Note: The Nocturnists is an audio-first experience with emotion and sound design that can be difficult to fully capture in text. Transcripts are provided to support accessibility and reference, but may contain minor inaccuracies. If quoting in print, please consult the audio when possible.

Emily Silverman: This is The Nocturnists, and I'm Emily Silverman. Today's episode features Dr. Nikki Mittal, a pulmonary and critical-care physician. Nikki tells a story from the ICU about caring for a patient who had suffered a devastating brain injury after cardiac arrest and a family preparing to withdraw life support. At the time, Nikki herself was going through a painful period in her personal life. After one difficult interaction with the patient's wife, she left the room worried that she had failed in the one part of her job that matters most, but on the day the family gathered to say goodbye, something unexpected happened.

Instead of asking Nikki for guidance or reassurance, the family asked if they could pray for her. Nikki originally performed the story at a live Nocturnists Satellites storytelling event produced by the San Bernardino chapter of the California Academy of Family Physicians, with support from the California Health Care Foundation. In my conversation with Nikki, we talked about the realities of working in the ICU, how physicians navigate conversations about death and dying, and the moments when the usual direction of care shifts. First, here's a clip from Nikki's live story.

[music]

Dr. Nikki Mittal: I'm standing there facing this woman, and she's my height. I'm only 5'2". We start holding hands, and she starts praying. She says, "Dios, Dios, Dios," "God sent you here, and God tells me you're a very smart person. You're a smart doctor. You're supposed to be here to help these patients." As she starts chanting and praying, everyone in the room starts doing their own chanting and praying, and it's not in unison.

Everyone is just speaking their own words. You could feel this whole energy starting to rise up in the room. I'm trying not to cry. I'm trying to just be present and put out all of my good energy into the universe for this family to have some peace with this moment. As she keeps praying, all of the other voices in the room drown out. All I hear is this woman holding my hands, staring into my eyes, and I can just hear very clearly every word she's saying.

As she start with these, like, "Nikki, you're a good doctor. You're very kind. You're smart," she starts instead to peel me open, seemingly speaking and addressing things that have been weighing down in my heart. "I know you're going through a hard time. I know you're walking a very difficult path. God tells me you're going to be okay. I know the choices you're making right now aren't easy, but you must keep going because it's the right choice, and everything will be okay."

Now, at this point, I don't know how she knows this about me. I've, of course, been a mess. Every time I'm in this room, I'm holding it together. It feels like she's staring directly into my soul and just picking out all of these things that have just been making me feel like I'm going to collapse at any moment. She's taking them, and she's just giving them wings, and making them lighter, and addressing them all.

As she keeps talking, oh, if I was a mess before, you better believe I was a mess now. I have big, ugly tears streaming down my face. I've got snot screaming down my face. I am squeezing your hands. I am shaking. I am trying not to collapse in this moment as she is just pouring all of this love in her hardest moment onto me. Really, in this moment where I'm supposed to be her support, she's actually just lifting me up.

[music]

Emily Silverman: I am sitting here with Dr. Nikki Mittal. Nikki, thank you so much for coming on the show.

Dr. Nikki Mittal: Thank you for having me.

Emily Silverman: Nikki, you told a story at one of our Nocturnists Satellites shows. To begin, maybe you could just tell us a little bit about that experience. What was it like to stand on stage and tell your story?

Dr. Nikki Mittal: I'm not a stage performer normally, actually, so it was a little bit daunting. The story was so impactful for me, so I felt very honored to get to tell it, and then I got to go last. I got to watch other people go up, which was nice. Then the thing that I didn't really realize until I was standing at the mic was that you can't actually see anyone in the audience, which made it incredibly helpful, because it is a very deeply personal story. I think if I was making eye contact with people in the audience, it would have thrown me off a little bit more. It was really cool.

Emily Silverman: Your story takes place in the ICU. You are a pulmonary critical-care physician?

Dr. Nikki Mittal: Yes.

Emily Silverman: You're an attending, yes?

Dr. Nikki Mittal: Yes.

