“So few grains of happiness

measured against all the dark

and still the scales balance.

The world asks of us

only the strength we have and we give it.

Then it asks more, and we give it.”

—The weighing, Jane Hirshfield [1].

As I drive East to the hospital watching the explosion of early morning colors, my anxiety pierces the stillness, as I anticipate the day of work ahead. That colorful morning light promises a day as varied as its vibrant hues and shades. This day distinguishes itself from others—I will be caring for critically ill adults in my Paediatric intensive care unit (ICU). As I get closer and the day brighter, I hope that I will have the strength to shoulder that weight.

He is visibly struggling to breathe, and we tell him that we will have to intubate him. We watch him go pale with the fear of death; disobedient tears roll down his face. He asks no questions. We allow an unconditional silence to reign for a few seconds, a silence so opaque that no one can estimate its depth. As I watch him, something swells up urgently inside my chest wanting to pour out, but that is impossible. I quickly move to the window, and the emotions that bubbled up so painfully and so stormily, sink back down resetting the scale.

We keep him asleep in seemingly lifeless state, a dreamless sleep, untouched by consciousness of life’s burdens. Time passes and we wake him up. He stares back at us in befuddlement, as if rudely awoken from deep slumber. Despite the disfigurement from weight loss, illness has not stolen the expression of pride on his resolved face. As he slowly emerges and we eagerly try to communicate with him, a timid sadness creeps back into his gentle eyes. We promise him recovery. Hope sways in and out of the picture, at times vanishing into the distance.

As his medical condition fluctuates, we carry the weight of that promise.

Tap, tap, tap, tap, tap—she pats his arm lovingly. This gentle gesture, so starkly contrasted against the intrusive beeping of the monitors, the alarming of the ventilator and bustle of providers, is etching in my mind. Rhythmic and comforting, the patting continues like a metronome, against the backdrop of medical updates, poor prognoses and bad news. We tell her that he will not recover and that he will not survive, Tap, tap, tap—she continues. We tell her that we have done all that we can. She tells us about him, about them and their life. Tap, tap, tap. As she continues to pat his arm, she searches our faces for hope and for the possibility to scale the balance in his favor.

A family spends time with their loved one who is dying. They have mustered their ability to distance themselves from their reality and spend moments trying to capture and share happiness. We hear faint laughter from his bed spot. A junior trainee is reticent to participate in this moment and interprets the scene as a lack of insight into the gravity of the situation. A senior nurse and I understand the importance of that fleeting laughter and comradery, which only superficially and momentarily help them forget the tragedy of their situation. For a moment, they allow themselves to ignore their inner turmoil, the grim predictions and the oppressive sadness that live in the deep of their minds. As the terrible finale draws near, they allow themselves moments of joy to transiently shift the balance.

In another room, a loving husband lies in bed waiting. The day’s activities—turning and suctioning—are the only discernable notes that break the monotone rhythm of the undifferentiated tedium that is supportive care. I watch his tidal volume increase as he takes a deep breath from the ventilator. He confirms that he is fatigued, and that the ventilator air is unpleasant, as he scribbles on his whiteboard. He asks for the windows to be opened. We reassure him that he is ready to breathe on his own and he is extubated. He speaks softly, only semi audible monosyllables cross his lips while the muscles on his face strain heavily. He is so fragile and triumphant in this moment. That weight in me shifts.

His bed faces the window. Three of us watch rays of sun burst through the thick cloud cover, dispersing a blinding white light and forcing us to draw the blinds. As we tell him his wife is coming, his eyes glimmer with relief. We speak about when he will drive her to her upcoming immunization. I caution him about his present state, the rehab ahead and taking things slow. But he is hopeful and the scales balance.

It is not what I expected. Our preparation focused on the physical weight of caring for these patients and safely proning their large bodies. The responsibility of caring for patients outside our comfort zone—practicing, at times, unfamiliar medicine—also weighed heavily on our subconscious and fed our anxiety. Yet, it is the emotional burden of caring for these patients and their families that weighs most heavily on us.

At day’s end, I drive by a park where people of all ages, happy and seemingly carefree, enjoy the sunset which predictably and gently marks the passage of time. I watch a couple exchange a warm embrace, a healthy child laughs, and at home, my son interrupts my thoughts with his complaints about dinner. As I slowly re-enter this other world, beautifully colored with trivialities and normality, the scales balance.