death


I must have been looking disturbed. A couple of people, including the chief resident, asked me how I was handling the one patient’s death, and then stood still to listen to my answer. That’s the closest to those ‘debriefing’ things I’ve ever gotten (and I hope not to get any closer; surgeons don’t do well talking about feelings involuntarily). Just to have them ask was all I needed, and I told them I was fine. After all, in a way, when someone’s been deathly ill in the ICU for weeks, it’s a relief all around when they go. I feel kind of guilty, to be this relieved, but after all, they’re probably relieved to be done with the whole thing too. Except I’m fairly certain they’re in hell now (lots of Buddhist paraphernalia); in which case none of this is very good. . .

One of the patients who died recently had an autopsy, and I felt like I ought to go. I would be less of a good doctor and surgeon if I neglected anything relating to my patient, even now that she’s dead; but I also felt like a very bad person, to be semi-comfortable with seeing a person I’d known cut up in pieces. In the end, I got called away before matters had progressed very far; which was just fine with me, and I’ll wait to see the report in a week. (And the pathology residents: I can’t even imagine having that job. I can kind of picture what it would be like to do ER, or medicine, or radiology. But pathology is not just a different species, it’s a couple genuses [geni?] away. How can you be a doctor and not touch live things?)

A patient I’d been taking care of all month died today. Like before, I wished I could join the family in their mourning, but that wouldn’t be right. I’m not really part of it, and they need their space. I didn’t know him when he was alive and a person, only when he was living on a ventilator with us sticking needles at him all the time. I didn’t even know any good words to say at all. “I’m sorry” – but you can’t go repeating that forever, and I couldn’t think of much else. I’m sorry, I tried to stop him leaving; I’m sorry, if I could undo this I would; I’m sorry, we’re not miracle workers after all.

Failing that, I wanted to go sit in a corner and not talk to anyone else. Talking to the coroner, always so businesslike, not high on my list. But you have to. And then there were all the other patients who needed to be paid attention to, and just because one person died is no reason to go neglecting or ignoring the others. So I went and did all the appropriate procedures, and they weren’t much fun. A needle here or there. . . but I couldn’t save the one guy who really needed help.

I don’t know which was worse, talking a family through their loved one’s death, when I’d only seen the patient for five minutes beforehand, and we only had an hour to work through it (like yesterday), or handling it after a month of struggling together, like today. Strangers or long-term acquaintances, it doesn’t get easier.

I’ve been calculating all month, and I work out my prospects for the rest of the year as follows: nearly all the second year rotations are unpleasant, and nearly all of them last for more than one month. So the chances of September being even more miserable than August are at least 70%. This is not good. Without hope, things fall apart.

Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast.

Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER.

I’m not good like the social workers are with grieving families. I watched closely the other day, the last time a patient died, and the family was dissolving in the hallway. I hate watching people cry; it’s horrible to be involved, but outside enough that you can’t quite join in. The social worker was really good. The main thing I took away was a much higher level of physical involvement than the medical personnel usually allow themselves. So tonight I tried that, and it seemed to go ok; and other than that I said all the comforting things I could think of.

I hate being comforting, under any circumstances. The things the patients and families want to hear from you are usually at varying odds with the truth or with reality. I’m getting better at it, but it still gives my truth-gauge quite a twinge to make all kinds of reassuring statements: things will be ok, everything will be fine, it’s better this way, there was no pain, he’s comfortable, it will be all right. . . The phrases that people expect from doctors, need to hear from the doctor in order to have peace with themselves. . . I don’t really believe most of it, but I have to say it. . . like the parts of the Orthodox liturgy asking for Mary’s intercession; I don’t believe it, but it’s too important (and beautiful) to not say. . . So I read my lines, and try to give a convincing impersonation of a reassuring doctor.

I was going to keep talking, but it was getting too incredibly morbid. I’m tired of the ICU, can we go on to September now?

My shoulders are sore from doing compressions, and my hands ache from holding the seal around a face for ventilation, or squeezing a bag of saline to make it run faster. Three codes in two days – far too many.

