Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (4 page)

You shrug at the thought. Your fate as well, perhaps.

Pam must be thinking of the same thing. “Just kill me when I get like this,” she tells you.

“What'd she get?” you ask Jack, meaning drugwise.

“She got three of epi and three of atropine.”

“Hold CPR,” you say, hand up. The patient is now connected to your monitor and you want to see the rhythm.

Flat line. Zippo.

“I feel like I'm not doing CPR,” Julie says, “I feel like I'm beating a dead horse.” She folds her arms, glaring at you, daring you to have her restart CPR.

You glance back down at the patient and the glance confirms your first impression: it's criminal to go on.

You raise a hand. “Anyone object to terminating this code relatively early?”

Julie glares around the room. No one else moves.

You check your watch. 5:38
A.M.
In the hour of the wolf.

Code called 5:38.

The nurses are drifting out of the room when Father Minke, the priest on call in the ER this month, peeks in. “Am I too late?” he asks.

“Well, Father.” You are peeling off your gloves. “I guess it depends. She's been declared dead, if that makes any difference.”

“Okay,” he says, paging through his prayer book. You look at him again, quizzically. You didn't call him for this death.

“Father, what are you doing up this late?”

He
hmmms,
distracted.

“Father?”

He looks up at you. “I was watching TV,” he says, as if that explains everything. He goes to the foot of the bed, opens up his prayer book and begins, in an almost imperceptible whisper, his bedside prayer for the dying and the dead.

Everyone gets this, regardless of creed, if Father Menke is in the mood.

You stump away, back into the ER. Your job is the secular side of death.

Step 1: When someone dies: fill out the paperwork. In this case, the eponymous “death pack.” These are supposed to be in the drawer by the door. You poke around there until you finally unearth one. The envelope contains a set of forms and a conveniently provided toe tag. You must fill out the forms with information about the deceased (but you may give the toe tag to the tech so that
he
can put it on the body—that's why you went to medical school).

You open the pack and pull out the first form. Name, age, social security number. Cause of death? You think for a moment. What you usually write here is: cardiopulmonary arrest. After all, the heart has stopped beating and the body has stopped breathing. Someone, though, probably a pathologist, pointed out once that this was the
definition
of death, not a cause, so you sit there, pen tip tapping against the paper. What am I supposed to write? you think. Cause of death: Old age? Human nature? Cell apoptosis? God's will?

You write: cardiopulmonary arrest.

As you finish up the form, Bill, the ER tech of the day, comes in. He has an empty body bag in his hands.

“I wish someone would think to put this bag on the bed before they put the patient on it,” he grumbles. “Do you know how hard it'll be to put the patient in it now?”

You hand him the toe tag and walk out. You are on your way to Step 2: Call the coroner.

When you call you actually talk to the night shift deputy coroner, a Mr. Loredo. You've talked to Mr. Loredo so many times that you recognize his deadpan voice in an instant. Mr. Loredo sounds the way you expect a deputy coroner working night shift to sound. He's not real happy to be there and he's not real happy you called. He has a nasal, monotone voice salted with a bit of country music. He gives you the impression that he has seen everything, and, in fact, Mr. Loredo may be one of the few people in the world that, given the nature of his job, actually
has
seen everything. Once Mr. Loredo asked you for the cause of death and you told him you thought it was secondary to a butcher knife, the blade of which had transected the left ventricle of the heart of the deceased. He said, without a beat, “When was the patient pronounced dead?” and he just went chugging along with his list of questions without pause until he got to the last one: “Any sign of foul play?” And you said, “Well, Mr. Loredo, I'm no detective, but the guy does have a knife sticking out of his chest.”

Now, at last, he paused. “Okay,” he said after a moment's reluctant reflection, “I guess that means he's a coroner's case.”

Mr. Loredo's job is to ensure that nothing is a coroner's case. In fact you've heard that the best way to get away with murder in this state is to dump a body somewhere in these city limits and have someone find it when Mr. Loredo is on.

“Cause of death?” he asks you tonight.

