Hair Clips for Esma

Lila Flavin

March 1, 2020

I pressed myself into the wall as they wheeled her past. The child’s feet were flopped to the side, pudgy thighs sticking out from under tangled sheets.  The black belt around her waist held her down to the stretcher. I followed them into the room as a nurse stuck a needle into the crook of her arm and I flinched. I still hadn’t learned to hold my expressions steady when we hurt our patients. The chubby toddler didn’t move. She didn’t even cry as the fluid pushed its way into her veins. 

“She’s febrile to 104,” the resident said. “Tachy, too.” He jammed at the mousepad, then flicked the IV bag. He checked her blood pressure, tightening the cuff around her rolls of fat. “I think she’s septic,” he said.

I backed further into the room as I watched her blood pressure creep downwards on the monitor. I wanted to be helpful, but I was a medical student and lacked the necessary training. After a while the resident looked up, remembered I was there, and told me it was late, that I should go home. When I didn’t move, he said, “She’ll be alright.” Her lips were gray. As I walked out of the hospital, into the cold night, there was a part of me that stayed in that room. How could I go back to my apartment, and my normal evening of preparing dinner and watching TV, when her life was in crisis? 

The next morning, I put on the gloves, the gown that reached my ankles, and the mask, then turned the knob on the door. Her crib was in the center, wires connecting her to a blinking monitor. Other than a couch pushed against one corner, the room was empty, with no traces of any visitors at all.

I walked towards the crib, leaned my shoulders against the bars. Suspended from the crib was a collection of dangling toys, a squishy yellow one and hard blue one. I looked over the bars at the child, who I’ll call Esma. Her lips were pink now. Her ears were covered with downy hairs, pierced with small studded earrings. She had a c-shaped dimple on her chin. I whispered her name through the bars and she turned towards the sound, saliva pooling at the corner of her mouth. Her eyes tracked mine. I pressed my hand into hers; her muscles were soft and underdeveloped. She didn’t squeeze back on my fingers.  Her lips opened and closed without a sound. 

I brought the stethoscope to her back, listening to her lungs, which sounded like crinkling tissue paper. I whispered as I examined her, telling her that her heart sounded strong, that the medications were working. I was surprised to hear the gentleness in my voice and relieved by how natural it felt. The role of caregiver was new to me and I was pleased that it was one that suited me.  

“How’d she look?” the resident asked later. 

“She looks so healthy. She looks like a normal kid.” 

He smiled. “No, I mean her lungs. How do they sound?” 

“Oh, right. Yes, lots of consolidation.”

“The junkiest I’ve ever heard,” he replied.

When I returned to her room the next morning, her hair was combed and pulled into pigtails using two scrunchies. I touched her hair and glitter covered my gloved hand. I didn’t know who had done her hair—not her parents, who hadn’t been able to visit. I imagined that a person working overnight had slid the elastic off her wrist. Had she whispered to Esma as she combed her hair? 

As I stood in the hospital room, it comforted me to know that someone else, a member of the hospital staff, had momentarily ignored the pulse oximeter on her finger, the tube poking out from her shirt, and had seen this rosy-cheeked child whose hair needed a good brushing. I took it as proof that I was not alone, that it was possible to have moments of softness in a setting that demanded stoicism.

In the weeks that I cared for Esma I hoped she’d recognize me, turn her head when I walked in the room, squeeze my hand, maybe even smile. I knew it was impossible: her nerves lacked the ability to send the message to her muscles. And yet, I waited for a sign that I was as important to her as she was to me. Or perhaps, I wanted something in this hospital, with its plastic-wrapped syringes and professionally disinfected toys, to feel familiar to her.  

When I met Esma, I’d already made it through clinical rotations in psychiatry, family medicine, and surgery. The hospital was beginning to feel less foreign to me. Even as I gradually adjusted to the setting, it wasn’t until I was alone with my patients that I felt I could relax: we were both out of place in the hospital and perhaps we saw that in each other.  

