“Won’t it Be Hard to Say Goodbye” – Part II

A few weeks ago I spent the early part of the morning in a hospital conference room listening to the workings of the children’s ED.  Baby boy in tow, I left the meeting and drove further south to the DFPS building for a bio parent visit. Pensive following the collision of my medical world and my foster mom world, I drafted this post, which has been one that has been brewing for months now.  Consider this a sequel to the “Won’t it be hard to say goodbye” (Nov 2013) post.

Often physician groups will devote time to “M and M”, morbidity and mortality. A time to review as a group particular cases with bad outcomes and what went wrong, what could have been done differently, what could be changed in the future.  This morning a patient was mentioned who had presented to the ED, was sent home, and came back a few days later with a very significant disease process.  The physician who had seen the patient on the initial visit spoke up, and as he described what had happened on the initial visit and the numerous times he has reviewed the chart since then, I could see his eyes watering.  Ugh, I have been there, and wow is it painful.  As a Christian, I know that it is God who sovereignly ordains the time for man to die, as is the motto at a Kenyan missions hospital, “we treat, Jesus heals”.  As a physician, I know intellectually that there are times that despite my intervention, despite my appropriate thought process and assessment of risk, etc. there can still be bad outcomes.  I remember my first boss out of residency telling me years ago about a patient he was involved with who had died.  He shook his head and said, “sometimes you just have to reconcile that you didn’t do anything wrong, you were just in the wrong place at the wrong time”.  Well, that was the sentiment that I felt hearing the story today, knowing full well that had I been the one seeing the patient on the initial visit, I would have also sent them home, and then I would have been the one pleading with my conscience to be fully assuaged by my colleagues reassurances that they would have done the same thing.

I am going to tie this back into foster care.  See, again and again, I hear, “I could never do that, I am afraid of getting attached and having to say goodbye”.  The sentiment reminds me of medicine.  And I do hear that with some frequency when I mention pediatric ER to people, “oh, I could never do that.”  Just like my colleague, who spoke with an obvious burden that morning over the patient he had treated, we all go to work every shift knowing that we are taking the same risk.  That at some point, some child is going to come along, and despite your best care and concern, things aren’t going to go as you would expect and there will be resultant significant morbidity or even death.  The physician will then be left picking up the pieces, reviewing the chart over and over, running it by their most trusted co-workers, asking themself and others again and again, “should I have done something differently?”.  That’s a heavy burden to carry.  I am reminded of an adolescent I saw years ago in the ER.  I poignantly remember him lying on the gurney in the resuscitation room and my putting my hand on his shoulder, looking down at him, and saying, “(his name), you are very sick, but we are giving you the medications that you need and they are getting ready for you to go up to the PICU … it’s going to be okay.”  But it wasn’t okay.  He went to the PICU and died 12 hours later.  I was devastated.  I was left reeling over his case, I could probably still tell you his vital signs, every medication that was given, every presenting symptom, etc. and if given the right audience I may still be tempted to rattle off his case in hopes that yet again I can hear the, “I would have done the same thing” platitude.  I remember the distracted tone in my voice for days afterwards when my children would ask me for something and I would look at them blankly, realizing that my mind was again wandering back to lab values, and IV fluids and my final conversations with that patient and his mother.  Despite my best efforts to reassure myself that there was nothing I could have done to change that outcome, I can still feel my eyes water when I think about him.

Recently a question went around on the Pediatric Hospitalist Medicine listserv along the lines of, “how do we, as hospitalists, deal with kids dying, the multitude of abused patients we see, unexpected bad outcomes, etc, etc.?”  The sentiment of the post being, ‘sometimes this is emotionally very hard, help me figure out how to cope and still be able to function in my non-hospital life’.  This single email prompted more responses than any other listserv topic.  And they were passionate responses, and responses from listserv “lurkers” who had never posted before, things like – ‘I listen to music, I take time on overnight shifts to sit in the rocking chair and hold a traumatized baby, I meet with the residents and we go over the case and use it to teach about compassion, I talk with my spouse over a glass of wine, I review with my colleagues, etc., etc.’.  But here’s the point, and listen closely, not one person, not one, said, “you’re right, this is emotionally just too hard, maybe you/we should quit?”  No one would have written that!  It almost seems comical to even suggest it.  Why?  Because we all go to work every day believing that we are making a difference, that we are helping families and children in significant distress, that we are using our skills to change the outcome of illness, often devastating illness, from bad to good.  Man, that’s worth it.  That’s worth the risk, that’s worth the (at times) emotionally heavy burden.

I find a similar resolve in the foster family warriors I meet.  Erik and I are such newbies at this, I don’t give us any credit.  But those families that have loved and said good-bye, and loved again and said good-bye, and loved again, they are true warriors.  And I know that they would tell you the same thing I would tell you about pediatric hospital medicine.  Yes, it may be painful at times, but it’s more painful to know that the need is tremendous and children are hurting and not do anything about it. Yes, there is significant risk that in this process you will be hurt, but the chance to impact a child’s life by providing them a safe, loving home for even a time, is worth so much more.  Again, it may be hard, but it’s worth risking and even enduring the hard, to have an impact that is great.

So again, I say this to make a point about fostering.  See, whether we are talking about medicine or foster care, you must realize that it’s not that any of us have developed some super-human strength that allows us to separate our emotions from work that needs to be done. Man, going back now 15 years even, I can tell you details and names and faces of children and their families who I have witnessed facing that most unimaginable pain of childhood death. They are forever etched in my mind, and sometimes when I’m reminded of them I may even be moved to tears, or else prayer for them, wishing that there were anything I could do to ease the pain I know they still experience.  In response to the listserv query I mentioned above, one person wrote, “the day that any of us stop being affected by the sad cases we are involved with, is the day we should stop practicing medicine.”  Similarly, foster parents fall in love with kids too and feel the pain of loss as poignantly as anyone. In fact, if one had the ability to take foster children into their home and remain completely unattached, well, maybe they shouldn’t be fostering.  No, it’s not that any of us know the equation for blocking our emotions.  On the contrary, we’ve made the conscious decision that we don’t care if it hurts sometimes, we don’t care if it’s painful at times, because without doubt, it’s worth it.

So, thank you, to those of you who’ve read this far and are among those foster families who have loved deeply and said “goodbye” and done it again. You know who you are. You not only have given those children a tremendous gift, you have inspired others to follow you on this path. After all, people like Erik and I have been watching you – and you’ve given us the courage to take a risk for the sake of a child in desperate need.

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