Emily Silverman: Tell us, how far out are you from fellowship? Where do you practice? What's your practice like? What kind of ICU medicine do you do?

Dr. Nikki Mittal: I did my residency and fellowship at USC in Los Angeles, and I finished in 2015. At this point of this story, I'm 9, 10 years out. I've been practicing at the county hospital. I just left that job, but that's where I got my first job out, and was for 10 years. That was full-spectrum ICU and a county population. I had residents and fellows and a lot of teaching, and ran everywhere, doing all of it.

Emily Silverman: For people listening who are medical students, who have never been in an ICU, or maybe somebody who's not in medicine and has been fortunate not to have to ever be in an ICU, can you paint a picture for us? What is the ICU as a space? As an ICU doctor, tell us a bit about a typical day, or what it feels like to be at work in the ICU?

Dr. Nikki Mittal: The ICU is, I think, a lot of controlled chaos, lots of noises, alarms, people, but there is a rhythm and control to the whole unit. There's a lot of patients on ventilators, and the ventilator is very rhythmic. There is vent alarms. There's IV pumps beeping. There's just a lot of noise. Then, when things are getting hectic for a patient, someone's not doing well, there's just compounded noise on top of noise.

My brain, and I think probably a lot of ICU physicians, are ADD, ADHD-ish, so the constant task-switching and noise interruptions actually works well for me. It's a place that I definitely thrive. On top of all of the noise, there's a lot of emotion. We see the extremes of life and death. We see people who are brought back from the brink of death. There's so much joy and happiness that this person is better and going to get out of the ICU. Then we see the patients that we know are not going to survive.

We have to carry a lot of that weight as well with these families. I think it's actually the patients that aren't going to survive, like addressing those with kindness and compassion, I think, is equally as important as all of the other procedures and medications and things that I do, so being able to help these patients and their families understand what's going to happen. It isn't like a ton of bricks falling on them when their loved one passes away. I think it's just so vitally important to the job of an intensivist. I take that part very seriously.

Emily Silverman: There's different types of ICUs. There's medical ICU, surgical ICUs, neuro ICUs. Do you do mostly medical or only medical?

Dr. Nikki Mittal: I do medical, but our medical ICU, we don't have a neuro ICU or cardiac ICU. It's like a full mix medical.

Emily Silverman: Oh, okay, so you see cardiac patients and some neuro patients as well?

Dr. Nikki Mittal: Yes, so we do heart attack, strokes. We do anything that's coming through, that isn't surgical, that's an adult ICU, because I only practice adult medicine, will be in our ICU.

Emily Silverman: That's what you meant when you said "full spectrum." It's like you're the generalist of the ICU.

Dr. Nikki Mittal: Yes.

Emily Silverman: That could be on the medical side, anything from septic shock to pancreatitis or things like that. On the cardiac side, people in severe heart failure, people having heart attacks. Then on the neuro side, people having strokes, but also people having traumatic brain injuries, brain bleeds, that kind of stuff?

Dr. Nikki Mittal: Yes, and then preeclampsia, eclampsia, anything that's not going to be surgical ICU will come to us.

Emily Silverman: These are the sickest patients in the hospital.

Dr. Nikki Mittal: Yes.

Emily Silverman: There's a lot of doctors who would look at that and run as far as they could in the opposite direction. They would rather be in their outpatient clinic and that kind of thing. I'm just wondering. You mentioned a little bit of thriving on the task-switching and things like that. Just curious, what drew you to ICU medicine specifically?

Dr. Nikki Mittal: Actually, my mom and sister are both family med physicians. Well, I didn't think that I wanted to practice pediatric care. I veered away from family medicine, and I just decided that adults is where I wanted to settle. When I went into residency, I went in with the intention of being outpatient primary care physician with a focus on LGBTQ and HIV care. That was my niche that I wanted to do.

