When the Worst Doesn't Happen

I speak fluent snark. “Dark and twisty” is my love language. When work is slow, I cannot enjoy it; I anxiously wait for the other shoe to drop. I actually talk with my colleagues about how the way for parents to avoid their child ending up in an ICU is to kick dogs—it seems our patients’ families are always the nicest people in the world, and that their children are so sick is just incredibly unfair. I know it’s a coping mechanism and not a particularly elegant one. Always expecting the worst is a very blunt tool, but it’s gotten me this far. It’s stopped me from being overcome by sadness and the sometimes frank brutality of practicing pediatric critical care.

Recently, my penchant for bleak irony was tested. Okay, that’s understating it; it sustained severe damage. A truly ill child came to us days from dying unless we mobilized everything our hospital had to offer and carried out his care with (forgive me) surgical precision. This kid was great: kind, intelligent, funny, and loved so deeply that it was palpable from outside his room. His family was terrific: kind, intelligent, funny, and the unabashed givers of that love. Our patient and his family moved through the world as a team—all for one, one for all. The responsibility of caring for this little boy was massive. So many things could go wrong, and he would only live if a very narrow path of things went right. And the people in this family very obviously did not kick dogs. I was terrified. I think all of us were terrified, honestly.

A couple of days into his ICU stay, he started to decompensate. As I turned over my care of him to the night shift, I thought, “Here it comes.” On my way to the parking garage, I thought, “Here comes the awful. And he’ll still survive, but it will be a rough few days.” But when I came in the next morning, bracing myself for the worst, I found he was the same as I’d left him; his condition had plateaued, not continued its downward slide. As my post-call colleague signed him out to me, I clicked through his flowsheets and labs wide-eyed. He wasn’t just stable. He was kind of stably good. “Okay,” I thought, picturing this great kid and his amazing family, “maybe good things happen to good people.” That thought was fleeting, though. I still had a day shift to get him through, so I armored up by thinking of the Serenity Prayer for intensivists, “It can always be worse.”

We rounded on him that day as a massive multidisciplinary team, a herd of nurses, residents, and fellows watching three attending physicians teeth gnash about what the right thing to do for him was. The benefit/burden calculus was at the varsity level. Our patient’s family was right there with us: some of them in person, some of them on the phone, asking great questions, helping us hold the uncertainty, and then committing to what we thought the best way forward was. However, as the day shift came to the night shift, he had another decompensation. “That’s it,” I thought after signing out to the night shift, “Tomorrow will be awful. He’ll still probably live, but it is going to be hell for everybody involved until then.”

I rehearsed rounds in my head on the drive in. I wanted a solid opinion formed when the other two attending physicians and I started our teeth gnashing. And then, right before rounds, a call came that the cure for his condition could be on the way. We just needed a little bit more time, like 12 more hours. Then, the anxiety took on a different quality. We didn’t have to play not to lose; we could start playing to win. Playing to win meant six distinct things had to go perfectly. The first three happened seamlessly. “Huh,” I thought, “Okay, maybe good things happen to good people.” The next two followed in quick succession. Then, I felt my armor crack, and I started feeling hopeful that everything would work out. “Don’t do it,” I thought, “Don’t get hopeful. You’re going to break your own heart.” Snark. Dark. Twisty, Bleak irony. Then the last domino fell, and the last thing that had to happen happened without any iota of a hitch. As I looked at my patient and his family, a switch flipped, and I allowed myself to fully believe that good things can happen to good people. And then I took in all the people who cared for him, how hard they worked, how meticulous they were. And then I considered how luck, the universe, God, or Whatever intervened, and suddenly, we found ourselves in the absolute best-case scenario. I was overcome. With overwhelming joy. With gratitude. With awe. It felt amazing, and I let myself just be in it. No anxious “plan B” making, no dry humor, no “great, on to the next.” And do you know what? Days later, I still feel that joy, and I can look back at my anxiety with a bit of amusement.

Always expecting the worst can, oddly, feel safe. Many of us have developed the magical thinking that if we plan for the worst-case scenario, the worst-case scenario won’t happen. Or if it does, at least we’ll already have a plan. But the flip side of always expecting the worst is that it blunts the happiness available to us when good things do happen. It can stop us from recognizing the parts we played in getting the good outcomes. I’ll probably never get rid of my doom-and-gloom disposition, but I will start playing with the concept of equal airtime. For every eye roll to draw attention to the irony, I will look for the good. Good things can happen to good people. And maybe, just maybe, that includes me, too.