Broken Hearts

School of Medicine

This submission earned Juhi Varshney second place in the Synapse Storytelling Contest's personal essay category.

It was my first day off after a string of emergency department shifts as sub-intern, and I was sad. I wished that I wasn’t. I wanted to rewrite the feeling, as if I could delete it like a line of text and type in something hopeful and upbeat in its place.

It was a beautiful day, the fickle San Francisco sun beaming down as a breeze crackled through the trees overhead. I wanted to feel wonder at new storefronts I’d never seen before as I walked this stretch of 16thStreet, joy at the colorful murals tucked around its corners. I wanted the strangers that I passed to know that I was smiling through my mask when we made eye contact. I wanted to imagine myself as the young woman perched over the outdoor seating that was overtaking the sidewalks of cute cafes, who looked like she didn’t have a care in the world as she poked at her pupusa and sipped a colorful drink, her hair dancing in the wind. I wanted to appreciate the smell of char that seeped through taqueria window I waited in line outside, the fall of sugar crystals from the churro I ate impatiently on the walk back to my car. I could feel the pulsing city underneath and around me, construction workers tweaking a window and folks milling around their tents propped against sidewalk, couples of all ages strolling hand in hand, the swirl of overlapping conversations filling the air. The neighborhood felt alive today, and I was alive too. As I let myself feel my sadness, unsure when it would ebb, I realized that broken hearts still beat.

I thought about my watcher last week who came in with a history of alcohol use disorder, varices, and a presumed gastrointestinal bleed. He’d been living on the streets for years, and he had visited the emergency department multiple times these past few months. He was too altered to answer our questions, but his hemoglobin was so low that we didn’t need the story after all. His blood alcohol level was through the roof. I’m not sure he understood what was happening as I tried to explain our plan to him. I couldn’t help but wonder – what brought him back to the bottle each time? What had he seen? And what hadn’t he seen, the kind of tenderness and love and protection that I take for granted every day, that he should have had?

I remembered a prickly patient who lit up when she talked about her grandkids. She had developed a swollen foot over the last few days. It turned out there was a rash over the swelling too, maybe fungal but I wasn’t sure, that started right when she moved to a new shelter. She’d had a below-the-knee amputation on the other side years ago so I had no counterpart to compare it to, but when I examined her lone foot towards the end of her physical exam, she coughed. Casually, I asked how long she’d been coughing, did anyone at the shelter have it too? She got moved to an isolation room and I was taken off her case, and I knew it was wrong but I hoped her COVID test came back positive so that she could get put up in a hotel room that night.

I saw a middle-aged woman who presented with crushing 10/10 chest pain. She’d been seen for this a few times recently, and all the notes wanted to diagnose her with GERD despite no improvement on omeprazole. We did a full work up and after completely normal imaging and labs, when I tried to get a better sense of the triggers of her pain, I learned that the pain got worse after she watched news about the pandemic and when she worried about finances now that she hadn’t been working. It turned out that she’d felt anxiety like this before, shortly after her brother was detained by ICE last year. I printed off some materials on COVID-induced anxiety in Spanish, and we chatted about how anxiety exacerbates pain. After strong return precautions, we sent her out, like a wisp of wind disappearing into the night breeze. I hoped her pain improved but there was no real way to ever know.

And I couldn’t forget the sweet woman with a “headache” who arrived around midnight on my first night shift. She’d been living on the streets for a while and just wanted some time under a roof. She didn’t really have a headache, she confided to me during our lovely, somewhat circular, conversation. I returned to her room soon after with a plate piled high with snacks from the pantry, and she was all packed up ready to leave, like she’d been quickly swept out the door plenty of times before, like she was all too familiar with not feeling welcomed in spaces like ours. We had an empty waiting room though so I took my time working up her non-emergent complaints and let her get a nap in. When we had to discharge her back to the street around 4 AM, it was harder on me than it was for her. She said that she was used to this – but I sure wasn’t.

One skill I’ve practiced during my emergency rotation is my bedside echocardiograms. I’ve learned how to capture a slice of someone’s heart with the ultrasound probe and through one glance at fuzzy black and white images, get an immediate sense of their cardiac function. I can say whether they’re dehydrated or not, if they’ve got fluid in their lungs too. I’ve seen young healthy hearts, I imagine mine looks like that too, with decisive ventricular wall contraction and an anterior leaflet of the mitral valve that hits up against the septum when it opens up. But I’ve also seen hearts that whimper each time blood pools in, that can’t bring themselves to squeeze all that well, hearts that are so weak that the blood gets sent backwards to the lungs. These hearts still beat though, despite the odds.

Ultrasound is a quick way to get a general sense of someone’s cardiac reserve, but there’s plenty it doesn’t tell us. It doesn’t reveal that I’ve felt vulnerable and sad and painfully human these last few weeks. Ultrasound doesn’t show us how losing a home can break a heart or how living on the streets changes people. Or what kind of pain brings some patients back to the bottle or the needle. How our patients mourn loved ones lost to trauma and violence, how families fracture after someone gets deported. How lives have become untethered, shattered, in the wake of a ruthless pandemic that has no real end in sight. But neither do we see how our patients push through and move forward each new day.

I’ve learned that we don’t really lean into these questions in the emergency setting. We’ve got so much on our plate already, stabilizing tenuous codes and bringing vitals back to a steady place, making sure we don’t miss a hidden injury on a trauma patient, following ominous lab results as they change during a shift, giving strict return precautions when we discharge patients, especially when we send them home without real answers to their symptoms, repeating ourselves for the interpreter phones who can’t hear anyone through the layers of our masks. Our role is to make sure our patients don’t actively die in front of us. But plenty of people are dying slowly of broken hearts, aren’t they?

It makes sense to look away from the broken hearts; we can’t fix them in the emergency department and maybe we ought to just focus on what’s under our control so we don’t burn ourselves out. But I can’t bring myself to look away just yet. Maybe bearing witness makes me feel like I’m honoring my patients’ pain, or maybe it’s that opening myself up to the hard stuff allows me to feel the unexpected moments of connection too, but I’m learning that it’s not about trying to keep our hearts from ever breaking - it’s about how we find ways to mend them time and time again.