To Morning

A shriek in the darkness drew out my shallow, sleeping breath in a singular gasp. Disoriented in the windowless room, I felt a familiar pounding in my chest that jostled my brain awake. As I fumbled for the light, the small black box continued its ear-splitting siren as it fell off the nightstand and bounced under the bed. I knelt on the gray, stained carpet and fished the beast out from the dusty collection of medical journals and soda cans that lived there. Squinting in the fluorescent light, I saw that the digital numbers coalesced on the pager screen and formed a room number. I grabbed the white coat on the chair and ran.

Three years before, on my very first call in this busy Chicago hospital, the senior resident had directed me in a perky voice to formulate “elevator thoughts” on the way to evaluate a patient. This sort of preplanning worked well on the way to see a child with a fever in the emergency room or an elderly patient who had fallen out of bed. But this particular call came on the code pager, meaning a patient had stopped breathing or had no functional heartbeat or both. This was the third code in the last twelve hours. And so there would be no elevator (the stairs were faster) and no coherent thoughts—except a blistering disbelief that my sleep total for this thirty-hour shift was going to be around twenty minutes.

I knew colleagues who loved the rush of a code, and as a new resident caught up in the action but without real responsibility, I suppose I had loved it also. But now, just months away from finishing residency, I was one of the senior residents in the hospital at night. I dreaded my free-fall adrenaline response to a code that meant someone was dying, apparently against their own or someone else’s wishes. At that moment, flying down the dim stairwell in the predawn stillness, I was short on both adrenaline and compassion. Parcels of it had been left all over the hospital—the largest discarded at the bedside of a twenty-year-old woman who was now dead.

Previously young and healthy with no underlying medical conditions, she had arrived in the emergency room earlier in the evening. She was pale and breathing rapidly but joking with her mom and aunt that their girls’ night out would have to be postponed. However, the high fever, telltale rash, and initial laboratory tests all pointed to meningococcemia, an uncommon but highly lethal infection that can collapse vital organs in a matter of hours. One of the greatest risks is a condition known as disseminated intravascular coagulation, the bacterial toxins causing the coagulation system to go haywire. Blood clots in all the wrong places, cutting off oxygen supply and causing organ death. Finally, when the body can’t clot anymore, it bleeds—from delicate vessels close to the surface and in dark, internal hollows.

I watched and hovered as the young woman’s body did exactly this, succumbing to the raging infection. Several hours after her arrival in the emergency room, she was sitting rigid and upright, clutching the bedrails and struggling to breathe. I looked into the wide, panicked eyes of the patient and her family and explained that the medicine we were administering would help relax her before we inserted the tube that would help her breathe. Later in the evening, her heart began to race, trying to compensate for a dangerously low blood pressure. I did my best to communicate to her mother and aunt the severity of her condition and the medications and procedures that might be necessary, all of us peering out from behind the paper gowns and masks required in the rooms of those with serious and contagious infections. They clutched her hands, one on each side, leaving only when the nurse quietly but firmly asked them to step out when the code began. The chaplain guided them away as thick purple blood trickled from her nose and mouth with the chest compressions. My colleagues and I marched down the code protocol, cracking vials of ultrapotent medications, hanging bags of IV fluid and blood, pushing them with a silent prayer through her veins. Her blood pressure continued to fall, and her heart ultimately failed despite our desperate attempts to do something, anything, we could. I looked down at her young, bloated face, the dark eyes so similar to those of the women who had been at her side all night long. 

Our training had taught us about moments like this, how to tell a family in a compassionate but direct way that someone they loved had died. Looking into the eyes of the dying young woman at that moment, I couldn’t imagine what I would possibly say.

A few minutes later, the anxious faces of her family crumpled as I quietly delivered the unthinkable news: “We did all that we possibly could, but Tamara has died. I’m so very sorry.”

What had that news cost the patient’s mother, her aunt, her grandmother, coming from the mouth of a pony-tailed, bleary-eyed girl not much older than the child they had lost? Did they understand that my quavering voice and lowered eyes came from a place of real compassion? Or that my hasty exit at the sound of the pager was because someone else was now trying to die? The universe had not stopped, had not allowed us a reprieve. I would need to pull myself together in some other dark stairwell, the wails of grief trailing behind me. I prayed consolation would come for her family in time. My own fragile solace came from a deep knowing that her medical care had been correct and thorough and timely. This time the universe didn’t cooperate; we were all humbled, face-to-face with our own breakable humanity.

