End to Beginning

Five days until Christmas. Last Christmas Eve and Day I was in the University Hospital ER. Seems to be that only the very sick or very lonely come in over the holidays. No one else is motivated to wait.

Last night I was moonlighting at the Childen's Hospital. With the cold snap (ice on my car this morning!) in Southern California, seems that even the parents have been keeping their little ones inside and warm. I only had two admissions over the course of 6 hours. And the Children's Hospitals are usually busier in the winter with all of the respiratory viruses going around.

A couple weeks ago an unmanned F/A-18 with both engines out skimmed the trees on the hill above our house. And crashed into the new home of a Korean man and his young family two blocks away. His wife and two baby daughters, along with his mother-in-law were all killed. The pilot parachuted out and landed behind the house across the street from us. The neighbors who saw him said he was dazed and kept saying he hoped his plane hadn't crashed into a house.

My mom and brother, with whom I'm living now, were out for a bike ride and came back to find the whole area blocked off with emergency vehicles rushing to the scene. They didn't know at first where the plane had crashed and couldn't get to the house. My boyfriend, who had been working nights, was asleep in the house. With his phone off. Mom called me in a panic and told me what they knew at that point. I didn't know what to think. I called his number. Called the house number. Rushed to my car (I was walking toward the parking lot) and switched on the radio, scanning the stations for news of the crash, specifically where it had landed. It didn't take long for them to report the street names. Very close, but definitely not ours. My terrified thoughts of him in the rubble dissipated in a wave of gratitude and relief.

And then I felt concern for the as of yet unreported casualties from where the planed had landed.

I hugged him tight when I got home that evening, remembering those minutes when I imagined I might never be able to again. And I thought of the man up the hill who had lost the things in the world that mattered most to him. His grief is unimaginable to me--unimaginable in its reality.

Grief wafted through the hospital that month as I was on the in-patient service. More people under my care died that month than had in any other single month in residency. Some expectedly and some unexpectedly.

My first week there, I got a page to a phone number I didn't recognize. I called back and the receptionist mumbled something about "county medical examiner" and transferred me. They asked if I recognized a name they gave. It took me a minute since the name was not what she'd asked us to call her during her admission, but I figured it out. "She was found dead in her apartment." I was stunned. She'd looked fine when we sent her home. Breathing comfortably after her COPD exacerbation and telling us she didn't want to go home because she was lonely there or that she didn't feel right breathing still. She didn't want to go, but she was better from all we could tell. The next day I got the call because my name was on some of her prescription bottles. They wanted me to sign her death certificate--natural causes. She'd had many underlying medical conditions. I deferred to my attending. He called minutes after I'd hung up with them and filled in some of the information I'd been too stunned to gather: she was "found down." Paramedics tried to revive her for 30 minutes. There were empty pill bottles around her. Her oxygen was still on. I kept remembering her sister's voice as I talked to her on the phone. She'd sounded just like our patient.


The next week, an 84 year old man came in after months of complications following a hip fracture and fixation. He had recurrent pneumonia, worse everytime he came in, despite our strongest antibiotics. He had been bed-bound for two months. During his admission with us the orthopods left a note saying he could finally get up and start walking on his fixed hip. They must not have noticed that he was on the highest ventilatory settings we could do without intubating him (which he didn't want). Or that he couldn't even take off the breathing mask long enough to eat anything. Or that he didn't want a feeding tube yet. But they gave him permission to walk. He'd been waiting months for that. And he never would walk again.

Before he broke his hip, by all reports, he'd been an active independent man. Cantankerous, according to his daughters, and strong, tough, sturdy--as so many of his generation seemed. Stoic and strong and slowly dying off. The same generation as Pop. Almost the same age as him, too. He'd been a WWII vet also.

Since he broke his hip, he'd been depressed--unable to do the things he wanted. And probably feeling like a burden to the family members who visited daily and held his large strong wrinkled hands.

For three days we'd maxed out his BiPap--and uncomfortable mask that covers the nose and mouth and forces air in. He hadn't wanted to be sedated and have the tube placed in his throat to place him on the breathing machine. But then he changed his mind one morning. His daughter was there and another was on her way from Texas. He didn't want to wait for the second one to get there--he was running out of time and he knew it I think.

I called the anesthesiologist and the ICU team. Mr. A was alert the whole time--for all those months, he'd never lost touch with anything that happened around him. The anesthesiologist assured him they would take good care of him and pushed the sedating medicines before putting the tube in his throat. Once that is in, he needed to be continuously sedated to prevent him from pulling it out. When they sedated him for the intubation, that was the last time he was alert and aware of this life. He looked around as they leaned him back that last time. I couldn't read his eyes behind that mask, but mine began to tear up.

I imagined he knew, as I did, how sick he was and how this would probably end. I'm not sure why he changed his mind about getting the breathing tube. Dying without breath is a scary way to go. But he didn't appear scared. If anything, he seemed resigned, and somewhat peaceful as he looked around that last time--a island of quiet among the sea of activity around him preparing to force him to take a few more last breaths. Maybe he did it for his family, so they would know he tried everything he could to stay with them. Maybe he did it because he was scared at the end. Maybe he did it because he didn't want to face saying goodbye the other way--the awake way. Maybe he didn't want to wait for his second daughter because he didn't want to see them grieve. Or he no longer wanted to be conscious of his gasping breaths as they trickled away from him in that final countdown.

