It was a day
“It was a day; only a day. You have a dark and troubled mind, My Lord.” The words float back to me in pieces. “It was a day.” I have just finished a thirty hour shift as the intern doctor in the intensive care unit. I smelled death this shift. It smelled like disinfectant they use to clean the bed after my patients die. I’d been the one to break the news to her daughter, Chandra, about her 60 year old mother dying. I persuaded Chandra to allow us to change the struggle to preserve life to an invitation for her mother’s death.
Initially, in the haze of shock, she did not grasp what I tried to tell her. “Your mother is dying,” I should have said. I learned it in medical school. Before that even I should have asked her what she understood about her mother’s condition. When faced with telling someone of her mother’s eminent death and with my own agenda of convincing her to let us withdraw live-preserving efforts, all I could say was: “She is very sick.”
“It is very serious. She is very sick,” I kept repeating like some scrub donned parrot paralyzed by fear of death and failure. I caught myself rattling off words like “pressers” and “breathing tube” in attempts to make her understand. Not yet ready to learn that she would soon be a motherless child in this world, Chandra ruminated her mother had felt well until yesterday. They live on the other side of the country. Her mom had recently been diagnosed with lung cancer and she’d been on dialysis for end stage renal disease for over a year. When asked, Chandra told me, her doctors at her home had told her to go on the “Dialysis at Sea” cruise. “Enjoy yourself,” they’d said. Chandra said her mom had always wanted to take a cruise. They’d just returned from the two week trip to Hawaii. She was trying to figure out if she should go get a hotel and start to arrange to have her mother med-evacuated to their home. She was still in denial, the first stage of grief. “You should probably wait here,” I tried to say it gently, “your mother is very sick.”
She understood that her mother was dying when I asked her if she’d like us to stop our failing attempts to rescue her mother’s body from following the likely already departed essence of her being. She began to cry. Alone here, without friends or family she repeatedly thanked me and put on a brave gaunt smile. She wore a soft black fleece; her body was as round as her mother’s naked cold body I’d just left with my fellow who struggled to find pulses and vessels to insert central venous and arterial access lines. I couldn’t tell if they looked alike, one was alive with small braids in her hair pulled into a high pony tail and dark round cheeks; and the other was ash-colored and dusky with her mouth gaping open around the breathing tube helping to keep her body’s metabolism limping along. The dying mother wore small gold earrings pressed into her ears in the shape of flowers.
I hugged Chandra, an awkward sideways hug in side-by-side chairs, made more uncomfortable for me by the fact that my resident had suddenly shown up to ascertain if I’d managed to establish that we were switching management to “comfort care.” When I glanced at his business-like dark eyes, blinking back the tears in mine, I remembered what he’d told me when we first heard about Chandra’s mother’s pulseless electrical arrest and three rounds of CPR in the emergency department: “Oh well. One less fat black woman who hasn’t taken care of herself.”
At the time, silently appalled that he’d said that, I turned away from him and buried myself in copying down her labs from the computer. If I ignored him long enough, he would go off in his whirlwind of action and jolting activity. I find it hard to maintain a sense of humanity and peace in places where people become so frigidly practical about death.
I wondered if he uses those thoughts and words a protection or a mask, or if he truly feels that way. I wonder if I am overly sensitive to the struggles of the loved ones left behind by those who die in oblivion on our wards. After all, I don’t know these people. I never knew them in life. I don’t know why her mother chose to wear those flowered earrings this morning. I don’t know if, by taking this cruise with her daughter, she accepted that this lifetime neared an end. I make up stories of their lives in my head. I extrapolate facts into a brightly colored and meaningful picture of lives. And of deaths.
And so I hug Chandra as she cries. I turn my face from the resident and look out the window toward the ocean they have just crossed together only to part on this shore. He tries to rush me along. “We’ll give you a moment,” he says. I have learned that when he says this it really means, “I have more important things to do now.” I don’t want to leave her alone. I offer thin comfort by promising to try to get her a phone and contact social work to talk with her again. I wish I could do more. I could have, but I chose not to sit there with her longer and instead let myself be pulled back to the storm of line insertion and dialysis machine and catheters and ventilators. “So, comfort care?” my resident asked as soon as the door shut Chandra behind us. “Yes,” I said.
As soon as he communicated that information to the ICU fellow, the medical frenzy began to subside. We called for a morphine drip to replace the five pressers keeping her heart barely pumping. Once the morphine arrived, the respiratory therapist removed the breathing tube, the dialysis nurse unhooked the huge rectangle dialysis machine that tried to duplicate what her kidneys would never again do, and the ICU nurse cleaned up the bloody hairy mess we’d made. When they removed the ugliness of our attempts to perpetuate her body, the nurse covered her with a clean white blanket.
