimately linked to that drive for perfection. While surgeons were free to choose individually how they cared for patients, they had to be prepared throughout their training
and careers to be entirely accountable to the professional
group for any decisions they made.

Bosk observed that insofar as death was concerned,
this accounting was done primarily in Morbidity and
Mortality, or M and M, conferences. These conferences
provided an opportunity for the surgeons of the hospital
learn by discussing recent surgical deaths and complications.
According to Bosk, however, M and M was also a rite
where a strong sense of professional coherence was
instilled into an otherwise highly independent group of
individuals. As Bosk phrases it, these conferences were a
special ritual “for witnessing [these errors], resolving the
confusion they create, and incorporating them into the
group’s history and the individual’s biography.” And this
ritual function was so important that even “those accustomed
to letting others cool their heels” cleared all other
obligations in order to attend M and M.

Bosk’s findings remain valid today. If you throw around
the words “patient death” to a group of surgeons,
wlll almost reflexively want to go to M and M. And
than the patients discussed and the surgeons
involved, there is little variation in the way M and M’s are
run across the country. Even the manner of presentation — always the
passive voice and delivered as flatly as
possible — is unchanged from Bosk’s experiences. While
are some exchanges that seem calm and reasoned, others
are impassioned, and the raised voices and emotions
always point, however subconsciously, to something
than a difference of opinion among professional
colleagues.

Occasionally deaths are chalked up to a disease’s
natural course. More often, surgeons identify a single mistake and
categorize it as an error in technique, judgment, diagnosis,
or management. Whatever the category, by the
of the conference, the surgeons in the room almost inevitably
come to the same conclusion: the responsibility
for the error — and thus the patient’s death — lies squarely
on the shoulders of the attending surgeon.

In rereading Bosk’s work recently (my sister gave me
the book when I was in medical school), I found the familiarity
of his subjects to be disconcerting; it was as if Bosk had
dipped into my brain and culled out memories of M
and M. I heard the interrogations from the audience and
the offending surgeon standing alone under the spotlight. My
gut churned as the surgeon under fire shifted,
wincing as the old wound was flayed open once again.

Having stood there in that line of fire, I know what that
wound is. It has little to do with the conference or the attacks
or even the error itself. Rather, it is that horrible
sense that maybe it was your fault, that maybe you are
truly to blame for your patient’s death.

Harold “Dutch” Smulder was a sixty-five-year-old World
War II veteran, reformed alcoholic, and unrepentant three-pack-
a-day smoker who developed cancer of the esophagus
when I was a second-year surgical resident. Unruly
tufts of blond and white hair offset the downward drag of
his jaw, and his long face had a softness to its contours, as
if there were a prominent layer of fat stowed underneath
his facial skin. He was the last branch of his family tree, a
gruff, almost flinty lifelong bachelor who never gave people
a lot to hang on to in conversation.
I, of course, fell for him almost immediately.
In the week before his operation, I visited him twice a
day for formal work rounds and then would stop by his
room during my nights on call. If I prodded, Dutch would
warily spit out a few anecdotes about the war. If I laughed
hard enough at one of his jokes, he would guffaw, his rubbery
lips opening wide and his eyes disappearing in the
depths of his cheeks like one of those Chinese wrinkled
dogs.
I liked to think that Dutch enjoyed my visits and even
developed a kind of teasing affection for me. One evening
Dutch complained that he had had problems with the
lunch. I immediately thought of his tumor, alarmed that it
might be growing so quickly that we would not be able
remove it. He watched me for a moment and then began to
laugh. “It’s not because of the tumor, Doc,” he said,
patting me on the shoulder. “It’s because the food in this joint
is so damn awful.”
The night before Dutch’s operation, I went to his room
with a consent form in hand. The attending surgeon, I told
Dutch, was famous for his skill, particularly with this procedure, and he would perform the surgery while the chief
resident and I would assist. Given the scope of the operation, Dutch
would likely be in the intensive care unit for a
few days afterward.
Dutch nodded and looked at the form. He silently
pointed to the list of potential complications that I had
written at the bottom. Some of them, such as leaks from the
new connections, were specific to this operation; others,
like wound infections, were potential risks of any surgery.
I rushed through my explanation; I did not want Dutch
to be frightened. “There is a 30 percent risk of some kind
complication and maybe a 5 percent risk of death,” I

Dutch looked at me. His mouth was twisted, and he
fingered a loose thread on his hospital-issue gown. “So you
think this operation is the right thing to do, Doc?” he asked.