The last one, I just went up to the floor to check on a patient I’d transferred out of the unit, and they called a code down the hall. I had to be one of the closest people, so I thought I’d go check. It was real. The patient got intubated, and we had a line in, and it felt as though things were under control. Airway, rhythm on the monitor. . . so why was the patient so blue? I found myself doing compressions, and trying to persuade everyone else in the room that I really had not felt a pulse, and the rhythm on the monitor was nothing more than PEA (pulseless electrical activity). . . It’s hard to talk while doing compressions properly, but it wasn’t hard to prove. . . Not much good in the end. (Note to self, ekg leads aren’t enough, you need pulse ox and blood pressure too; and just because the patient had a pulse two minutes ago doesn’t mean they still do.)

When I was younger (a whole year ago), I used to go to these things and be all quivery and excited because I thought we might save somebody’s life. Now, like the rest of the senior residents and attendings, I don’t worry too much, because I know it’s not going to work anyway. Even if by some chance we got a circulating rhythm back, the patient will, 95 times out of 100, die in the ICU anyway.

I woke up this morning and I couldn’t figure out why my shoulders ached so much. It took me a couple of hours to even remember the code the day before, and connect my frantic compressions to the current situation. It was several hours later that I remembered the code before that, which was why my hands hurt. Ok, I’ve got it all straight; I’m ready for the next one.

Surgery has no room for errors. If they happen, there’s nowhere to hide. You cut the wrong thing in the OR, and everybody knows about it. Even if it’s something as relatively simple as getting into the hernia sac you were trying to get around, everyone knows because you have to call for a suture to repair it with. Anything bigger is even more obvious.

When your patients die, everyone knows that too. What happened to so-and-so? Where’s the patient who was in that room? What’s with the blood and paper all over the floor? Why’s your attending so gloomy today (in fact why is the entire service colored grey)?

You also can’t hide in the sense of withdrawing from the life of the hospital. Just because one person died, there are still a dozen others needing help, even others with the same problem. That’s what’s really getting to me right now. One person died, and there’s another patient with an extremely similar problem, whom we simply have to operate on. It would be irresponsible not to – and yet it feels irresponsible to go ahead. Statistics say there was a 1% mortality rate, and that patient bought it – so really the next hundred ought to do great; but I don’t want us to do that same operation again so soon. It seems like tempting fate. I can tell the attending doesn’t want to, either. For a guy who doesn’t talk much anyway, the main way he shows emotion is by talking even less, and more inaudibly than usual (which is harder to deal with than another attending cursing and swearing). But he has to take the case. There’s no one else who can do it, and the other patient can’t wait.

I guess it would be more accurate to say there’s no room for denial. Errors, and inevitable complications, occur. The big thing is not to hide from them. You can’t be so insistent that there were no technical errors that you refuse to go back to the OR for postop bleeding. You can’t ignore an enterotomy and hope it goes away without you stitching it up, and admitting to yourself and the scrub and the circulator that something slipped. You can’t pretend that the patient didn’t die, and that if you don’t even think about a patient with that disease for a month, it will somehow undo their death.

(Which is why I hate euphemisms, especially at M&M: “The patient CTB (ceased to breathe).” Come on guys, we’re surgeons. The patient died, is what they did. They’re dead. That’s why we’re discussing it.)

I hate it when my patients die. Somehow it feels worse when I wasn’t there at the time, as though in addition to generally having let them die, I also failed to be with them when it mattered. At least I didn’t have to see the family. . . I can’t even think about them. I can say to myself, the person I was talking to yesterday is dead and gone. . . but I can’t bring myself to even imagine the family, how they received the news . . .

If you have to ride a motorcycle, please wear a helmet.

I may have mentioned that before.

We have three patients right now who weren’t wearing helmets. Two of them are missing large sections of their skulls, and all three have ventriculostomies draining cerebrospinal fluid, trying to decrease the pressure on their brains. Their CT scans look literally like mush. They’re not dead, and they may, two months from now, leave the hospital, but I doubt if any of them will ever talk again. And there was one earlier in the week who died in the ER (at least one of the ones in the unit was completely expected to die at the scene).