Halfway through my pediatrics rotation, I had time off for break. Esma was doing better: she was responding to the medications and her fever was down.  I opened the door, breathing in the quiet of her room. The midnight person had arranged Esma’s hair so it was half up and tucked into a beret. I made sure the door was shut, then I moved my mask to the side, and kissed the girl’s small forehead. 

When I got home, I stuffed my white coat into the hamper and told myself to leave the hospital behind. I packed a suitcase and left for the airport early the next morning where I planned to meet my parents, brother, and sister. As I stood in line at customs in Bogota, Colombia, kicking my duffel bag forward, I realized that the last six months had felt like an extended study abroad experience, every month or so going to a new hospital and a new specialty service, where I learned new acronyms and new ways of talking. There was a part of me that wanted to get as far away from the hospital as possible, and another part that longed for the familiar. I didn’t want to be in a new country. I wanted to be home where I could spend time with my classmates, the only people who knew exactly what I was going through, but it was too late to turn back.

A few days into the trip I got sick, most likely a virus I’d caught from one of the children in the hospital. Each time I swallowed, I felt sharp prickles inside my throat. I had a fever and alternated between shivering and sweating on the hotel’s smooth white sheets. I was angry that the hospital’s viruses had followed me here, onto the plane, into this new country. I pictured the resident, still at the hospital, eating dinner from a Styrofoam container, and felt guilty for feeling sorry for myself. He was still there and I had escaped.

I’d brought a spiral notebook with me on the trip. Before we had started our third year of medical school, our deans had told us to “process”, that it was our responsibility to deal with what we experienced so we could come back refreshed for our patients. I flipped to an empty page. I didn’t want to process. Processing was for people who didn’t have fevers, who were rested, and happy; but I wanted to feel better and didn’t know any other way. I pushed hard on the pencil but no words came. I put away the notebook. I couldn’t process this alone: it felt too big.

When I got to the hospital after break, I had a set of hair clips with me. I’d seen them dangling from a hook beside the grocery checkout and planned to leave them in the crib for the midnight person to put in Esma’s hair. I played with them in the pocket of my white coat on the elevator ride up. When I opened the door to Esma’s room, there was no one there. 

I went to the back room. “Did Esma leave?” I asked the resident. He was in between bites of a sesame bagel. There was a glob of cream cheese on his thumb and I waited to see where it would end up. 

“You didn’t know?” he said. “She died. When was it?” He scratched his head. “I think it was at least a week ago. I remember because I was on.” 

“Wait, what? She died? Esma died?”

He nodded. He passed me the sign out with the names of the new patients, his fingertips leaving a grease stain in the top corner.

I searched for her name. Could he be mistaken? 

“I’m sorry,” he said. “Esma wasn’t a great learning case. I’ll help you find a better one.” I could tell he wanted to say more but I was glad when he didn’t. Even if he had asked if I was alright, I would have assured him I was fine. I wanted him to think I was capable and quick, not sentimental. 

When I got home that night, I fell onto the couch. My partner asked how my day was and I shook my head. I cried while feeding myself forkfuls of pasta. As the tears flowed, I thought—this is too much. After I stopped crying, I put the hairclips in my dresser and shut the drawer.

The following week, I told my clerkship director that my first patient had died. I hadn’t planned to tell her and it surprised me even as I said the words. She looked at the place where my hands gripped the chair. She scooted closer. “It’s funny,” she said. “We do lots of reflection with residents when a patient dies. But we don’t do it for medical students. Your time here is so brief, we forget how involved you are in the care.”

She was right. Every month or two they got a new group of students; there was just enough time to learn their names, teach them to care for young patients, evaluate them, and send them off to do it again. Residents, on the other hand, trained at the same program for several years. I understood the constraints, the pressure of having so much to teach students in a short window of time, but still, I was frustrated. In the back room, huddled around the white board, we’d discussed the importance of the first years of a child’s life. Infants and young children absorb everything; they learn to smile, to grasp toys, to say one or two words; those first years are the foundation for all the learning that comes afterwards.1 

Medical students are not children. We’ve worked hard. We’ve proven we can meet deadlines, learn large amounts of material, manage stress. We’re able to endure short-term challenges for long-term rewards. But developmentally, if becoming a doctor is a fifteen-year process, we’re young. We’re in our first stages of development. Why not invest in these early and formative years? Why wait until residency to teach us to cope? 