I knew what I had read in books and medical journals, and
Dutch fit the profile of the esophageal cancer patient with
the best possible chances of benefiting from surgery.
Of course, the operation would have to go smoothly, and he
would have to recover, but those seemed like such minor
steps to me.
Without hesitation, I looked at Dutch and nodded.
“Yes, Dutch. The operation is the right thing to do.”
Dutch smiled and then took the pen from me, writing his
name in shaky script on the line reserved for patients.
“Carry on, Doc,” he said. “Carry on.”

I was on call the night after Dutch’s operation. The operation had
gone exceedingly well. Through an incision in his
abdomen and one at the base of his neck, we had removed
Dutch’s entire esophagus. Since the tumor appeared to be
localized to a small segment of the esophagus, we had
likely given Dutch the best chance possible of survival.

And I, the member of the surgical team with the
slimmest limbs, had been the one who, with my entire arm
in Dutch’s chest, had confirmed that we could pull his
stomach up and reconnect his gut once again.

At 2:00 a.m. on the night after the operation, I made a
quick visit to the surgical ICU. The usual facility was
under renovation, so Dutch and the other lCU patients
were in a temporary unit, one originally designed for less
critical patients. Dutch was in the corner room. He still
had not awakened from surgery and had a tube to help him
breathe. The nurses had placed his hands in soft restraints
to prevent him, in a moment of confusion, from pulling on
the tube or any of his extensive wiring.
“Dutch,” I whispered to him. “It’s Dr. Chen.”
He squeezed my hand in hazy recognition and then
fell back asleep.
I left the ICU but a half hour later received a frantic
page to return. Because Dutch was in that corner room, no
one had seen him wriggle his right arm out of the restraint
and then, in his sedated state, pull out his breathing tube.
By the time I arrived, Dutch’s heart rate had dropped
from 95, when I last visited him, to 60. He looked bluish,
and I felt the skin on my own inner wrists turn cold.
One nurse was struggling to compress Dutch’s chest,
while others had wheeled the code cart into the small room
and were drawing up medications from vials. I could hear
the hospital operator’s airy voice-we called her Glinda
because she sounded like the good witch from The Wizard
of Oz-repeating over and over again on the hospital PA,
“Code Blue, Surgical ICU. Code Blue, Surgical lCU.” I
scrambled to the head of the bed and asked the unit secretary
to get hold of the senior resident, who was on call from
home that night.
The respiratory therapist and I first tried to use a mask
to give Dutch oxygen. Each of us pulled up on Dutch’s jaw
and cheeks, sealing his flesh against the plastic to prevent
any oxygen from escaping around the mask. The swelling
in his throat, however, obstructed his trachea, and each of
our administered breaths of oxygen only blew up his
cheeks and dislodged the mask from our hands. Looking
over my shoulder, I could see that Dutch’s heart rate had
slowed further, to 45.
Dutch was suffocating.
I called out for a breathing tube and looked inside
Dutch’s mouth. All I could see were pink swollen tissues
instead of the dark tunnel that should have been his airway.
I tried to force the tube down Dutch’s throat twice,
unsuccessfully. After the second attempt I looked up at the
monitor again and saw that Dutch’s pulse had
drifted down further, to 30. The nurses were giving
atropine to try to reverse the slowing rhythms of his heart,
we all knew that without oxygen, everything else was futile.