My first year as an intern, I did a month in the ICU. It was during swine flu. There's a lot of young patients coming in and just dying, and I did not understand what was going on. As I went through it, didn't matter what rotation I was on, I was going to apply myself. I was trying to do my best, but I was like, "This is awful. I hate every minute of this. I need to be done." I got through it, and I got to do a bunch of procedures, which, again, that's not what I'm going to do in my life anyways.

Then, when I switched out, I switched to the next rotation onwards. I was like, "This is so weird. I think I have Stockholm syndrome because I kind of miss that. What is going on here? What is this feeling? It doesn't make any sense to me." Then I happened to get another month of ICU as an intern. At USC, there was only 5 out of the 55 interns I got to. Just like, "Whatever. The universe was telling me that this is what I needed to do."

I was one of those five interns. Now, I had mostly a year of internship under my belt. It was towards the end of my first year, so I had a little bit more of a grasp on what was going on in medicine and my role as a doctor. Then that second month through, I was like, "Oh, no, this is absolutely for me. I've got to do this. Okay, how do I apply? What do I do to get there?" Then the rest is history, I guess I say. [chuckles]

Emily Silverman: When people talk about pediatrics, you mentioned peds, they sometimes talk about how you're taking care of the child, but you're also taking care of the parents of the families, especially when the children are so young that they can't speak or communicate. You're speaking and communicating with their surrogate decision-makers, their parents, their family, their caregiver. It becomes almost like your patient isn't just your patient. Your patient becomes the family unit.

I wonder if you see it that way in ICU medicine as well, because, as we know and as listeners may or may not know, a lot of patients in the ICU do end up intubated and sedated and are lying on a bed, prone, and sometimes even paralyzed. Super severe illness could be like that for weeks, and you can't speak with them. The only human who you could really speak to are the people who are coming in to visit, and the family and the decision-makers. I was wondering if you could speak a little bit about what it's like to be in that space. I think it has maybe a bit of a metaphor to the pediatric space in that sense.

Dr. Nikki Mittal: I never thought about it like that in relation to the pediatrics, but you're so correct. It is that you aren't treating just the patient. You've got a whole family member. Oftentimes, on these patients that I know aren't going to survive, I think the best thing I can do for them is to take care of their family and to bring their families some peace with the fact that this is not going to be a good outcome.

It is that everyone in that room that has love for this patient is also part of my care plan. What am I going to do to ease this? That's the best way as I can in this moment, take care of this patient, because I can't fix his stroke or his heart attack or whatever it is. What I can do to honor him and respect him as a patient is to be kind and let his family understand what's going on so that they aren't wracked with all kinds of, I don't know, guilt and sadness and anger over his passing, at least to the best of my ability.

Emily Silverman: These families are often in really different situations. For example, there could be an elderly person who's chronically ill, who's been ill for a long time, who's been in and out of the hospital for a long time, and has been slowly decompensating. This is a person, maybe, who's been in the ICU a few times. Now, they're back in the ICU. This is something that the family might be used to on some level.

There might be some amount of acceptance in the family, or some amount of denial in the family about the illness trajectory of that person, of that patient. Then on the flip side, you might have a family where it's like, "My husband was jogging yesterday and then popped an aneurysm in his brain. Now, he's in a coma, and my entire life just changed overnight." It's like things fell off a cliff in a way.

I'm wondering. When you're walking into a room, attuning to where the family is at and how they're processing the illness of their loved one, and, obviously, there can be really sticky family dynamics. Not everybody in the family agrees with each other. Not everybody in the family agrees with the medical team and the medical decisions. That is a very different skill set than knowing how to titrate pressors or how to execute the perfect extubation. [laughs] How do you think about that skill set?

Something that's so important to have in the ICU, it is such a technical and scientific specialty with extremely advanced technology. You've got ECMO machines to understand acid-base really well, and PaO2s, and all of that. It's very sciencey. At the same time, [chuckles] you got to walk in a room and attune to the family dynamic. It's almost different skill sets that, in some ways, you might think are rare to coexist in one human, but a lot of ICU doctors have it all. They can do it all. Just wondering how you think about, particularly the more interpersonal and relational aspects of ICU care. It's quite the work to be doing.

