The night I called Code Lavender

July 1995. It was my first night of internship, the next step after medical school.

I’d already admitted a half dozen patients to the Cardiac Intensive Care Unit from the emergency room under the watch of a third-year resident. The CCU was the scariest first-night internship assignment there was. Even some patients joked about avoiding heart attacks in July when the new interns started each year.

My next admission was Mr. Jones. “I never met a steak I didn’t like. But then, you can probably tell that. I guess I’m paying for that now!” He joked. He was alone, divorced, no one with him out in the waiting room.

Mr. Jones looked small in the hospital bed—pale and diaphanous, his mustache soggy from the sweat beading on his upper lip. His chest pain had receded with the intravenous medications we’d ordered to hold his blood pressure down. I’d just finished explaining the coronary angiogram, the procedure we’d scheduled to see if there were any clots in his arteries, when he reached for my hand:

“Doc,” he said. “I’ll be okay, right? Nothing bad will happen to me? I won’t die?”

“Of course you won’t!” I said. “It’s a routine operation. The mortality is less than 1%. You’re going to be fine,” I assured him in my clean white coat, proud of remembering a statistic.

He squeezed my hand. I left to continue my all-night rounds, going patient to patient to make sure they were tucked in and to prepare for reporting to the attending physician in just a few hours.

Dr. Kahn arrived at 8 am for rounds. He wore a collared shirt under a black tailored suit, no tie, weekend casual. His strong cologne made me woozy but kept me awake. There were several other doctors-in-training, a nurse, and a clean-cut pharmacist named Mark whose smarts endlessly saved me in that first CCU rotation.

We stopped outside Mrs. Rosen’s room. I was up.

“Dr. Makoff,” asked Dr. Kahn. “Can you tell me what you heard when you listened to Mrs. Rosen’s heart?”

My own chest started humming as I realized I’d failed to note the details of her heart murmur on the white index card in my coat pocket. Was it systolic? Diastolic? On the left, the right? Whooshing? Radiating? I couldn’t remember.

“Um. Well, I know she had a murmur. But honestly, no. I don’t remember the details. I’m sorry.”

I trembled as I waited for the infamous wrath of Dr. Khan. But it never arrived.

“Ah, first night of internship. Understood! Let’s all go take a listen together.”

And we filed in, making a U around Mrs. Rosen’s bed, silently watching as Dr. Khan pressed his stethoscope first to each side of her neck, then the right upper chest, then left. On to the base of the heart, then over to the left side of her rib cage, asking her to hold then breathe several times over.

When we emerged, I noted that Mr. Jones was still not back in his room. I wasn’t worried because I hadn’t been to the cardiac catheterization lab before and wasn’t sure of the protocol. Perhaps he was in the recovery room lifting from anesthesia.

But later I noticed that Mr. Jones’ room was all cleaned up. New linens dressed the bed and the floor sparkled like it was prepped for a new patient.

And then I got the news.

He had a rare complication. A freak accident. His coronary artery dissected on the table.

Mr. Jones had died.

My chest heaved as I took in this information. I’d assured him he would be alright. I couldn’t believe he’d just been there, nervous in his bed, and now was no more. I felt out of my own body, like I was watching this scene in disbelief.

I’d experienced patients dying in medical school. And sure, I’d worked with cadavers, those already dead. What made this so different was a new sense of responsibility. I was the doctor who took his history and physical, who ordered his treatments, and who discussed the risks and benefits of his options.

I was the one who helped him make the decision to have the procedure that would take his life.

I felt at fault, as though I should have made the choice harder and not diminished the risk. I shouldn’t have assured him he’d be okay. I should have done something, anything, different than what I’d done.

I was the doctor who took his history and physical, who ordered his treatments, and who discussed the risks and benefits.

I was the one who helped him make the decision to have the procedure that would take his life.

“Come on, Eve. Let’s go to the autopsy and see what happened,” my resident nudged me, excited. “It’s not often you get to see things start to finish. This is a great opportunity for you.”

But I felt crushed. Exhausted. Not lucky.

I followed her down into the windowless bowels of what felt like a huge submarine. The sweet gummy smell of formaldehyde that had stuck to my clothes for all of first year of medical school eked around the corners as we neared the post-mortem room.

And there was Mr. Jones, like a wax replica of himself, his yellow-white belly already bisected.

In his gloved hand, the pathologist held Mr. Jones’ bloody heart, outside of his body. He displayed the splayed vessel to the group around the metal table.

But I could not focus.

I struggled to move on from the life to the death of my patient, especially faced with such a gruesome display.

This was the norm in medical education. We were rushed through the hardest parts, no time to process.

A man had just died. He was the 1%. I needed a moment.

It would be years before I learned how crucial it was as a health care provider to give such moments their due. Such strong emotions demand time. Unacknowledged and unaddressed, grief threatens your integrity. Whether you are one to explode or implode, the potential damage to your psyche, to your body, or to your relationships is enormous.

Unacknowledged and unaddressed, grief threatens your integrity. Whether you are one to explode or implode, the potential damage to your psyche, to your body, or to your relationships is enormous.

Nearly 20 years later, as a palliative care doctor, I learned how to hold space for the suffering of patients and their families. But I also learned to acknowledge my own needs and those of my colleagues when we were impacted by what we witnessed every day. We had to let our feelings breathe to stay whole.

My Code Lavender

In 2014, at that same hospital, our palliative care team came up with a way to ask for support when we needed it. We called it “Code Lavender.” And soon after, I would need it.

I was in the hospital room of a 30-year-old patient named Joshua. His parents had flown in from Boston to see him. His condition had taken a serious turn, and I knew we would lose him soon, unthinkable as that was for his parents.

But nothing prepared any of us for how Joshua would die.

As his liver and kidneys failed, the toxins made him increasingly disoriented. But that day, unable to express what he was feeling, Joshua just held his stomach and moaned all day. I stood at his bedside for hours pushing medications that the nurses weren’t allowed inject, trying to manage what seemed like pain.

But as the sun went down, something changed in Joshua’s color. He looked ashen grey.

“Joshua, what is it?” I asked.

“I just…I don’t…” and suddenly, in one large mass, a clot of blood launched from his mouth. His eyes rolled back, and just like that he was suddenly, horrifically gone—right in front of his parents.

“No! No! Joshua. No!” His mother lept to her feet from her stoop on the darkening window. She was wailing, her husband trying to contain her writhing body, but she wouldn’t have it. She ran out of the room and he followed as they flew as far away from the monstrous scene as they could.

I walked to a small chair just outside the room and eased myself down. I texted my colleague Todd.

“Code Lavender,” I typed. “Please.”

Todd was there in minutes. “Do you want to tell me what happened?”

“I don’t think I can right now,” I said in a daze. So we sat there quietly together until my body whirred down from the events of the day.

I needed that moment, that pause, and the kindness of my colleague, to metabolize what I’d seen before I could be present when the parents returned. Before I could move forward in any way.

Since that day, Code Lavender and other programs caring for the well-being of medical staff have spread to hospitals throughout the country as part of a much-needed humanizing trend in the medical profession. Narrative medicine and other attempts to put the human connection back into the increasingly quantitative and automated practice of medicine have strengthened the emotional bond between health care providers and those they serve. It’s a welcome development, but the closer connection means even greater emotional vulnerability for providers, especially when outcomes are tragic.

I could have used a Code Lavender the day we lost Mr. Jones, but it didn’t exist at the time. Instead, I got an autopsy.