There are moments in the hospital when time seems to
suspend itself. Each second draws itself out, and actions
take on a slow, dreamlike quality, as if they are replaying
themselves even as they occur. As the events unfold before you,
observer and participant, you find yourself reacting
not with the rational and deliberate thoughts you have
been taught, but as if nature, not some professor, had
etched the responses into your neurons. In these moments
when you are faced with life or death, it is as if the distillation of
all those hours caring for sick patients bubbles to your
brain’s surface, and what you find yourself doing feels
as natural as the most primal of reactions.

Looking at Dutch’s falling heart rate and his swollen
neck, I realized that he needed a cricothyroidotomy, an
inch-long incision just below the Adam’s apple for a
breathing tube. I asked for Betadine, a scalpel, and a sterile
surgical clamp. I had performed a cricothyroidotomy
only once before — on a pig in an Advanced Cardiac Life
Support course the week before internship — but my hands
acted as if the routine had been embedded in my genes. I
poured the Betadine over Dutch’s neck, and the brown liquid
splashed over the bed and onto my scrubs. I felt the
flatness below his Adam’s apple and drew the knife down.
I pushed the blunt surgical clamp toward the hack of his
throat, plunging it into his airway and spreading the steel
jaws to create a hole large enough for a breathing tube.
pushed the tube into Dutch’s neck and down toward his
dying lungs.
We beat against Dutch’s chest, infused drugs,
delivered enough joules of electricity to his body to leave
oval burn marks where our paddles had been placed. His
lifeless body slid on the bed, pushed by our persistent,
rhythmic chest compressions, and every time we delivered
a shock from the defibrillator pads, his arms and legs
would flail like the limbs of a rag doll that had been thrown
across the room. The breathing tube was working; the
of oxygen in his blood was probably better than mine at
that moment, but we were, ultimately, too late. His heart
would never start up again.

Forty-five minutes later, I pronounced him dead.

Ten minutes after that the senior resident arrived.
“Oh, shit,” I heard him whisper as soon as he caught sight
of Dutch’s dead body. I followed him into Dutch’s room
but he ignored me, picking through the scattered EKG
tracings on the bed and the lab results strewn on the floor.
“What the hell happened?” he asked, looking not at me but
at Dutch’s body. I told him, and he threw the scraps of paper
he had collected back on the floor.

“Damn it, Pauline. You should have coded him longer,
an hour. I don’t care if his heart could not start up after
forty-five minutes.”
I felt my own drop to the floor.
”Now we are going to have to present this guy at
M and M and give some reason for why he died.” He
walked over to one of the phones to call the attending.
“Shit” he repeated over and over again.

He suddenly stopped and looked at me. “‘No, Pauline,
I am not going to present this case,” he said. “You are
to do it. You are doing the M and M.”

I listened to him talk to the attending over the phone
and then went to look at Dutch once more. The nurses
were clearing away the needles and blood and preparing
his body for the morgue. He looked cold and pale; the
breathing tube sprouted up from where I had slit his neck.

I stood there without moving. I thought of the summer
I was six. I had gone down the pool steps to swim, my legs
descending as if of their own accord. As the water
of the pool came to my chin, I felt my right leg swing out and
step down, pulling me into the shimmering whiteness of
water. I saw the sunlight disappear along with my
breath, swallowed up by the brightness. My feet
touched the bottom, and I struggled to push up with my toes.
As my head broke the surface, I began to scream, only
to sink back down, blinded by the bubbles of my own breath
and silenced by the water that filled my mouth and lungs.

As I wept by Dutch’s room, I felt as if I had fallen in
the pool once again, each gasp giving me less and less air utnil
I could breathe no more. Except that this time I had
taken Dutch Smulder along.

I spent the following week thinking about Dutch, going
over in my mind again and again each minute of that ilI-fated
resuscitation and the ten minutes I had spent alone
with him beforehand. I tried to remember the squeeze of
his hands, the placement of his wrist restraints, the
cricothyroidotomy. I even dreamed that I had loosened the
restraints as I left him earlier that night, and the dream
was so vivid that I no longer could remember the truth.