Dr. Nikki Mittal: You're so kind in the way that you explain it all. I've never really thought about it this way. You are opening my eyes to all kinds of aspects of my own career and life. Yes, I think I have always been an observer. I'm always watching everything around me. I'm not a writer, but I'm an observer. I think it's just very natural for me to walk around and try to gauge the mood and the sense of the room in any room, no matter what I'm doing in my life. I think part of that has been self-protective, right? I'm a small woman.

I've had situations in the past, just like what's going on around me. I think that has served me well, because then I walk into a room, and I can quickly gauge. Where is everyone? Are people getting along? Are people not getting along? Who is what? The other thing that I rely heavily on are the nurses, because the nurses spend a lot of time with the patients and in the room, and the family members that come through the room. They often know a ton of stuff about what's going on. "Hey, did you know that he's got a girlfriend and a wife?"

Emily Silverman: [laughs]

Dr. Nikki Mittal: "Did you know that the son and the daughter aren't friends anymore, and they don't get along, and they're both angry?" The nurses give a lot of information. Before I ever walk into a room, if I have the chance, I'll stop by with the nurse and just like, "Make sure that I have the up-to-date dynamics." That always helps a little bit, too, walking into these rooms. Sometimes you don't, and sometimes you just walk in, but I always try to get as much recon as I can before I walk in.

Emily Silverman: Yes, it's a different way of doing a chart biopsy. You go into the electronic chart, and you want to learn all about their prior cultural data and all that, but doing a "chart biopsy" on what's--

Dr. Nikki Mittal: The social.

Emily Silverman: The social, yes. It's so important. You mentioned the word "observer." Have you ever heard of the Enneagram personality test?

Dr. Nikki Mittal: No.

Emily Silverman: [laughs] I really love personality tests. It's just something that I've always loved. There's this one personality test called the Enneagram, and there's nine types.

Dr. Nikki Mittal: I'm going to write this down somewhere.

Emily Silverman: Oh, good. There's one, two, three, four, five, six, seven, eight, nine. I think it's Type 5. It's actually called the "observer." When you said that, it just made me think about the Enneagram because it's not evidence-based [laughs] at all, but it's built on spiritual traditions. I think there's something about the observer phenotype that lends itself really well to medicine in general, but I see medicine in particular like that detail-orientedness.

I once heard somebody say that ICU medicine is like baseball. It's a game that's won, catch by catch, or something. It was a baseball metaphor. The idea was, in baseball, to win a baseball game, it's actually not about stepping up to the plate and hitting the grand slam or hitting the home run and these majestic moments that it's making sure you always catch the grounder that goes to the shortstop. It's always making sure that you throw the ball to the first base and pitching well. It's almost more hygienic this way of thinking about it, that it's actually the accumulation of these tiny, little moments that make you win the game.

Dr. Nikki Mittal: Yes, it's not just the intubation. It's recognizing when and why and how you can adjust the vent in these little ways to turn them around. It is all the little details and all the little moves make the difference, I think. That's where my observer nature really comes into handy, because I'll be like, "Huh, that looks a little bit different than before, right? Isn't it a little more purple now, I think?" Yes.

Emily Silverman: Totally. Like, "Oh, we need to suction more today," and you do that every day for 12 days. It's like, "Oh, suddenly, they just look a lot better." We didn't really do anything, except suction them-- [laughs] The nurse switched. Suddenly, you have a nurse who's suctioning them much more aggressively, and it makes all the difference. I don't know. I'm just throwing that out there, but just wanted to throw out some respect to the observer, Enneagram phenotype. [laughs]

Dr. Nikki Mittal: I think also in the ICU, just like baseball, it's very much on your team.

Emily Silverman: Yes, team sports.

Dr. Nikki Mittal: No one thing is done alone. There's the RTs, the PTs, the OTs, the nurses, the physicians. It's just like any good patient outcome I've had has not been on me alone. It's because I've had this incredible team by my side that has walked with me and listened to the million orders I rattled off in three minutes and responded appropriately and had foresight that this thing was happening and pulled the pressers. Lucky to have the team that I get in the ICU.

