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<p>I have been lucky enough to never lose a patient.</p><p>I do not say that lightly. I know too many stories that end otherwise. Somehow, so far, mine haven’t in eight years.</p><p>There have even been moments that felt miraculous. A patient, weathered by years of psychiatric diagnoses and despair, finally responded to treatment. Another, minutes before the neurologist team was set to declare brain dead, took a spontaneous breath. And there was the man whose vena cava ruptured mid-surgery. I was just a student assigned to shadow the case. But I stayed with him and his wife through when I could slip away from my surgery rotation during that week she slept in the ICU. I prayed with her. I sat silently beside her. And, a year later, I was TA’ing for a radiology course. I turned a corner and there he was, walking through the hospital for one-year follow up. He recognized me. We hugged. He remembered my name and told me I’d make a fine doctor one day.</p><p>All of these maybe just short of a miracle (though be assured I did indeed pray). Stories that could have ended in death but none did.</p><p>Before medical school, I worked as an EMT. On my very first day, they handed me a bulletproof vest. I laughed. They didn’t. That was the first clue. I worked with Duke EMS and spent weekends volunteering in Vance County. The calls were chaotic. Sometimes they were dangerous. And always they were fast.</p><p>One night, we picked up a man whose body was beginning to betray him. He was unconscious. His limbs were curling inward. His pupils barely reacted. I started bagging him the moment we reached him and didn’t stop until we rolled into the emergency bay. His oxygen saturation started low, and during one hard turn on the road, it dropped even faster. I didn’t fully understand the physiology at the time. I only knew that when the brain goes too long without air, something irreversible happens. Something shifts. The medic let me give the handoff. As we were loading the stretcher back into the rig, she looked at me and said, If you hadn’t bagged him right, he wouldn’t have made it.</p><p>That stuck with me. So did the training. Our EMT course wasn’t exactly gentle. They threw everything at us including sirens, strobe lights, death metal blasting, and a man in a clown mask shouting in our faces while we practiced compressions, ventilations, and spinal immobilization. In one simulation, an earthquake had supposedly leveled a building. My partner was missing. When I finally found him, they’d turned him into a casualty. I hadn’t noticed. He was a massive firefighter, playing unconscious. When I reached him, he broke character just long enough to wink and ask why I had left him behind.</p><p>The scenarios were contrived, yes. But they were also an invitation. Into something heavier. Into the gravity of it all. I remember one instructor in particular, a gruff Israeli military medic. Toward the end of the course, his voice broke as he told us the number of patients he’d lost because someone applied a tourniquet too late. There was no theatrics in that story. Just a quiet warning. Pay attention. People don’t get do-overs.</p><p>But the closest I came to losing a patient happened before I had even begun formal training. In truth, it was a patient already lost.</p><p>It was a call in Oakland. Fire had arrived just ahead of us. A LUCAS device was already thudding against a man’s chest. He had been diagnosed with stage four throat cancer just a week ago. He lay on the floor in a pool of black bile. His eyes were open. Fixed. But as I stood at the back, gathering history and talking to his wife, I found that they locked on mine, like he was still trying to speak. Still trying to be seen. We worked him for three full rounds of epinephrine. Still no pulses when the LUCAS was paused. The medic made the call.</p><p>He was gone long before we got there. But his wife didn’t know that yet.</p><p>There were more than a dozen of us in the room. Medics. Firefighters. I was just a ride-along. The lowest of the low. But I was the one still talking to her. Gathering his medical history.</p><p>When she was told, she hugged me.</p><p>There were no words from me in that moment.</p><p>That night, my cousin, that paramedic asked me again how I was feeling. She knew, I had lost my father just a month before. Until then I had felt nothing but numb. That night, I didn’t feel numb. I felt sure. Becoming a doctor would mean getting there in time. It would also mean knowing how to stay when we didn’t.</p><p>She confirmed what I already suspected. He was pulseless when we arrived. The machine had been pumping but there was no one left to save. Then she asked me a question I have never been able to forget.</p><p>What if we could have saved him? What if something had gone wrong?</p><p>This is where the silence begins.</p><p>This note started as I typed on my phone while waiting in line for confession. I had nothing to say except the truth. I am heartily sorry. That is what I was there to say. And what I say now.</p><p>I wrote it because, while waiting, I came back to her question. What if we could have saved him? It was not a challenge. It was a kind of mercy. A way of saying, be ready next time.</p><p>So now I think ahead to that future first time. The moment I will have to walk into a quiet room and deliver news no one wants to hear. When we were trying, and there was still some flicker of possibility. And I know what I want to be able to say to the family that we did everything we could. That I did everything I could. Not because it is the right thing to say in a formulaic manner. Because it is the truth.</p><p>I want to have known enough. Practiced enough. Cared enough. So that when the time came, I did not hesitate or let the moment slip past. So that even exhaustion, or grief, or whatever I am carrying that day does not touch the work. Does not dull the edge.</p><p>And maybe that’s something I carry with me. An intensity. A weight. Very well. </p><div><hr></div><p>I have already seen what waits. I saw it in that room. His eyes were open. Fixed. The machine worked his chest in perfect time but the man was already gone. What was left in the room was silence and bile and the long stare of death itself. I met it. I did not turn away.</p><p>Fortune is fickle and I have already been blessed for too long. One day it will come again. I only pray that when it does, I will meet it the same way. Steady. Without fear. Without lying. Without flinching.</p><p>That is the vow. To know enough and care enough that I do not have to speak words I do not believe. To be exacting in my craft and honest in my sorrow.</p><p>I do not ask for perfection. Only that I am not found wanting.</p><p>This is the note I wrote to myself. Amor fati. It is a promise. 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