But what could I say, I kept thinking that Friday
morning after his death, to the attending surgeons, residents,
and students sitting in front of me? I had dreaded
M and M, but could I bring myself to say that it was I, not
the confused patient, who had let his hands go?

From the stage of the lecture hall, I began presenting.
“H.S. was a sixty-five-year-old-male with a past medical
history significant for alcohol and tobacco abuse who presented
two weeks ago with adenocarcinoma of the esophagus.”
Would the attending surgeons discover, I wondered
as my voice droned on in that passive haze, that my dream
had been the truth, that I had killed Dutch Smulder?

“H.S. underwent a transhiatal esophagectomy, complicated
only by excessive facial and neck swelling. He
remained intubated and on the ventilator postoperatively.”
As I spoke, I hardly noticed the notes melting in my hand
but instead felt Dutch’s heart against my wrist. I saw his
open belly in the operating room and felt his swollen hand
squeeze mine in the ICU. I heard him laughing a few
nights before the surgery, making fun of the hospital food
yet again.

‘”At two-forty a.m., the patient self-extubated.” I bit
my lip, trying to keep my voice and face impassive.

“A code was called. An emergent cricothyroidotomy
was performed.” The scene flashed in front of my eyes
once again: the Betadine splashing over his throat, the
against his neck, and the clamp entering his trachea.
I saw Dutch’s skin and lips become blue and heard the
beeping from his heart monitor drift off.

“Despite forty-five minutes of resuscitative efforts,
H.S. was pronounced dead at three-twenty-seven a.m.” I
emphasized the “forty-five minutes,” sure that I would
otherwise be held accountable. The room was silent and
audience stared at me grimly.
The interim chief of surgery at the hospital stepped up
to the podium. I had searched for him the day after Dutch’s death,
recounting the events and hoping for absolution.
“Well, that’s tough,” he replied. “Let’s see what happens at
M and M.”
His eyes bore into me now, and I suddenly became
of being alone, up front and center stage. “Doctor,”
he asked, ‘”what is the standard of care for patients with
esophageal cancer?”
I answered with all that I had read and researched,
but with every successful answer came another more
detailed and probing question. Questions from the audience rushed
forth about every possible detail of Dutch’s
last day until all was quieted by the final question.

“So, Doctor,” asked the department chief. “How do
account for this death?”

I heard the clock in the room ticking. I opened my mouth.
The water rushed in once again.

The department chief stepped toward me and began to
address the room. “I’ve talked to the nurses who were
working that night, to the nurse in charge, and to all the
doctors involved in H.S.’s case.” He paused just long
enough for me to cast one more glance at the impassive
audience. “My frank feeling on this case,” he continued,
“is that this unfortunate death was due to an unacceptable
temporary ICU setup. I’ve gone back and looked at that
corner room, and even I cannot see how anyone could have
adequately monitored a sedated, intubated, fresh postoperative
patient.”
I remember hearing a murmur of agreement through
the audience. Another attending surgeon volunteered the
story of her own patient who had been in that corner room
and poorly monitored. After that, the department chief
excused me to go back to my seat.

I had been officially absolved of guilt.

As the conference ended, a few attending surgeons
and residents walked by and patted me on the back. The
department chief put his hand on my shoulder. “Good job
with that code,” he said. “These things happen.”
I walked out of the room, and that was it. Although
that attending surgeon would never again perform an
operation like Dutch’s in that hospital, and a new ICU replaced
the temporary one, clinical life continued as it always had.
The senior resident smiled whenever we were on call
together, the interim department chief grilled others at
M and M, and no one ever mentioned Dutch’s name again.
And while I ached to share my grief with others besides
my best friend, Celia, I could not help but also believe
that there was nothing more to do and thus nothing more
to say. Dutch Smulder was best left buried along with
all the other initialed patients on that morning’s handout
in the annals of the department’s Morbidity and Mortality
conference.

