01 September 2013

Time of death

Note: This post describes patients' deaths. It has content that some would find graphic and upsetting. Please use discretion.
A phone call came in: a hospice patient had died at home. The hospice nurse I was shadowing needed to drive to the house to "pronounce" the patient as dead.

We entered the room to find the pale countenance of a disheveled-looking elderly woman. Her facial expression was contorted. The nurse motioned for me to proceed.

I gravely checked the patient's wrist for a radial pulse. None. I checked the neck for a carotid pulse. None. The patient's skin was still warm. I listened for breath sounds. None. I had listened hundreds of times for patients' breath sounds. For the first time, where I would have heard the familiar rushing of air, it was eerily silent.

I looked at the nurse and shook my head. She looked at her watch and cleared her throat. "Time of death: 1:27 PM," she announced. She jotted the time down on a form.

I looked on as the nurse and an assistant changed the deceased patient's diaper and combed her hair. There was a terrible stench in the room. Taking in the scene, I felt nauseated and unsettled. I wanted to leave.
A year ago, I joined an internal medicine resident in hospital. It was a teaching exercise: the resident was to supervise me as I interviewed and examined a patient. A few minutes into my interview, the resident's pager chimed. He checked the pager and departed in a hurry.

He returned an hour later, just as I was completing my examination. He apologized. I asked what he had been paged for. "A patient coded," he said, using the shorthand for cardiac arrest. "I had to do chest compressions for about 15 minutes and then had to fill out the death certificate and notify the family." He was surprisingly nonchalant when recounting what had transpired.

Months later, I ran into that resident outside of the hospital. I asked him how he could be so unshaken by a patient's death. "Patients die all the time," he said. "It's something you just have to get used to."

Right after chatting with him, I headed to a movie theater for a screening of "Grand Illusion." It is a wonderful film, made in 1937 by Jean Renoir. During the climax, the protagonist sacrifices himself to save the life of his friends. When that character died on-screen, I shed a few tears.

At that moment, I realized, though, that I would soon arrive at a point where witnessing deaths would become commonplace. Like my resident, death would have to become routine, something I couldn't dwell on for fear of falling behind schedule.

It felt unfair. I liked being unaccustomed to death. I liked that the death of an actor could made me cry. I didn't want that to change.

While studying at the hospital, I heard sirens come screaming into the ambulance bay. The sirens were more enticing than the textbook I was reading, so I headed to the trauma bay to see what was going on. An ominous sign greeted me: a trail of blood stretched from the ambulance bay to the resuscitation room. I joined a crowd that was gawking at the spectacle from afar. I gathered that the patient had been shot in the chest, their heart pierced by the bullet. Doctors and nurses were rushing to resuscitate the patient. One physician was doing chest compressions. Another was placing electrodes on the patient's chest. Finally, the patient's heart rhythm came onto the heart monitor: it was bad. Nothing was going to save him, not even a defibrillator. A minute later, the doctors "called" the case. "Time of death..." intoned one of the physicians, looking up at a clock on the wall.

And yet even this event smacked of the quotidian. While the doctors were performing chest compressions, I discovered that a spectator standing next to me was a friend I hadn't seen in weeks. In hushed tones, we exchanged pleasantries.

After the case was called, the onlookers began filing out. I returned to my desk so I could continue studying. But I couldn't focus. I could tell that I was still perturbed by what I had just seen.

Literature gives us the "bildungsroman," the coming-of-age story. I had always thought of "coming-of-age", of loss of innocence, as being the transition from adolescence to adulthood. But I think my journey through medical school, and by extension this blog, is a "coming-of-age" story of my transition from an adult to something else--a doctor, I suppose? I'm turning into someone different from when I started, someone more mature.

Before I started medical school, I always kept a good distance from death. But now that I am around the sick and the dying, death seeks me out. It pesters me. It ingratiates itself into my work and into my waking life (although thankfully, not yet into my dreams).

That said, the transformation is not complete. I am not comfortable or casual with death. And I am glad of that. It reminds me that I still am who I have always been.