Joshua Knew
Originally published at Welcome To The Dollhouse. You can comment here or there.
his time of year, right before Christmas, I always remember one of my first patients in residency, Joshua. His story was so powerful when it happened back in 1988, that I eventually wrote about it and submitted the essay to JAMA, where it was published in 1993. I realized recently that I had kept this story so close to my heart that I had never mentioned it to AdoringHusband. Tonight I thought I might share a revised telling of Joshua’s tale with you, my friends.
Joshua Knew
Joshua knew before I did that it was time. I went to see him just as I had done numerous mornings before. He lay on his bed, still, except for the slow rise and fall of his chest. His sallow skin was lined with fine blue veins. I drew closer, avoiding the tangle of tubing and wires that sprouted from him like roots from a plant. His small hands rested delicately on his distended belly. He was a small boy, appearing much younger than his 5 years. He slept peacefully, his sandy-blonde, sleep-tousled hair decorating his pillow. His round cheeks were spattered with brown freckles. A clear oxygen mask covered an upturned nose and slightly agape mouth.
I nodded my hello to his mother, who sat ever present at his bedside. I wanted to do my morning exam without waking him, as he had been having so much pain and discomfort. Luckily the pain meds seemed to be holding him today.
As I leaned over to listen to his chest with my stethoscope, Joshua awakened. His teal blue eyes fixed on my face. Gone was the hazy, unfocused look we typically saw when Joshua was awake. Now his eyes spoke of urgency and purpose.
“I don’t need this anymore,” he said, and pulled off the oxygen mask. “I’m ready to die now.”
I looked at his mother, trying to hide my shock. Where did this come from? How did he know it was time?
For three weeks I had struggled to make this child well enough to go home for what would inevitably be his last Christmas. Now, on December 17, Joshua was telling me that the fight was over. Five-year-old Joshua knew that it was time.
His mother reached to take his hand, brushing tears from her cheeks and I backed away from the bed still too stunned to process what I had just witnessed. Joshua had drifted back into unconsciousness. I felt a lump forming in my throat, and I knew that my tears would soon follow.
As I left the room, I struggled to regain control of my emotions. This was not the time to be the intern who falls apart. I needed to hold it together for Joshua and his family. These weeks on service caring for him made me feel so helpless, standing by, watching him die, bit by bit, unable to heal him. Whenever we thought one problem had improved, two more arose. But I wanted more than anything for Joshua to have his last Christmas at home. Joshua, however, had decided otherwise.
Looking through his hospital room window, I saw his mother speaking to him, pausing to kiss him softly on the forehead. She seemed so strong, while I felt as if I were being torn apart. I turned away from the window and saw Joshua’s father walking toward the room. I leaned back heavily against the wall, as if seeking strength from the building itself. Covered with the faces of gaily colored smiling clowns, the wall was a stark contrast to my solemn expression. He approached me, searching my face for some sign of hope. Slowly, I managed to form the words, to tell him that Joshua was ready to die. He set his jaw grimly and went inside. I followed reluctantly, feeling impotent and useless.
Both parents now sat next to him on his bed. They murmured softly, telling him how much they loved him and that it was OK to go with Jesus. They would meet him there soon.
I stood at a short distance, willing myself not to cry. I turned to watch the monitor, focusing intently on the tiny tracings. Gradually before my eyes, the heartbeat became slower and slower, until it stopped. His parents held Joshua as they cried in their grief. Mechanically, I moved forward when they had laid him back on the bed. I put the stethoscope in my ears, placed the diaphragm on Joshua’s chest, and listened to the silence. He was gone.
I mumbled condolences to the parents and hurried from the room. Walking rapidly down the hall, looking neither right nor left, finally I reached the stairwell. After closing the door behind me, I sat heavily on the concrete steps. A soft wail escaped from my lips as my heart began to ache. My eyes welled, blurring the gray stairs and walls into a wavering leaden blanket that felt smothering. Tears splashed on my cheeks as I wept for Joshua. Soon, however, angry sobs racked my body as all the frustration and impotence overwhelmed me. After a while, I could cry no longer. There was nothing left. So I sat, tracing patterns on the dusty stair, asking myself the unanswerable questions.
Why couldn’t I have saved my little Joshua?
Why does AIDS have to win every time?
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