We walked Chandra in to sit with her mother and pulled the curtain to leave them alone together. For her, I imagined, sitting there in the subsiding flurry of activity and loud voices and beeps and alarms, her now peaceful quickly dying mother must seem surreal. I found myself hoping they believed in God, thinking that might make Chandra feel less alone as her mother slipped away in this ultimately tangible episode in a lifetime of hellos and goodbyes. The greetings and partings had come before her mother died; they will continue after her heart stops. For years after, perhaps until the end of her own life, I imagine Chandra greeting her mother in moments of celebration. She remembers her at weddings and on holidays, with a sadness eventually eclipsed by the joy of having grown from her.
Her heart stopped at 4:25pm. Her nurse came to get me. “Asystole on the monitor,” she explained, “Flatline.” Flustered again and feeling shy and emotional and ashamed, I wrestled to get my stethoscope out of my white-coat pocket before entering the curtained room. To “pronounce” her dead, I needed to listen for the absence of breath sounds and heart beat. I needed to hear silence and see stillness.
No rise and fall of the chest greeted me as I placed my stethoscope to the left of her breast bone and glanced covertly at Chandra still sitting at the bedside now watching me. I don’t know if she wanted me to hear anything or not. She already knew why I listened. She knew, but still, when I finished this doctorly ritual and heard only silence, she asked, “So, she’s gone?” The resident and I both nod, “We’re sorry.”
Again we leave her. This time to get the requisite paperwork to record that her mother died. So many papers to prove she exist suddenly canceled out by the small stack to state that she died. I call the Coroner’s office to report the death and see if they need to do an autopsy. “Yes, hello, this is Dr. K---,” the words become more unfamiliar and distant to my ears, “I’m calling to report a death.” The woman on the other end asks for facts. “Name? Date of birth? Social security number? Address? Past medical history? Circumstances of death? Cause of death?” She concludes that it sounds like a natural death and gives me the waiver number to cancel the autopsy.
Chandra appears to hold up well as she calls the donor hotline to agree to donate her mother’s eyes for a research study. She stands by the phone across from me “yes, yes, yes, no, yes” to unheard questions, “Uh huh, yes, Okaaay,” she draws out the end and increases the pitch in just the same tone she did when I explained her mother’s dying to her. I can only imagine her numbness. Awareness of her mother’s death will seep into her over the next weeks and years, for the reminder of her life. But as knowledge of death trickles in, so can knowledge of life.
She already savors the time spent going to Hawaii with her mother. Her mother enjoyed the cruise, she tells me. I am glad of that. That is life.
After Chandra leaves, the man with the metal gurney and the white canvas rectangle tent comes to get her mother, now wrapped in a white bag and zipped up. He asks for help with sliding her over. They use some of the same techniques we use to move sedated or anesthetized patients. He wheels the now heavier gurney to the place in this hospital I have never visited, though I remember it from my medical school hospital. That room is metallic and cold. It smells of disinfectant.
The same disinfectant they use to wipe down the mattress after they remove the dead woman’s sheets from them. As the housekeeper wipes, the cleaner glistens for minutes on the plastic mattress before it dries. The room smells of sanitized death.
“It is a day.” I remember the words from a past life, as if they are spoken to me by the dead. “Only a day.” From a book I read, I think. The memory starts to return. Steinbeck, perhaps. “You have a dark and troubled mind, My Lord.” King Arthur. Why do those words return to me as I walk down the hill to my car in a haze of fatigue? The rest of my thirty hours had been filled with managing diabetic ketoacidosis, maintaining tact with another resident venting to me negatively, fighting down the constant nag that I am making mistakes and I don’t know enough to do this, bolusing fluid to hypotensive patients, adjusting ventilator settings, attempting insertion of an arterial line, performing my first thoracentesis, answering my beeper, and sleeping precious little.
In the midst of death and sickness and life, I struggle to keep peace with myself. If I do not anxiously expand doctoring to unmanageable proportions, this job is not so technically demanding. I gain experience and learn the routines and science. I no longer feel faint when I have to put in central lines or perform lumbar punctures. I know I can do this. I know I can witness death. I can live among the sick and try to guide their bodies and minds back toward health. I know I can witness life.
And, as I did with Chandra and her mother, what life I only peripherally witness, I imagine into existence. For her mother, I imagine Hawaiian sunsets and buffets at sea and time spent laughing with one she loves. For Chandra, I imagine denial and guilt transitioning into peace and celebration and acceptance. For myself, in my exhaustion, I imagine a “dark and troubled” mind. I grow tired sometimes of imagining others’ lives instead of living my own. I can do this job; I imagine I can. There are times, however, when I cannot imagine why I chose this over sunsets and real joys of my own.