For the remainder of medical school, I thought about Esma. Or rather, I thought about my reaction to her death. I pictured myself on the couch in my living room, the tears on my cheek, the cold pasta in my bowl. I told myself it wasn’t sustainable. I had to learn to get less upset. I had to detach more, to compartmentalize what I experienced in the hospital. My tears were a sign that I didn’t have the emotional toughness to make it in this field. I had failed at this test of stoicism. 

It wasn’t until I graduated medical school and started residency that I learned that my reaction was normal. Medical students remember their first deaths in vivid detail; they recall feeling flooded by emotion; most of the time no one talked to them about the death afterwards.2,3 Over time they begin to feel that it was inappropriate or unprofessional to feel so affected by the death, just as I had. For the first time, I saw that my reaction was not a sign I cared too much; rather, it was proof that I had known Esma, cared about her, and she was my first patient who had died.

In medical school my classmates and I attended hundreds of lectures and reviewed thousands of slides, but we never had a course on death and dying. This is not uncommon: most medical students learn very little about end-of-life care or its effect on providers, and as a result feel underprepared to provide quality care in this area.4,5  In the past few years, more medical schools have begun to incorporate palliative care education into the curriculum, including my own medical school, but it is not an accreditation requirement.6 Ideally, palliative care education should be integrated throughout the four years of medical school.7 Students should learn end-of-life communication skills through workshops with standardized patients, and learn how to treat pain at the end of life or how to refer to hospice through lectures, online modules, or pocket guides.7,8 

The night after Esma died I cried. I talked to my clerkship director. I went back to the hospital the next day and the next. I had a reaction to what I experienced, but that is not the same as processing. Medical students may have less responsibility and fewer work hours than residents, but because they are in their early stages of development they need more support, not less. There were two hundred other students in exactly the same stage of development as I was; we could have helped each other. When medical students process together as a group, they feel less alone, learn coping strategies, and become more aware of their emotions.9,10 There should be protected time for medical students to attend a sixty- to ninety-minute group session, with the same people each week, led by a qualified facilitator, where they discuss these difficult clinical cases and their reactions to them.9

I am several months into my residency training now and already have cared for several patients who are dying. Sometimes we debrief after a patient dies, but it is highly dependent on who I’m working with and how busy we are that day. The pediatric residents at the program where Esma died may have felt prepared to cope with a dying child and debriefed after the fact, as my clerkship director suggested, but that is certainly not the norm. Most residents will care for ten or more dying patients during their training, but eighty percent of them will receive no formal training on end-of-life care.11,12 Residents are often the ones to lead end-of-life conversations with their patients, most of the time unsupervised, even though they’ve never been formally taught to do so.13 The lack of training isn’t fair to patients and puts unnecessary strain on medical trainees, who are left feeling that they failed their dying patient in some way.14

There have been efforts to cope with death within the hospital, including debriefing sessions after a patient death, memorial services to reflect on patients who have died, or “death rounds” devoted to discussing reactions to a patient’s death, but none of these have been aimed specifically at addressing the needs of medical students.15-17 Because medical students are constantly changing hospital sites and specialty services, it is the responsibility of the medical school, and not the hospital staff, to ensure that students receive continuous support as they move through their clinical years. 

Sometimes after a particularly difficult moment in the hospital, I come back to my computer, log in, and tap uselessly through the chart, because stopping, even for a moment, and letting the gravity catch up to me feels overwhelming. There is often a medical student seated beside me at the computer. Perhaps she is watching my mechanical movements, my compulsive box checking, and computer clicking, and wondering how it is possible to appear stoic in these moments of intensity. It is only possible now because I have the experiences before me to fall back on. I have Esma to remind me that it will not be too much, that it’s possible to keep going.