We have at least seven patients who were wearing helmets. A few of them have concussions, but they should all be able to recover completely, neurologically. I think one of them lost a leg, three of them lost their spleens, one lost a kidney, they each have at least two broken bones (not counting ribs) – but that’s not much, since they can all talk. Only one of them is in the ICU.

There are some really cool-looking helmets out there. If you get one of the sleek black ones with the shiny visors, they can be much more macho than going bareheaded. And nobody looks macho with a trach.

Please wear helmets.

One of my patients died today, the first time that I was actually around for such an event.

He was kind of a hopeless situation from the time he came in a few days ago, but we gave it our best shot. His family knew the prognosis was bad, and today when some tests confirmed that he had basically no brain function left, they agreed to withdraw care. I talked to them from the beginning, putting out the likelihood that he wouldn’t recover and that a decision would have to be made. Today I was trying to hide, letting subspecialists talk to them, but of course it wasn’t that easy. “Alice, we finished our discussion, now they’re asking to talk to you.”

The family seemed like great people, a strong family. They had a spokesperson who asked questions, and then announced their decision. I told them what we would do (having just carefully checked with the nurses, since I had never seen such proceedings myself). After the decision had been confirmed several times, we took them back to the room, and the nurse and I took out the breathing tube and left them alone together. I guess I didn’t really need to be there for that step, but I felt like he was my patient and I didn’t want to hide anymore.

I got in a corner and cried. I don’t know why, it was the right thing to do, and the family knew it, but they were so sad to lose their father, I couldn’t help it. Some time I should figure out at least how not to cry when I’m talking to the family, it doesn’t really help the situation.

About half an hour later I came back to check, and the nurse was printing an asystole strip off the monitor. So that was that. It took me three tries to fill the death certificate out correctly. (I have no idea how I’ve gotten to the twelfth month of internship without having had to write a death certificate before.) And then the coroner’s office wouldn’t answer their phone, and I had to keep calling and calling.

Pursuing the issue of work hours: suppose a patient dies right before change of shift. The family has been notified briefly on the phone (via a message, because no one is answering, or perhaps a conversation cut short by grief and shock), but won’t arrive for at least a couple of hours. If the day team goes home as planned, the only person there to talk to the family will be the night float junior resident, who, with all the good will in the world, is overworked. Even if he gets time to talk to the family, they’ve met him maybe once or twice before, and have discussed little of their loved one’s situation with him. The attending and chief who did most of the interaction with them will be gone. As residents, we’re not about to ask our attending his plans, but we doubt that he’ll come in from home, on a night he’s not on call, to discuss how one of his cases went bad.

Your initial response, and our instinct, would be for at least the chief to stay in the hospital (trying to use the time to study or do something else productive) or perhaps arrange to come in from home when the family arrives.

But the chief has been operating late into the night for the last several days, and was in the hospital almost the entire last weekend. Staying a few extra hours to wait for the family, or even coming back for an hour later on, will push him over the 80hr limit, and hinder him from fulfilling his responsibilities later in the week. He can either stick with the rules, and satisfy himself with having spoken on the phone, or ignore the rules, misreport his hours, and stay around to fulfill this last ultimate duty to a patient and family, to talk with them personally about the death.

This is an extreme but very plausible scenario which illustrates the basic problem with the 80hr rule: an outside agency (government, and the ACGME, which is not surgery-specific) imposes an iron-bound rule which sets our regard for the law and for honesty in our reporting at odds with all professional instincts and obligations, and leaves us feeling guilty no matter which we end up following.

I’m in the middle of an experiment to see how many hours it’s possible to work over the course of a four-day weekend.

I hate it, I hate it, I hate it when my patients die. I can’t stop them. And they keep doing it, one after the other. Every twelve hours. We keep calling the same consultants. “Hi, please come and help, we have a patient septic, intubated, crashing, maxed on pressors, because of yyy. . . ” “Are we both awake? Didn’t we just have this exact same conversation twelve hours ago?”