Leaving the young woman’s family with the hospital chaplain, I winced at the next room number on the code pager. The area of the hospital known as the skilled nursing facility housed patients who were too sick to go home—or more commonly, back to the nursing home—but not acutely ill enough to qualify for a full hospital admission. Most of the patients were elderly, often in the advanced stages of dementia. Codes in the SNF were rarely successful. The team would go through the motions, cracking frail ribs with chest compressions, unable to locate accessible blood vessels beneath papery, gray skin. I arrived at such a scene in the room of an elderly man; his eyes were open, glazed, and vacant. Another senior resident was at the head of the bed squeezing air into his lungs with an oxygen bag and mask. A wide-eyed medical student pumped rhythmically on his chest, quietly mouthing the number of compressions. The intern was preparing the defibrillator, ready to shock the patient if an appropriate heart rhythm existed. “Do we know his code status?” I asked loudly above the din of activity in the room. The question seemed obvious, but on more than one occasion I had participated in a code while a misplaced chart was discovered with a large do not resuscitate label the team had overlooked.

The charge nurse informed us the patient was indeed a “full code,” despite the fact that the eighty-five-year-old had advanced renal failure and dementia. He had been sent from the nursing home with a fever and was completing a few more days of intravenous antibiotic treatment for a urinary tract infection. “The day shift says no one has been here to see him,” continued the nurse. “His nephew is listed as the next of kin, but no one can get a hold of him.” I nodded and glanced at the resident with the oxygen bag. “Should we intubate?” she asked quietly. “Let’s wait and see if that will be necessary,” I responded. She nodded in agreement and redirected the student’s hands on the patient’s chest. We both had experienced this before—terminally ill patients with family on paper but no one who was involved in their lives. Sometimes the story was as simple as greed, of wanting to keep a monthly disability check alive as long as possible. Other times it was painfully complicated—a now frail and helpless patient had, at some point, ostracized everyone around him through drink or drugs or abuse. Regardless of the circumstances, it was always poignant to be involved in a life-and-death decision for a stranger with no one else to speak for him.

My heart was still heavy with the loss of the young woman in the ICU, the defeat of watching her go in the face of everything we knew how to do. The faces of her family were still with me, grieving the loss of a future that would never be. Now we were keeping a man alive at the other end of life solely because we were medically and legally responsible to do so. His unfocused eyes were turned in my direction as we ran a “soft code”—doing what was required but stopping as soon as our efforts appeared futile. It was not a judgment on the value of his fragile and worn-out body or his worth to society. Rather, at these moments we are called to be our most authentic physician selves, to ease the burden of suffering, to be compassionate unto death. “I will follow that method of treatment which according to my ability and judgment, I consider for the benefit of my patient,” states the Hippocratic Oath. I reached for the patient’s cold white hand with my own sweating palm and held my other one up in the air. “Enough, that’s enough.” The team exhaled collectively—we knew this was right. I touched his forehead and whispered, “Rest well.” I wondered if anyone would come to his funeral.

Death notes written in the chart are detached and clinical. On paper we physicians stick to stark physical facts: “asystole unresponsive to epinephrine × 2, defibrillation attempted × 3 without success. Pupils fixed and dilated, no palpable pulse or audible breath sounds. Time of death 0253 a.m.” We reviewed the process of the code with the students and junior residents, making sure they knew what was done and why we had stopped. The paperwork was completed with quick efficiency, the body of the elderly man left to be cleaned and prepared for the morgue. There were new admissions lining up in the emergency room—pneumonia, heart failure, alcohol poisoning, stroke. Most of them would improve with medicine or surgery or time, would live to leave the hospital, would see a daughter’s wedding or the birth of another grandchild. By morning the needs of the living would have eclipsed the memory of tonight’s losses, the mourning left to families and friends or to no one at all. I spoke some superficial words of encouragement to the weary intern at my side and mentally divided up the work ahead of us.

We worked until our heads were heavy and nodding over admission orders, the first pink rays of dawn breaching the horizon. Two hours remained until rounds would begin on this April Sunday morning. I had fallen into the deep, drooling sleep that was now shattered by code number three. This time it was an elderly woman whose colon had been partly removed several days before for a localized cancer. Aside from some high blood pressure and arthritis, she was otherwise healthy, her surgical recovery fairly uneventful. Because she was in a unit where patients’ hearts are monitored continuously, a dangerous rhythm known as ventricular fibrillation was noted immediately, the electrical impulses too uncoordinated to function effectively. The best treatment is early defibrillation, or “shocking” the heart. The nurses had already pushed in the bright red crash cart and were placing rubbery pads on her translucent chest. “Dr. Johnson is on the way. He was coming in early for rounds,” breathed the head nurse. “Okay, good,” I replied, glancing at the sawtooth pattern on the monitor and welcoming the thought of the older doctor’s experience and calm. “Charging . . . all clear . . .” The woman’s chest heaved upward as the shock was delivered, the pattern on the screen unchanged.