There is something intensely personal about surgery. Our
hands are in our patients’ bodies, caressing them as no
lover ever could. All the usual assumptions about propriety
are cast away, and we literally hurl ourselves into the
path of a disease. We use our fingers to break apart the
filthy webs of infected loculations, our cupped palms to
scoop out clotted blood, and our gloved fingernails to pry
free adherent loops of bowel. Our work is an extension of
ourselves, but we come to believe much more — that we are
our work.

That lesson starts early in our training. I remember
not so much the first patient nor the first incision I ever
sewed closed, but the visit I made the following day. I was
the junior medical student on the vascular surgery service, and
that morning the head of the department joined
rounds. Our large group entered the patient’s room. After
the attending asked the patient several questions and did
a cursory physical exam, we all turned to leave. The
attending surgeon suddenly spun around at the doorway
and went back to pull down a part of the patient’s incision
“Didn’t you close this up?” he asked me.
I nodded, and he motioned for me to come to the
patient’s side. The closure looked beautiful to me; the edges
were aligned perfectly, each stitch was evenly placed.
Even the patient, despite having been pawed and
gawked over, was beaming.

“Come over and admire your handiwork!” ordered the
surgeon with a laugh. “It’s pretty good, isn’t it?” He
chuckled. He wiggled his own delicate fingers in the air,
if to emphasize his point: our hands are our instruments, our
interventions a direct extension of ourselves.

Over time, the line between our selves and our work
blurs. We see a patient walking around and will identify
that person as “I did her colon” or “I did his liver,” as if
we are responsible for that patient’s actual part. These are
narcissistic moments but ones that patients indulge in as
well. More than once I have overheard my patients say,
“That’s Dr. Chen’s work,” while pointing to the scars I
have left behind.

It is hardly surprising, then, that death for surgeons is
more than a passive process. It is immensely and profoundly
personal; it is about us. Surgeons will, for example,
do everything possible to prevent a patient from dying
“on the table.” While trying to keep a patient alive in the
OR is an honorable quest, I was struck as an intern by
the ritual that occurred once death became inevitable. The
attending surgeons would hastily do everything possible to
close up and rush the patient out of the OR, even if that
patient expired only a few minutes later in the ICU. The
first time I saw this happen as an intern, these quick exists
seemed superstitious. Later, after I witnessed the second
such death, I asked my friend Celia why there had to be all
this rushing about. “Because,” she replied, having posed
the same question a few days earlier to a chief resident, “a
death in the OR means it was the surgeon’s fault, and you
have to do everything to prevent that.”

Our fingers, no matter how nimble and graceful, are
always tangled up with the fate of our patients, and when
one of those patients dies, it is impossible to divest ourselves
of that sense of responsibility. We torment ourselves
with the what-ifs. Perhaps, if we had put that stitch in just
a little differently or removed that cancer a little higher up
or worked a little longer, then maybe our patient’s course
might have been different.

M and M, our professional ritual centered on death,
attempts to heal the rents in our professional fabric caused
by patient deaths. There are few other opportunities for
surgeons to discuss death. We may mention it in passing,
but we steadfastly reserve discussion for the conference,
which will give us, as a group, ritual absolution. M and M
requires a public accounting of loss and, in so doing, reconstructs the death into an event that affirms a core
value of our professional identity: the need to be infallible
in a highly variable world. In this way, M and M is like
death rituals in other cultures; it seeks to transform
death’s loss into an affirmative experience.

Unfortunately, the very rituals that were meant to heal
a community in death can also hinder that process. Peter
Metcalf and Richard Huntington, two anthropologists who
have studied rituals in funerary practices, write, “Whatever mental
adjustments the individual needs to make in
the face of death he or she must accomplish as best he or
she can through or around such rituals as society provides.
No doubt rites frequently aid adjustment. But we have no
reason to believe that they do not obstruct it with equal
frequency.” In the case of M and M, death is viewed wholly
through the lens of personal responsibility. Death is rendered optional,
and mortality becomes a quantifiable and correctable error.