You wonder for a moment what he would say if you told him, “Rabies.” Then you think, he probably wouldn't say anything at all. He would just ask the next question. So you tell him with a shrug, “Cardiopulmonary arrest,” as you scribble, scribble a note about the code for the closing chapter of this patient's chart. Your mind is already on:

Step 3: Notify the family. This is the hardest part of the job. Breaking the news. The bad news. As an ER doctor you get to give families the worst news they will ever receive and you get to do this almost every day. It's your job to say, “I'm sorry, but your mother, daughter, brother, husband, >insert name here<, has died.”

After saying this you always stop and there are a couple of heartbeats while the news sinks in on the other side. Disaster; shipwreck. This is the time when people hate you as a doctor. You have failed, flunked, dropped the ball. You should be sued—you will be sued. You are a quack; if they had gone to the hospital down the street this never would have happened. And a part of you believes all this because no matter how sure thing the death was, some part of you really believes that because you are a doctor, you really can perform miracles. And actually you've seen this happen. Only not today. Today you
didn't
save a life. That nightmare you had during your second year of medical school has come true. You couldn't save a life because you
are
a fake; you are an incompetent fool who never should have been a doctor. Hippocrates would have laughed you out of this profession.

But it's not Hippocrates that calls you to judgment; it's God. After all, you just went one-on-one with Him and God won. Forget the patient; this is between you and Him. But then, you've always had a very special adversarial relationship with God, just like every other practicing physician you know.

So they hate you and you hate yourself even though this has really very little to do with you. But each death still leaves its mark on you, every telling, every “I'm sorry but he has died…” always leaves its little bruise and sometimes more than a bruise. Last week, for example, you had a classic “sudden cardiac death” patient, a fifty-two-year-old male with no history of medical problems, no previous cardiac symptoms, who suddenly collapsed at church. You took the radio call—which didn't sound promising. On scene, per paramedics, the patient was apneic—not breathing—and the monitor showed an “agonal” rhythm, the heart's electronic death rattle. By the time the team arrived at the hospital the patient was in asystole—flat line. He was also wearing a tuxedo. In fact, he was the first patient you ever tried to resuscitate who was wearing a tuxedo. You had to hack away at the black tuxedo jacket with your trauma scissors, cursing all the while, in order to get your monitor leads on his chest. He stayed in asystole too, never a hint of anything else. After twenty minutes of drugs, cardioversion and CPR, it was clear that this was all useless, so you raised a hand. “Let's call it a day,” you said. Time pronounced: 4:14
P.M.
Pam immediately turned to the paramedic. “The tuxedo,” she said. “What gives?”

As it turned out, the patient was the father of the bride at a wedding. He had seen his daughter get married and then collapsed during the reception. The paramedics told you all this so you knew up front that, in this case, talking to the family was going to be a very bad scene. But still you weren't prepared. They were sitting in the grieving room, a tiny cubbyhole of a room back behind the security office. There was the patient's wife—the mother of the bride—wearing a beige dress, pearls and an orchid corsage; the groom was in another tuxedo, then the maid of honor, and, of course, the bride. A flower girl sat in the corner weeping, unnoticed and uncomforted. The rest of them sat there, stony faced, looking at you as you walked in the door. They expected the worst and they were dead on, but still you just stood there, looking at the corsage, the tuxedo and the pearls, anything but anybody's face. You had no idea what to say and you don't really remember what you finally came up with. Afterward you came out of the room quaking, and sat down out in the nurses' station in front of Pam, palms sweaty, hands shaking a little.
“I can't believe it,”
you told her, “I had to tell someone in a
bridal dress
that her father had died.”

“Bummer,” Pam had said.

But that was last week. Tonight, thank God, there is no wedding. This woman's death was a release if ever there was one. Still, you would give anything not to have to talk to the family. You are so tired you feel like your skin has been peeled away exposing every neuron to the open air.

“Who's the next of kin?” you ask Pam.

She pushes the chart toward you. “Daughter,” she says. “In Phoenix.”

You sigh, half glad that at the very least you don't have to talk to the woman face-to-face.