[music]

Emily Silverman: Tell us about this story. You're at a place in your life that's challenging. I think you describe in the story, you have a new baby, and you're leaving a marriage. There's just a lot of stuff for you interpersonally that you're struggling with. The one thing that you can always lean on, your rock, is that you're an ICU physician, and you're really good at your job. Then you show up to work one day. You inherit this family. There are some last-minute changes to their decision-making.

There's a little moment of friction with the family, where one of the family members approaches you and says, "I didn't really like this interaction that we had," or I think the word she said was, "You weren't kind," or, "That wasn't kind." I'm wondering if you can open up that moment for us a little bit, because as much as we like to believe that we're perfect, we're not. [laughs] What was it like for you to get that negative feedback in that moment and also at this moment in your life?

Dr. Nikki Mittal: Well, I think at this moment in my life, especially as an intensivist, it's like I try to control so many things, vents, pressers, meds, family members, emotions, right? All these things, I'm running around trying to control as things are going chaotically. It's this place I am in my life where everything is chaotic. I feel like I have zero control over it. Not only do I have zero control, did I cause all of it? It's really foreign. I'm really out of sorts with my own self. I've spent how long, I'm 43 now, building this life? It is just destroyed, seemingly.

While I think it's the right thing that all these things have to end and change, that doesn't make it easier. Is it the right thing? I don't know. I think so. I don't know. It's so difficult. I was like, "You know what? The only thing I know I'm really good at that I can do well is just be this doctor. At least let me go to work. Let me put these things aside and do good and just focus on the thing that I can do." Again, I mentioned how important I think it is to have these conversations with compassion and really be there for the family.

I knew I wasn't performing at my peak here with everything else going on in my life, but I didn't think I was failing. When she said to me, "You weren't kind," when you said that to us yesterday, I just felt this wave of nausea wash over me, like, "Oh, I'm failing everywhere. I'm failing my children by leaving this marriage. I'm failing myself. I'm failing my partner." I'm just failing everywhere. This thing that I'm not supposed to be failing at, because it is my rock, the thing I know, no matter what, I am good at, now, I'm just failing at that, too, like perfect.

Emily Silverman: This was a difficult conversation about end-of-life care that she was referring to.

Dr. Nikki Mittal: Yes. In my mind, the guy who had signed out to me had already had all of this conversation because they were going to withdraw. When I'm having the conversation for the first time, I definitely approached it differently than I did that day, but they had already been there for five days and made this decision. One of those "trust, but verify" things, I should have just started with my gut, where I normally start, instead of assuming some of this stuff had been covered, or that they understood what had been covered. That was where I wasn't really at my peak performance. I just jumped into the middle instead of starting at the beginning, where I normally would. It wasn't not kind, but it was just a little bit more matter-of-fact and a little bit less soft on the edges about how I deliver.

Emily Silverman: It also speaks to the challenge of handoffs when someone's been there for five days, and there's a narrative going, and then, suddenly, the doctor switches out. It's hard to plug right back in. Different day, different person. That's another challenge of this work. Okay, so she says this to you, and you have this feeling like, "Oh, God. Now, I'm failing in every realm," [chuckles] but you keep showing up.

Obviously, you keep showing up to work. You keep showing up for this patient and for this family. You're taking care of this person. Ultimately, they do decide to withdraw life support and let the patient die naturally. One of the family members, I think it's the same one, correct me if I'm wrong, she came up to you. She said, "I prayed, and I realized that God sent you here to help me come to terms with to accept my loved one dying." She changed her mind. What do you think happened?

Dr. Nikki Mittal: I don't know because even that next day and every day thereafter, when I saw her in the room, she didn't give me any extra kindness. She didn't smile. She didn't give me any inclination that she was okay with me. She wasn't mad at me. She was absolutely not mean. She was not rude. She was just very straight and dry. That next day, she just said, "We're going to withdraw on Sunday." I said, "Okay." The daughter must have gone home and just explained everything, but okay.