Caring for dying patients is a part of our job and we want to do it well. Our patients want us to do it well. But we cannot do it alone; as trainees, we need time to practice, to mess up, to talk to one another and realize our reactions are normal. Medical students will face life and death moments during their first two years in the hospital. They can learn about it with our help and with our guidance, or by themselves, standing in the doorway of an empty hospital room. 

1. Daelmans B, Darmstadt GJ, Lombardi J et al. Early childhood development: the foundation of sustainable development. The Lancet. 2017:389:9-11.

2. Rhodes-Kropf J, Carmody SS, Seltzer D, et al. "This is just too awful; I just can't believe I experienced that...": medical students' reactions to their "most memorable" patient death. Academic medicine : journal of the Association of American Medical Colleges. 2005;80(7):634-640. 

3. Kelly E, Nisker J. Medical students' first clinical experiences of death. Medical education. 2010;44(4):421-428. 

4. Lloyd-Williams M, MacLeod RD. A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum. Medical teacher. 2004;26(8):683-690.

5. Fitzpatrick D, Heah R, Patten S, Ward H. Palliative Care in Undergraduate Medical Education-How Far Have We Come? The American journal of hospice & palliative care. 2017;34(8):762-773.

6. Paturel, A. Let’s Talk about death. AAMC News: 2019. Published 2019 Jan 15. 

7. Head BA, Schapmire TJ, Earnshaw L, et al. Improving medical graduates' training in palliative care: advancing education and practice. Adv Med Educ Pract. 2016;7:99–113. Published 2016 Feb 24. doi:10.2147/AMEP.S94550

8. Shaw EA, Marshall D, Howard M, Taniguchi A, Winemaker S, Burns S. A systematic review of postgraduate palliative care curricula. Journal of palliative medicine. 2010;13(9):1091-1108. 

9. Gold JA, Bentzley JP, Franciscus AM, Forte C, De Golia SG. An Intervention in Social Connection: Medical Student Reflection Groups. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. 2019;43(4):375-380.

10. Weyers S, Noack T, Rehkämper G, Wenzel-Meyburg U, Schulz C, Schmitz A. “I just realized that something happened to me today” — An innovative educational approach to support students in dealing with the dissection course, death and dying. Annals of Anatomy - Anatomischer Anzeiger. 2017;210:160-163.

11. Wilson PM, Herbst LA, Gonzalez-Del-Rey J. Development and Implementation of an End-of-Life Curriculum for Pediatric Residents. The American journal of hospice & palliative care. 2018;35(11):1439-1445.

12. Schroder C, Heyland D, Jiang X, Rocker G, Dodek P. Educating medical residents in end-of-life care: insights from a multicenter survey. Journal of palliative medicine. 2009;12(5):459-470.

13. Schmit JM, Meyer LE, Duff JM, Dai Y, Zou F, Close JL. Perspectives on death and dying: a study of resident comfort with End-of-life care. BMC Medical Education. 2016;16(1):297.

14. Schroder C, Heyland D, Jiang X, Rocker G, Dodek P. Educating medical residents in end-of-life care: insights from a multicenter survey. Journal of palliative medicine. 2009;12(5):459-470.

15. Eng J, Schulman E, Jhanwar SM, Shah MK. Patient Death Debriefing Sessions to Support Residents' Emotional Reactions to Patient Deaths. J Grad Med Educ. 2015;7(3):430–436. doi:10.4300/JGME-D-14-00544.1

16. Schoenborn NL, Cheng MJ, Christmas C. A memorial service to provide reflection on patient death during residency. Journal of graduate medical education. 2013;5(4):686-688.

17. Smith L, Hough CL. Using death rounds to improve end-of-life education for internal medicine residents. Journal of palliative medicine. 2011;14(1):55-58.

Editor's Commentary

Lila Flavin is a PGY-1 in psychiatry at NYU Langone.  She has published short stories in Embark and Torrid Literature Journal.