Surgery is good when it works. But when it doesn’t, you took a person who was alive, at home, walking, talking, eating – above all, alive – and now they’re almost none of the above, and it’s because we tried to do something. Why did we do that? Please can I have the rewind button. . . please let’s go back a couple days and not do this. . . Jesus don’t let my patients die. . .

I do good CPR, I found out. Unfortunately they needed more than good CPR.

Somewhere in the last couple of years, I was near a city where the Body Worlds display (or one of the copy-cat shows) was stopping. After thinking about this for years, I’ve had enough of the ads (as it keeps travelling around the country), so here you go.

There are two primary ethical objections to these displays:

1) Our common humanity is denigrated by dissected bodies being displayed to public view as a matter of entertainment and moneymaking.

From a Christian perspective, the body is an integral part of what it means to be human. The Bible describes God forming Adam’s body and breathing life into it, and says that Adam was made “in the image of God.” To turn the human body into an object to be displayed for the enjoyment of crowds makes this crowning miracle of creation nothing more than any other animal displayed in a zoo.

But even if you wish to avoid a religious rationale, surely we can agree that the concept of Body World is of a piece with the modern entertainment culture, where horror films like Saw, Saw II, and Saw III (not to mention all the rest of their ilk) are viewed as acceptable amusements. Violence perpetrated on human bodies is now just a way to pass the time, not something revulsive. Similarly, Body World teaches us to accept the image of human bodies dissected, distorted, displayed – for our entertainment.

One of the greatest nightmares of medical school, gross anatomy, for centuries an illegal secret, and until recently at least a private activity, has been turned into mass entertainment for the crowds. I cannot express to you what it was like to cut up a human body, to destroy what another human person had used to live in, to love with, to see the sky from, the feel the ground by. . . At least I had the comfort, the excuse, that I was doing it for a reason – to be able to help hundreds of other people live, love, see, feel, a little longer, a little more comfortably. And it was, at times, a paltry excuse. To saw a skull open? To split a pelvis in half? To peel the skin off a face? To split a hand into useless threads? Who can do that calmly and claim to be still human himself? These phrases are the description of a monster’s activity. At least we had a reason; and I think our humanity survived. 

But what excuse is there, for the general public, to go and stare at bodies split open, splayed apart -amusingly posed? If you want to know what your inside is like, read Grey’s Anatomy; get a plastic model from the school supply stores; read Netter’s, if you prefer color. If you want to know how the thing works, there is no scarcity of physiology books, in all ranges of readability. The craze about Body World has nothing to do with a sudden hunger for anatomical knowledge. It stems from a fascination with the forbidden, the weird, the indecent.

Like the rest of the violence and indecency which is now commonplace in our society, the Body World displays serve the purpose of destroying our conscience and filching our reverence for humanity as something separate from the animal kingdom.

2) These particular humans almost certainly had no say in the disposition of their bodies; and even if you allow that it might be all right to use bodies this way, if their owners had knowingly and completely consented, it is wrong to participate in the exploitation of individuals who in their lifetimes were the victims of a cruel state.

We all ought to have known better than to think that Chinese bodies were come by honestly (and you had only to look at their faces to know they were Chinese). Recently ABC’s 20/20 removed the possibility of further self-deception by investigating the body-selling trade in China. Protest as he may, the inventor of plastination cannot deny that his original bodies came from a shady source, as he is now loudly promising not to use unethically obtained bodies anymore. The news stories mention thousands of people currently offering their bodies to be used in these displays, but the fact remains that there is no good documentation of the origin of the bodies that are currently touring the country. And for anybody who thinks any Chinese person whose body is being used actually freely consented to this arrangement, I have a bridge in Brooklyn to sell you.

But, even if all the unethically obtained bodies were cremated, the objections in my first point would still be reason enough not to see these exhibits.

For a much better-written exposition of the moral objections, please see Thomas Hibbs’ essay, “Dead Body Porn”.

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