I didn't think that it had anything to do with me. I don't know when she came to this moment of peace with me, the wife, but I'm so grateful she did because it is one of the greatest impacts the patient's family has had on me. When they all came to the room, I had seen four people of this entire family. Two brothers, a wife, and this one daughter. They just, behind the scenes, decided that they were withdrawing.

I had told them, "I know you guys live very far away from this hospital. I'm sure your kids are working. We can do an iPad meeting. We can go on Zoom so that they can all ask their questions, because I know a lot's going on. It sounds like maybe you guys didn't know what was going on." She said, "No, Wednesday. We're going to withdraw on Sunday." I was like, "Does anybody have questions for me or want to meet?" She said, "No, Sunday." "Okay." It was just very out of nowhere and very matter-of-fact. Again, not angry, not particularly sad, just straight, matter-of-fact. It was really strange, I thought.

Emily Silverman: It wasn't just, "No, we made a decision. We're going to do this on Sunday." It was, "No, we made a decision. We're going to do this on Sunday," and, "God sent you to help me accept this," so what did it feel like to hear that?

Dr. Nikki Mittal: I was a little bit happy because I was like, "Okay, she doesn't hate me."

[laughter]

Dr. Nikki Mittal: "Maybe I haven't completely failed at my job." I actually run the critical-care course for the UC Riverside School of Medicine med students, their fourth year. I tell them, like, when someone's family has maybe inappropriate or a reaction that you're not expecting, you should always consider what you did wrong. The natural default, like, "I should have done something different." If you play through that and you didn't and you were right, then it's not about you. It's about them.

You can do everything right, but patients cope, and patients' families cope with bad news and these heavy things in ways that you can't always control or expect. When you get something wild, just remember. It's just about their grief and where they are in coping with this process. As many times as I've told students that, I was just not in a space to even take my own advice.

When she was like, "You weren't kind," I wasn't like, "Oh, I think I was fine." This is not about me. It's about her. I was like, "Oh, my God, I failed." When she said, "Oh, God, sent you to me so I could understand and be at peace with this, and that you were going to tell me what was right," I felt very validated like, "Okay, I'm not a failure at this entire thing that I've spent my whole life building towards all of med school, all of residency, all these missed holidays, and I'm not failing."

Emily Silverman: She says this, and you feel a little bit of relief. There's this feeling of, "Okay, she doesn't hate me," which is a good feeling, but then it goes further. She says, "Could I pray for you?" Not just, "Could I pray for you?" but, "Can the family pray for you?" I think you said there was 13 people in the room, 10 people in the room, something like that.

Dr. Nikki Mittal: No, there was 13 kids, plus their partners, plus a few brothers. It was just probably 25 people in this small ICU room.

Emily Silverman: Wow. Okay, and this is the--

Dr. Nikki Mittal: There was chairs, standing room only. There was just people everywhere in this room.

Emily Silverman: She says, "Can we pray for you, Doctor?" You say, "Sure"?

Dr. Nikki Mittal: Yes, of course, yes.

Emily Silverman: You've probably heard that before, I feel like most doctors. You'll have a sweet patient grab your hand and say, "Can I pray for you, Doctor?" There was something else about this, so she starts praying, and the rest of the family starts praying. The way that you described it in the story was really beautiful. You say they weren't all praying in unison. It's not like they read a prayer out loud, and they were all saying the same words out loud. It was different than that.

It was this woman was praying in her own way and with her own words, but then all the people in the room were also praying in different ways, different prayers, different words. It was almost 12 or 15 different prayers happening at the same time, but all of them were pointed at you. These prayers are going on further and further, and then she starts to say some things that feel a little bit like she knows things about you that she shouldn't. [chuckles]

You said in the story, I think, "Please, God, let's pray for this doctor. This doctor is going through a hard time," but there's no way she could have known that. She's piercing into your soul, in a way, and she clearly read something off of you about the fact that you were going through something. You have all these people, this whole family, praying for you and placing that attention on you, and you're standing there. What was that like in that moment to have all that attention placed on you in that way, in a loving way, and also in a way that felt like, "Ooh, I'm being seen in a way that I didn't expect"?