Initially, in the haze of shock, she did not grasp what I tried to tell her. “Your mother is dying,” I should have said. I learned it in medical school. Before that even I should have asked her what she understood about her mother’s condition. When faced with telling someone of her mother’s eminent death and with my own agenda of convincing her to let us withdraw live-preserving efforts, all I could say was: “She is very sick.”
“It is very serious. She is very sick,” I kept repeating like some scrub donned parrot paralyzed by fear of death and failure. I caught myself rattling off words like “pressers” and “breathing tube” in attempts to make her understand. Not yet ready to learn that she would soon be a motherless child in this world, Chandra ruminated her mother had felt well until yesterday. They live on the other side of the country. Her mom had recently been diagnosed with lung cancer and she’d been on dialysis for end stage renal disease for over a year. When asked, Chandra told me, her doctors at her home had told her to go on the “Dialysis at Sea” cruise. “Enjoy yourself,” they’d said. Chandra said her mom had always wanted to take a cruise. They’d just returned from the two week trip to Hawaii. She was trying to figure out if she should go get a hotel and start to arrange to have her mother med-evacuated to their home. She was still in denial, the first stage of grief. “You should probably wait here,” I tried to say it gently, “your mother is very sick.”
She understood that her mother was dying when I asked her if she’d like us to stop our failing attempts to rescue her mother’s body from following the likely already departed essence of her being. She began to cry. Alone here, without friends or family she repeatedly thanked me and put on a brave gaunt smile. She wore a soft black fleece; her body was as round as her mother’s naked cold body I’d just left with my fellow who struggled to find pulses and vessels to insert central venous and arterial access lines. I couldn’t tell if they looked alike, one was alive with small braids in her hair pulled into a high pony tail and dark round cheeks; and the other was ash-colored and dusky with her mouth gaping open around the breathing tube helping to keep her body’s metabolism limping along. The dying mother wore small gold earrings pressed into her ears in the shape of flowers.
I hugged Chandra, an awkward sideways hug in side-by-side chairs, made more uncomfortable for me by the fact that my resident had suddenly shown up to ascertain if I’d managed to establish that we were switching management to “comfort care.” When I glanced at his business-like dark eyes, blinking back the tears in mine, I remembered what he’d told me when we first heard about Chandra’s mother’s pulseless electrical arrest and three rounds of CPR in the emergency department: “Oh well. One less fat black woman who hasn’t taken care of herself.”
At the time, silently appalled that he’d said that, I turned away from him and buried myself in copying down her labs from the computer. If I ignored him long enough, he would go off in his whirlwind of action and jolting activity. I find it hard to maintain a sense of humanity and peace in places where people become so frigidly practical about death.
I wondered if he uses those thoughts and words a protection or a mask, or if he truly feels that way. I wonder if I am overly sensitive to the struggles of the loved ones left behind by those who die in oblivion on our wards. After all, I don’t know these people. I never knew them in life. I don’t know why her mother chose to wear those flowered earrings this morning. I don’t know if, by taking this cruise with her daughter, she accepted that this lifetime neared an end. I make up stories of their lives in my head. I extrapolate facts into a brightly colored and meaningful picture of lives. And of deaths.
And so I hug Chandra as she cries. I turn my face from the resident and look out the window toward the ocean they have just crossed together only to part on this shore. He tries to rush me along. “We’ll give you a moment,” he says. I have learned that when he says this it really means, “I have more important things to do now.” I don’t want to leave her alone. I offer thin comfort by promising to try to get her a phone and contact social work to talk with her again. I wish I could do more. I could have, but I chose not to sit there with her longer and instead let myself be pulled back to the storm of line insertion and dialysis machine and catheters and ventilators. “So, comfort care?” my resident asked as soon as the door shut Chandra behind us. “Yes,” I said.
As soon as he communicated that information to the ICU fellow, the medical frenzy began to subside. We called for a morphine drip to replace the five pressers keeping her heart barely pumping. Once the morphine arrived, the respiratory therapist removed the breathing tube, the dialysis nurse unhooked the huge rectangle dialysis machine that tried to duplicate what her kidneys would never again do, and the ICU nurse cleaned up the bloody hairy mess we’d made. When they removed the ugliness of our attempts to perpetuate her body, the nurse covered her with a clean white blanket.