Usually you try not to notify a family on the phone, but tonight there doesn't look to be a choice. You paw through the chart and miscellaneous pieces of paper that have accrued during the course of this death until you find a phone number for the daughter. You dial the hospital operator and it takes her a long time to answer; she was probably asleep in her chair.

The call rings through, rings and rings until finally a sleepy voice asks, “Hello?”

“Hello, Mrs.…” You shuffle frantically back through the stack of papers in front of you looking for the registration sheet. “Mrs.…You had it just a moment ago. Finally you give up. “Are you Helen Jablonski's daughter?”

“Yes,” she says, not sounding much more awake than before.

“This is the doctor calling from Hope General Memorial Hospital. I'm afraid I have some bad news for you.”

“Hmmmm?” the woman murmurs, oblivious.

Always it comes up, how to put it into words. Most medical experts tell you not to use euphemism—don't use “passed away,” or the even more delicate “gone.” Use dead—died—has died. You personally have always like “passed away,” especially with the death of someone very old. It seems to evoke a gentle slipping from one spiritual plane to another—something appropriate to the death of someone who has lived out their full term of life, as, you believe, this woman has.

You take a deep breath and say, “I'm afraid your mother has died.”

There's a long pause; the tossup moment. Anything can happen now.

“Oh,” she says, still sleepy. You're not sure she heard.

You take another breath. “I'm terribly sorry but your mother has passed away,” you say again, to be sure she understands. “I'm the doctor in the emergency room and I'm afraid there wasn't much that we could do. The paramedics gave her medicines to restart her heart and put the breathing tube down her to breathe for her. We continued this in the hospital but we were unable to bring her back.”

“Oh,” she says again. There is a pause and she says, “Well, thanks for calling.” And the line goes dead.

You stare at the receiver.

“What did she say?” Pam asks.

“She said thanks for calling and then she hung up.”

“She hung up?” Pam asked. “But you have to find out what funeral home they want.”

You look at Pam and shake your head. “You call,” you say pushing the phone toward her. “I'm at the end of my rope.”

You look up at the clock. You want to be busy doing something so that you wouldn't think about the resuscitation but you are too tired to move. Face it, you think helplessly, there isn't a time when you see an elderly patient like Mrs. Jablonski that you don't think of yourself there in her place.

Stop! you think. You close your eyes and discover that by rubbing them you generate dozens of colored lights that dance on the back of your eyelids. Then you open them again and discover the intern sitting in front of you, ready to present a patient. He looks to you so bright, so young, so ready for the future—even at five
A.M.
—that there is nothing else that you can do but close your eyes once more and let your face drop back down into your hands.

Congratulations: you have successfully declared someone dead. Now, as an encore, sometime during this shift or the next, you'll get to do it all over again.

The Farmer's Wife

I've had two or three patients who have reached up and gripped my hand and whispered, “Don't let me die, please don't let me die.” One patient I took care of, a guy with a terrible cardiomyopathy, thirty-two years old, exactly my age then, was wide awake and alert but had a systolic blood pressure less than forty—no matter what I whipped his heart with. He, for sure, said, “Don't let me die,” as I stood there, one hand on his carotid, staring up at the monitor, saying, “You're going to be fine, fine,” while I was thinking, This is it. This is the end of the line. This guy is going to die. So dopamine, ephedrine, atropine, epinephrine, the whole drug box. Nothing worked and, by God, he died, staring me straight in the face until the very end, with terrified, accusatory eyes. I was letting him die, those eyes said, even though I was trying with every thing I had
not
to let him die.

And there was another one, another patient, fifty-five, a smoker, chest pain, vital signs okay. Normal ECG. I was standing by his bed talking to him, once again half watching the monitor, just out of habit. The patient had a perfectly normal sinus rhythm rate of 82 when he reached out suddenly, grabbed my hand and said, “I'm going to die.” The monitor went straight line, asystole. I stood there a moment, stunned, while a nurse, who had seen it on the monitor in the nurses' station, came running over, shouting, “Hell's bells, we've got an arrest here!” I fumbled for the Ambu bag while the nurse started CPR. Thirty seconds later the patient reached out and popped me on the nose. I turned away with a yelp while the patient, freed of the face mask, shouted, “What happened? What happened?”