The room was now overflowing with nursing staff, doctors, students, respiratory therapists, and lab technicians. At some point I noticed a thin, shaking figure in the corner, his blue eyes wide and panicked. Perhaps he had arrived for an early morning visit. Perhaps he had been there all night. In the pressured rush, no one had noticed the quiet little man who was now watching his wife trying to die.

One of my medical school professors frequently reminded us, “You only see what you are prepared to see.” When Dr. Johnson arrived, he walked straight through the crowd to the patient’s husband, placing an arm around his shoulder. He had been their doctor for over twenty years, attending to them together in the clinic. Undoubtedly, he was prepared to see this man at his wife’s side. We continued with cycles of chest compressions, oxygenation, more defibrillation, and medication. The chaotic heart rhythm continued, undeterred by anything we did. Doctor and patient spoke quietly for a few moments, their heads bent together in private conversation. The man nodded in understanding, and the two of them approached the bed together. “Thank you, everyone,” called out Dr. Johnson. “That’s enough now.” The room was silent as activity abruptly ceased. “It’s okay,” he murmured in the man’s ear. 

“You can hold her hand. She will know that you’re here.” The man shuffled forward hesitantly, tenderly lifting his wife’s hand to his cheek. “Bessie,” his voice cracked. “Where are you going without me?”

The breath caught in my chest, twisting open a space that now felt enormous and raw. I exhaled, turned away from the crowd, and gazed out at an exceptional sunrise over Lake Michigan, a soaring skyline watching its city awaken below. The familiar sounds of alarms, telephones, and hospital banter drifted in through the door as the team filed out. Oblivious to all of it, the man held his wife’s empty gaze in his own unblinking eyes, the last agonal beats of her heart flickering across the monitor. Suddenly aware that I was an unnecessary presence in this intimate moment, I turned and stepped out into the bustle and chatter of weekend rounds.

“Hey, so what happened in there?” I blinked absently, looking into the bright eyes of my alert and curious colleague who had arrived to take over the next shift. What did happen in there? A man wordlessly said good-bye to the woman he had loved since he was a teen. A soul slipped silently away. The sun rose again, and it was magnificent. I unclipped the code pager from my scrubs and placed it in my friend’s outstretched hand. “Oh, one of Johnson’s patients, a few days postop. V-fib. Nothing we could do.” I recognized the momentary flash of sympathy and panic and relief cross her face, felt it in my own chest as she attached the pager to her hip. The baton had been passed. After rounds she would update the patient list, unceremoniously removing the names of the three who had died, grateful it had not happened on her watch. I finished rounds, attending to lab results, vitals signs, and the usual morning greetings. The needs of the moment required all that was left of my caffeine-fueled attention. The dead would be left where they had fallen.

It was nearly noon when I tossed my stained and rumpled scrubs into the hospital laundry cart. My clothes from the previous day were still folded on the desk in the call room. I didn’t feel like the same person who had put them on yesterday morning. Slinging my bag over one shoulder, I leaned against the cool steel wall of the elevator as it hummed its way down eight floors to the hospital lobby. I stopped in front of the long row of glass windows to fumble for my keys. Visitors circled in and out of the revolving door, sweeping in with the fragrant air—the first warm day of a long-awaited midwestern spring. On another day I might have taken the El downtown, found a patch of grass along the lakefront bike path, listened to the waves crash on the graffiti-covered breakwall, and basked in a few vacant, sun-laden hours until it all began again—but not today. Instead, I imagined the moment when I would close the blinds in my tiny apartment a few nondescript blocks away, pull the covers over my head, and sleep away this glorious afternoon. In the darkness it would be easier to forget their faces.

A timid hand on my shoulder startled me. I turned to a face that seemed vaguely familiar, her haggard eyes apologetic. “I’m sorry, Doctor. I didn’t mean to bother you. I’m Tamara’s aunt, um, from last night?” Her steady gaze drew me back to the bedside of the young woman, the panicked eyes of her family meeting mine, her face bloating, blood pressure dropping, nothing, nothing working. Together we had hovered over her, masked and gloved and gowned, shielding ourselves from infection and death with thin yellow paper. I wished now for a protective mask for the aunt with the broken heart, a papery veil for my own weary spirit. Was there a cool, dark place of rest for the grieving? “We wanted to thank you,” she whispered. “We know you did all you could. She was a beautiful girl. She would want you to know that.”

Her dark eyes held mine in a long silence, unmasked, both of us beginning to lay an unfinished life to rest. This unexpected compassion would not erase the exhaustion and doubt of a questioning young physician, but her gentle gift would allow a measured peace until morning.

I embraced her, and stepped out into the light.

Author Bio

Anne Jacobson

Anne Jacobson is a family physician for the Cook County Health System in Chicago, Illinois. She earned an MD from the University of... read more

Comments

Unicia

February 12, 2016

This was very beautifully worded. Thank you for the insight on your perspective of dying patients.