We take care of the living, and remember those who passed, what they taught us, and how they touched us.” These were some of the words my parents said to me after I called them, sobbing in tears, that my patient had passed away. She was only eight years old. To most of her doctors, she was the patient with retinoblastoma that had metastasized to her liver, causing her to go into liver failure. The first time I met her, she was already one month into her final hospital stay. Her legs and abdomen were so edematous, and she would groan every few hours in pain. However, after caring for her for three weeks, I felt we had done a great job adjusting her medication regimen. She was down 5 kg, looked a lot less puffy, and her pain and nausea seemed slightly better controlled. Then suddenly one morning, her blood pressure started dropping, her heart rate increased, and she had a fever – she was in septic shock. After a conversation with her mom, she told us that she wanted us to start whatever medications she needed to keep her stable. She was sent to the PICU and started on pressors.

When she returned to the floor, she was more yellow than ever, was on three antibiotics, groaned more, and talked less. Her ammonia levels were so high, it was shocking to even hear her verbalize any short sentences. Mama, qiao-ke-lee nai (chocolate milk). Mama, neng (I can). Mama, tai er xing le (so nauseous). Mama, du zi hen teng (my belly really hurts). Mama, shou bu liao (I can’t bear it). Mama, jiu wo (save me).

She was a sassy, young girl with incredible talent as a pianist. She was able to play any tune on her keyboard after listening to it. However, by the time I met her, she was already too weak to play. She was more mature than I could ever see any other 8-year-old being. I would spend hours in her room every day, watching her mom feed her, talk to her, and readjust her to make her more comfortable.

The day before she passed, I started my last 24-hour call shift of my 4-week rotation on the cancer ward. That evening, I spent a few hours talking to her mom about her life and the things she loved. I learned about her favorite foods and songs and about how she understood the seemingly complicated biblical stories her mom read to her even though she was so young. She ate more than she had in the past week that evening. I watched her as she slowly savored some watermelon, sipped on chocolate milk, regular milk, water, and apple juice, and nibbled on some seaweed (the hot and spicy Big Roll ones). As her mom wiped her mouth and I held out the basin for her to vomit into, she confessed that she might have swallowed too quickly from being too eager for the flavors of the food.

Around 6:30 a.m. on Sunday morning, she had lost a tooth, and because she was in liver failure with no coagulation factors or platelets, she could not stop bleeding. It felt like all the blood had been suctioned from her body as I looked over at the blood filling the canister connected to the suction catheter. She kept groaning with labored breathing. We collected her labs early that morning and started to give her some blood products hoping it would stabilize her until my fellow and attending could be in-house. I signed out to the day resident, went home, and slept until the afternoon. I woke up to a text message from the day resident telling me that she had passed away a few hours after I left. My heart ached for this mother who had loved her daughter so deeply – who sat by her every day, slept by her every day, only hoping to comfort her daughter.

Writing about this is difficult because her death is not supposed to be about me. It’s about her and her family and the tragedy they were forced to face. But the trauma that we as resident physicians face from witnessing a pediatric death affects us far more than we may think. Shift work requires us to come in, work, and leave. The small doses of emotion that we gather from spending time with our patients eventually build up into a large emotional investment. After my patient died, I felt like the opportunity for closure was ripped away because I wasn’t physically there for her mom when it happened. By the time I found out, her mom, whom I had spent every day talking to for the past four weeks, had already left the hospital. All I could do was cry for her and pray for her family.

When this job requires you to move on to the next patient, the next problem, the next illness so quickly, it drains our compassion and empathy, leaving a tired and burnt-out vessel. So how are we supposed to refuel that compassion and empathy to keep going?

How to sustain compassion

Silence. Warmth.
It’s not only the words that are said, but the feelings that are shared.
Sadness and joy. Death and life.
It’s not just the single day you are there for. It’s about being there. Everyday.
Forgiveness. For the anger, for the brokenness, for the irrational words and thoughts.
Forgiveness for yourself.
You are taught to extend grace to others, but more importantly, you must extend some to yourself.
Measured empathy, but endless compassion.
Sharing the weight. Sometimes knowing that it can’t always be shared.

Shouli Tung is a pediatrics resident.