Dr. Nikki Mittal: It was really overwhelming. It was palpable. I could feel this warmth around me, and all of these people chanting separately. Whatever they were all saying, I couldn't actually make out any one, single sentence outside of what this woman, who was facing me, I'm looking at her eye to eye, is saying. It was palpable. It was powerful. It felt enveloping, supportive, loving. It was mystifying, because she is.

She's like, "I can tell you're going through a hard time, and I can tell you're making hard choices, but the choices you're making are the right choices, and you need to keep going." I'm thinking, "Am I hearing this, or am I now just officially going crazy? This is it. I've hit my breaking point. I'm having a nervous breakdown. This is all too much for me." I think I'm hearing it. I understand Spanish. The interpreter, though, is standing right next to me. She's repeating it in English.

I was like, "No, I am hearing everything that I think I'm hearing." I'm not making it up with a bad translation because I'm crazy. She's literally saying all of these things, and then I just started crying. There was a question. I'm leaving everything. What else isn't serving me at this moment that I need to clean out of my life? Do I need to be here at this job? How is this job serving me relative to now being a part-time, 50% custody parent? I commute very far to this job. Is this the right thing? Am I sacrificing what kind of mother I am because I'm commuting an hour each way to this hospital?

I'm working in the ICU, which sometimes is unpredictable hours. How is that going to impact my children, now that I don't have a partner at home to be there when I'm late? Is it going to be a nanny that's going to be with them instead of a partner? Does that make me a bad mother, or all of these things? She was like, "You were supposed to be here taking care of these patients. These patients here at this hospital need you, and you could be at other hospitals." It was just so specific. I was like, "Oh, my God. Can she read my mind? What is going on? How is this happening?"

Emily Silverman: Wow.

Dr. Nikki Mittal: It was insane. Then, even when I walked out, the interpreter, I really squatted down and just finished ugly crying out at the nurse's station. I've been at this hospital for nine years. I know all of the interpreters. I've never seen this interpreter either. She was very kind. She goes, "Honey, are you okay?" I was like, "No, I'm not." Okay, that was so much. Even she was like, "I've been in a lot of those, and I've never been in anything so powerful. I'm not sure what she's talking about, about what you're going through, but I can tell you're going to be okay, because you're really special for them to have done that, and you are going to be just fine." I was like, "Who are you?"

Emily Silverman: [laughs]

Dr. Nikki Mittal: "Where did you also come from? This is crazy."

Emily Silverman: Oh, my God.

Dr. Nikki Mittal: "I've never seen you. This family just did this." I've never seen that interpreter again. I don't know if she just works-

Emily Silverman: Was she real? [laughs]

Dr. Nikki Mittal: -Sunday that I'm never on, or I don't know what it was, but I know everyone at this hospital. I've been there for so long. "Who are you, and how are you also coming and telling me that I'm going to be fine?" That's something you've never seen before, and so that must mean I did something right.

Emily Silverman: Did that experience shift your spirituality in any way, shape, or form? I don't know. To me, it sounds like a spiritual experience, and I'm wondering what kind of impact it had on you. I used to be somebody who didn't believe in magic, or didn't believe in oracles or messaging coming from the universe, but I've had a few moments where not quite as intense as what you're describing, but you have these moments. Sometimes you're like, "I don't know. This feels like something from beyond." I'm wondering if it shifted how you think about those things.

Dr. Nikki Mittal: I don't know how I would describe my spirituality. I believe in signs from the universe. I did not match at my number one program that I was told I was going to match at, this, "A tale as old as time," and then I ended up at this program. I was crying when I opened up my envelope, and it turned out to be the best thing for me. Year and a half later, two years later, it's now my number one program for fellowship, and I get to stay there.

