Halloween in the MICU: I was on call overnight, wearing a headband with droopy bumblebee ears, black and yellow clashing with the somber gray haze of the team room. Thus far, my call nights had torn 10,000 holes through my soul. Each was a devastating routine during which people of great medical mystery would rush in and then die by the next day without a clear cause. On rounds, we would struggle to make sense of it logically; emotionally, there was no making sense of anything. I wondered how many more ghosts I would see this night.

As if in response, a beeping pager sent me down to the emergency department, where I ran into them: ghosts, and vampires and witches, their half-costume, half-human bodies splayed over stretchers in terrifying, chaotic angles. Tattered angel wings glistened fluorescently on one side of my patient; on the other side lay her boyfriend with devil horns. “The streets of heaven are too crowded with angels tonight,” I said, and he laughed with me because we both knew that these weren’t angels, and this wasn’t heaven.

Two more people died the next day, and I pictured myself as Charon, the ferryman rowing a boat across the river Styx toward Hades. Surrounded by ghosts, working and working, unable to look up toward the passengers, unable to change course or row against the tide. I felt completely powerless; I could not find meaning or make a difference. And even if I could change something, would it be enough? Could it ever be enough?

It was a sandstorm of despair, but before the dust could settle into apathy, I fell in love with a patient and his family. He was a very old gentleman with a rare but clearly diagnosed condition with a poor prognosis. He had initially wanted to go home without further therapies, but ultimately chose to pursue advanced diagnostic and therapeutic strategies with seemingly limitless hope for cure. His specialists performed a high-risk biopsy before administering a novel therapeutic treatment. Although his recovery was long and complex, he improved considerably, providing a spark of hope for his providers and sustained faith in the positive impact of scientific advancement. He winked at me when he left the ICU.

The next morning, he was back on our service, having coded for unclear reasons. All he had wanted, initially, was to go home. What if I had pushed him to see his clinical chances of recovery more realistically, or even to reject such a high-risk procedure given his wish to go home soon? On the other hand, what if he had survived and gone home without complications? There was clearly no right answer, and I wondered wearily how much I could have changed what happened. The only thing we could still do was honor his wishes in the moment. With his family, we transitioned him to comfort care. His wife’s tears are still on my white coat.

This death was different. It left a restlessness that lifted me away from sadness alone. I had gone too far by falling in love with his family, with his other providers, with the chance for hope glimpsed during his initial medical course. “There are lovers content with longing. I am not one of them,” says Rumi. And so I began to consciously eschew complacency and defeat. I sought to capture my wistfulness and use it as fuel to drive forward days of small victories. It was an advanced emotional recycling, in this green city; an electric generator to light up faces with smiles; a sublimation of heaviest iron setbacks into bubbles of progress; a transformer to right the ship toward something better.

In medical training, I think there’s an emotional processing that precedes the necessary ability to dream. Indeed, the tide is frequently against us, a relentless siege of challenges beyond our power as individuals: patients making choices that worsen their health; homelessness, poverty, violence and abuse; patients falling through the holes within existing health care policies; medical errors, limits of medical diagnostics and therapeutics. And yet, there are the little things that can keep us going: seeing a previously depressed patient smile for the first time; connecting with other providers over a mutual clinical experience; seeing someone recover from treatable illness; finding temporary solutions for patients who cannot access care; fixing systematic and individual mistakes with integrity; and helping to bring a conflicted family together in united affection for their loved one. At some point, whether in internship or otherwise, we touch the balance between what we can and cannot change; and only then can we push that boundary, dare to dream further without accepting the status quo, and forge on without stopping until we find solutions.

Indeed, the solutions are inspiring. You see medical research advancing practice, care providers making unique efforts to ensure their patients will receive care in spite of the system’s failures and leaders motivating their teams to take pride in the practice of medicine. You see it yourself on this blog through initiatives that make an impact beyond individual cases, yielding practical and lasting systems-scale changes. So we keep fighting through the frenetic days and peaceful sunsets, the bleary nights and hopeful sunrises. To relieve suffering not only in the moment, but also in the future. To not lose confidence from our mistakes, but to find smart ways to prevent them in the future. To not only forgive ourselves and our patients, but to also make each person see the strength in themselves. To not reject the system, but instead join it and change it. To not just follow the rules, but help make them. And to remember that, when we do feel powerless, there is great power all around us and within us.

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