By defining death only as the result of errors, we erase
face of our patients and insert our own fiercely optimistic version
of immortality. While admirable in some
respects, this paradigm also denies our essential humanness. When
we refuse to accept our own fallibility, we deny
ourselves grief. In the end, then, M and M may prevent us
from reaching what we so desperately want to
achieve: the very best care for our patients.

There is a paradox to rituals. While they safeguard the status quo
and control unpredictable individual variations,
rituals can also inspire creativity. They can supply the
framework needed to introduce new meaning to an event.

M and M has in recent years become the focus of a
new approach to death and dying. Long regarded as an
instrument for denying death, M and M has more recently
been transformed into one of the primary venues for incorporating
end-of-life care initiatives and formally addressing
the personal significance of patient deaths. In 2002 the
American College of Surgeons issued a new mandate to
improve end-of-life care training for surgeons. One of the
key vehicles for this change has been the M and M conference.
Internal medicine training programs have not only
incorporated M and M into their training programs but
have also begun to use this conference similarly as an educational
tool for end-of-life care.
Perhaps the very characteristics that compel us to find
fault first with ourselves-that profoundly personal stake
in a patient’s death-have transformed this ritual into
something greater.
It has been twelve years since Dutch died. Although
the attending surgeons at M and M chalked Dutch’s death
up to a problem in the temporary ICU’s setup, I continued
to ask myself for years about the course of events that
night. What if I had taken extra care to tighten his wrist
restraints the first time I saw him? What if I had resuscitated
him for fifteen minutes more? What if I had
encouraged him to sign the operative consent?
I have cared for hundreds more patients since Dutch
died and with that experience, I understand the events
that night a little differently now, perhaps more like
interim department chief than the young resident I was.
I have found some peace, but Dutch still comes back to me.
He is a ghostly apparition who appears whenever I see a
patient with esophageal cancer, perform a cricothyroidotomy, or run an emergency resuscitation.

And there is one other event that brings Dutch back.
Each July 1, a new class of interns appears on the wards. I watch
those interns, remember my first weeks, and then
imagine what the years ahead hold for them. I wonder if they
too, win carry the same burdens as the rest of us.
That is when I see Dutch again, signing his name for
and telling me to carry on.

A year after I had finished all my training, a patient died
the wards of the liver surgery service. An intern had
examined the patient, left the room, and within minutes
called back when a nurse noticed that the patient had
become unresponsive. A team that included the covering
attending surgeon tried to resuscitate the patient for close
to an hour without success.
One of the nurses called me that afternoon. “I know
you are not covering, but would you mind going to see that
intern”? she asked.
I walked over to the floor. It looked no different than usual.
Nurses were busy in patient rooms, phlebotomists
walked by carrying their plastic picnic baskets filled with
gleaming empty tubes and requisition slips fluttering. I
walked into the small office -reserved for interns. Papers
films were piled about haphazardly. The intern sat
huddled over a computer.
I introduced myself. For a moment I saw fear flicker
over his eyes, as if he expected me to bawl him out.
Instead, I asked him what had happened and how he felt.
He was cagey at first. Then I told him about Dutch. I
told him how hard it was for me and how, years later, I still
thought about Dutch. “But you know what?” I said to the intern.
“I think I am a better and more compassionate surgeon because
of Dutch.”
He sat there, face impassive. I was not sure if I had said
too much.
But a couple of days later, there was a knock at my
door. My office was set off a corridor in another wing of the
hospital, nestled among cardiologists and far from other
liver surgeons. Visitors were rare.
I opened the door and it was the intern. His face was
still impassive.
“Just wanted to say thank you,” he mumbled.
As he quickly turned to walk away, I only had time to
say, “No problem.” But I spent the rest of the day with
Dutch’s grinning face in the back of my mind.

Discussion Questions:
Has this piece changed how you might handle your own first death? How and why or why not?
How did this piece make you feel? Why?

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