I open up the same envelope that says the same program. A couple of years prior, I immediately started bawling. This time, when I get to stay there for fellowship, I'm jumping up and down. It's this fellowship that I didn't have any idea was going to be on my radar. I think that was a sign from the universe that this is the place for me. I do believe in signs from the universe.

This is just one more sign from the universe that, okay, the days that you doubt yourself, the days that you think you are just ruining everything epically, it's okay. Keep going. This is right. Just set this incredibly low moment personally with everything that was going on. It really lifted me up and gave me some peace to just keep marching forward despite what fresh hell I was going to be coming to walk through in this new path that it was going to be the right path to walk through.

Emily Silverman: Typically, people think about doctors helping patients or doctors healing patients, but it's so relational. The healing flow sometimes moves the other way. It sometimes moves in reverse. I'm wondering if you have ever thought about that, or if you've seen that a lot in your practice, in the ICU in particular, which is such a heightened environment. How do you think about this idea of patients and their families healing the medical team?

Dr. Nikki Mittal: Oh, yes, no, I definitely do because I think there's those patients and their families, and you give them bad news. They immediately turn around and thank you, and are so gracious. I always try to imagine if I'm in their shoes, and I'm getting this horrific news about my family member. The first five thoughts in my head aren't to think the people taking care of my loved one.

I'm always just reminded of the kindness of people in that moment and the graciousness, and how many times, especially right after the pandemic, where I'm in a county hospital that doesn't strongly believe in COVID or the vaccine or all these things. We are in the trenches of COVID, and all I'm doing is getting called all kinds of names by people who just don't believe that their loved one is dying.

We deal with a fair amount of abuse, disbelief. Again, some of that is just people not coping with the emotions that they're having to deal with, with someone dying. Don't think a lot of that's about me. In the end, I still am there seeing it. I'm still absorbing people's sadness as I walk through this journey with them about someone in their life passing away or having this catastrophic injury that's going to change everything.

There's really distinct times and patients that I can still think back to and remember where I felt they impacted me specifically. Not at all because of the medicine, lots of cool medicine stuff I've gotten to do, but because of the nature of how they handle things and how they approach me and how they've approached the patient and the situation. It's just a master class in grace sometimes.

Emily Silverman: That's beautiful. Well, I think that's a really nice place to end. Anything else you want to share with our audience about your story about ICU medicine, about storytelling? Anything?

Dr. Nikki Mittal: No, the storytelling was so fun. Actually, right before I got picked to be on the Satellite, I was telling another story about being on a plane to Chicago one day to someone. This guy was laughing so hard. He was like, "You could be stand-up comedian. You've got a knack for telling stories." I was like, "Huh." Then next week, I get this email that, like, "Your story was chosen for the Satellite." I was like, "Ah, the sign from the universe." He was warning me, like, I'm going to get this thing that I just tossed out there, being like, "Let's see."

It was a lot of fun. I think just reliving it and being able to share it gave me a renewed sense of peace, and also allowed me to reevaluate everything that I have done and gone through since that period, and really made me appreciate that family more. I had actually already written them a thank-you letter. I wanted to relay that, the impact that she made on me. I'd never really sent it. This brought me back to just reminding me that I should pay my gratitude to them now, a lot later, as a thank you for the piece that they gave me.

Emily Silverman: Well, maybe you can send them this episode if you find a way. In which case, I'll say a word of hello to them and to their family. Well, thank you so much, Nikki, for braving the stage, for participating in our Satellites program, for the courageous work that you do in the ICU, taking care of all that full-spectrum critical care medicine, and for coming on the show to speak with me today. It was a pleasure.

Dr. Nikki Mittal: Yes, thank you for having me. It was lovely.

[music]

Emily Silverman: This episode of The Nocturnists was produced by me and producer and head of story development, Molly Rose-Williams. Our executive producer is Ali Block, and Ashley Pettit is our program director. Original theme music was composed by Yosef Munro, with additional music from Blue Dot Sessions. The Nocturnists is made possible by listeners like you.

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