We walked Chandra in to sit with her mother and pulled the curtain to leave them alone together. For her, I imagined, sitting there in the subsiding flurry of activity and loud voices and beeps and alarms, her now peaceful quickly dying mother must seem surreal. I found myself hoping they believed in God, thinking that might make Chandra feel less alone as her mother slipped away in this ultimately tangible episode in a lifetime of hellos and goodbyes. The greetings and partings had come before her mother died; they will continue after her heart stops. For years after, perhaps until the end of her own life, I imagine Chandra greeting her mother in moments of celebration. She remembers her at weddings and on holidays, with a sadness eventually eclipsed by the joy of having grown from her.
Her heart stopped at 4:25pm. Her nurse came to get me. “Asystole on the monitor,” she explained, “Flatline.” Flustered again and feeling shy and emotional and ashamed, I wrestled to get my stethoscope out of my white-coat pocket before entering the curtained room. To “pronounce” her dead, I needed to listen for the absence of breath sounds and heart beat. I needed to hear silence and see stillness.
No rise and fall of the chest greeted me as I placed my stethoscope to the left of her breast bone and glanced covertly at Chandra still sitting at the bedside now watching me. I don’t know if she wanted me to hear anything or not. She already knew why I listened. She knew, but still, when I finished this doctorly ritual and heard only silence, she asked, “So, she’s gone?” The resident and I both nod, “We’re sorry.”
Again we leave her. This time to get the requisite paperwork to record that her mother died. So many papers to prove she exist suddenly canceled out by the small stack to state that she died. I call the Coroner’s office to report the death and see if they need to do an autopsy. “Yes, hello, this is Dr. K---,” the words become more unfamiliar and distant to my ears, “I’m calling to report a death.” The woman on the other end asks for facts. “Name? Date of birth? Social security number? Address? Past medical history? Circumstances of death? Cause of death?” She concludes that it sounds like a natural death and gives me the waiver number to cancel the autopsy.
Chandra appears to hold up well as she calls the donor hotline to agree to donate her mother’s eyes for a research study. She stands by the phone across from me “yes, yes, yes, no, yes” to unheard questions, “Uh huh, yes, Okaaay,” she draws out the end and increases the pitch in just the same tone she did when I explained her mother’s dying to her. I can only imagine her numbness. Awareness of her mother’s death will seep into her over the next weeks and years, for the reminder of her life. But as knowledge of death trickles in, so can knowledge of life.
She already savors the time spent going to Hawaii with her mother. Her mother enjoyed the cruise, she tells me. I am glad of that. That is life.
After Chandra leaves, the man with the metal gurney and the white canvas rectangle tent comes to get her mother, now wrapped in a white bag and zipped up. He asks for help with sliding her over. They use some of the same techniques we use to move sedated or anesthetized patients. He wheels the now heavier gurney to the place in this hospital I have never visited, though I remember it from my medical school hospital. That room is metallic and cold. It smells of disinfectant.
The same disinfectant they use to wipe down the mattress after they remove the dead woman’s sheets from them. As the housekeeper wipes, the cleaner glistens for minutes on the plastic mattress before it dries. The room smells of sanitized death.
“It is a day.” I remember the words from a past life, as if they are spoken to me by the dead. “Only a day.” From a book I read, I think. The memory starts to return. Steinbeck, perhaps. “You have a dark and troubled mind, My Lord.” King Arthur. Why do those words return to me as I walk down the hill to my car in a haze of fatigue? The rest of my thirty hours had been filled with managing diabetic ketoacidosis, maintaining tact with another resident venting to me negatively, fighting down the constant nag that I am making mistakes and I don’t know enough to do this, bolusing fluid to hypotensive patients, adjusting ventilator settings, attempting insertion of an arterial line, performing my first thoracentesis, answering my beeper, and sleeping precious little.
In the midst of death and sickness and life, I struggle to keep peace with myself. If I do not anxiously expand doctoring to unmanageable proportions, this job is not so technically demanding. I gain experience and learn the routines and science. I no longer feel faint when I have to put in central lines or perform lumbar punctures. I know I can do this. I know I can witness death. I can live among the sick and try to guide their bodies and minds back toward health. I know I can witness life.
And, as I did with Chandra and her mother, what life I only peripherally witness, I imagine into existence. For her mother, I imagine Hawaiian sunsets and buffets at sea and time spent laughing with one she loves. For Chandra, I imagine denial and guilt transitioning into peace and celebration and acceptance. For myself, in my exhaustion, I imagine a “dark and troubled” mind. I grow tired sometimes of imagining others’ lives instead of living my own. I can do this job; I imagine I can. There are times, however, when I cannot imagine why I chose this over sunsets and real joys of my own.
posted by S. at 7:50 PM
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