I'll never know what he thought then. But it seemed to me, as they tilted his bed back and adjusted his airway for the tube insertion, that the essence of him left. That last glance around was a farewell to this life. I wanted to be next to him, but it wasn't my place. I wasn't part of the pieces of his life that mattered most to him. I was only part of the end. His daughter waited at a distance for the fuss of intubation to be over so she could hastily brush away the tears she hadn't meant to shed and go back to holding his hand and being strong for him.

He died a few days later, on the ICU service. They, along with the family, decided the chances of any meaningful recovery for him were essentially zero. Even if, by some miracle he made it off the ventilator, he would never been the strong capable person he envisioned himself still to be.

Once patients are intubated, the are transferred to the ICU team, but I still went to see him the next day. His daughters were there then, looking at him sedated, intubated, now with a feeding tube in his nose also. "He would be so angry to see himself this way," they agreed.

I thought again of Pop and how lucky it was that he went so peacefully at home--the way everyone, among their chest of secrets and fears, wishes to die. I was glad he hadn't been in the hospital when he died. And I was sorry Mr. A had to spend the last months of his strong independent life in and out of care facilities, weakening gradually and dependent, in the end, even for food and breath.

The next day, they turned off the ventilator, and he died shortly after.


My third week brought another death--a 45 yo man who had been homeless for 22 years, and drinking heavily for 30. He had destroyed his liver but had somehow managed to make it on the streets, working odd jobs to pay for his beer for all of these years. That speaks to his resourcefulness. When he was admitted, I had a bad feeling it could end badly. The intern and medical student caring for him kept saying maybe he would make it through this admission. I tried to help them keep reality in mind. I saw no good way out of the hospital for him. Even our day-to-day plan was just that: plans to get us just to the next day, maybe the one after that. On rounds, we shied away from talking about his future.

The day of his admission, we ask, like we do with everyone, if he would like to have compressions and a breathing tube if his heart stopped or he needed help with breathing. He did. Even before he started bleeding in to his back, he looked scared. We had to collect fluid from his swollen abdomen to see if it was infected on that first day. He was scared of that too, but he tried not to show it. He thanked us for taking care of him and apologized for being such a trouble.

He would get intermittently confused during his stay there. He sometimes needed a sitter or restraints. But there were times when he cleared enough for the social workers to ask him repeatedly if there was anyone he would like us to contact for him--any single person in the world who would care that he was in the hospital--that he was very very sick. He said he'd think about it. The next day, he said, "No. There's no one." He had a daughter who he never knew because her mom was a heroin addict and had succumbed to HIV/AIDS. I imagine him during that night, searching in his head through all the people he must have known in his life, trying to imagine if anyone would care if he died. And coming up with, "No."

He had a large internal bleed and we kept giving him blood products but he was so sick that no one wanted to risk trying to fix it surgically. One morning, the loud-speaker which announces Code Blue (someone basically dead who needs attempts at resuscitation) crackled to life and announced a room number. Fear struck in my heart as the number sounded familiar and I scanned our patient list; it was his room. We ran down six flights of stairs with the ICU team shouting to them his underlying medical conditions and recent history.

We arrived out of breath to find him without breath or heart beat. Compressions, medication, and electric shocks got a heart-beat back. The shocks sent his body into temporarily stiffened awkward postures before his muscles relaxed again into oblivion.

He, also, was transferred to the ICU team. I saw him the next day and he looked worse than every: belly more swollen, skin the color of dried lemons, intubated, sedated, blood products still pouring in through his veins and pouring out into his abdomen. The following day, an ethics meeting was held and it was decided to remove life-support, without which he died quickly. With no one to notify. His death and his life made me sad.

I wondered with the med student who'd cared for him also if he had friends on the street and if they would wonder what happened to him when he never came back. If they would care. He thought they would accept that something had happened and move on quickly, too concerned with their own survival to grieve over another for long.


My fourth and last week on service brought another death--a 37 year old male with AIDS and pneumonia so bad it soon caused a hole in his lung which leaked air into the chest cavity suffocating him from within. Despite his out-patient doctor assuring me that he would just be in for a few days for some iv antibiotics, it quickly became apparent how very sick he was and how advanced his lung infection had become. Amid a flurry of discussion about his desires to be or not to be intubated, he became more and more short of breath and anxious. Once he'd reiterated his desire to not be intubated, we started morphine to relax him and enable him to say goodbye to his sisters and his partner. He died the day after I left, reportedly peacefully with his loved ones at his side.


And so it is.

I have been seeing more of the end of this cycle of life lately. Though I do not like most things about obstetrics, I do miss that part of the newborns--the "new" part. I miss the freshness and health and hope and potential.

I start back on pediatrics in three weeks, though I'll be in the ICU there for the first four weeks.

We can cure. And we did help many of the adults on my service last month--help them see more years of their lives, helped cure their infection, or ease their pain. There is help and there is service in this profession, but there is also grief--a tangible reality of grief in some ways akin to the man whose house and family used to live just up the hill.

In his stunned address to the country, he thanked those who had helped him already and he asked for advice on how to get through his pain. He said he knew others had experienced loss and he just wanted to know what to do. How to go on.

And maybe that is what we all ask for: help. Help surviving loss. Help accepting joy, even at ends. Help in gratitude for the blessings we have now. And help sharing with those in need.

I think of my cousin's Christmas card full of her peaceful and deep joy in her three children, one with a congenital heart condition and doing wonderfully well and two 12-month-old twins she adopted from a mother who lived on the streets. She shared a story of the oldest boy braving his vaccinations at the pediatrician but crying and pleading with the nurse to "not hurt his babies" when it came their turn for vaccines. And then showering them with hugs and tender words after their shots.

Indeed, new beginnings are everywhere, once we have finished grieving old ends.


May you and those you love share in the warmth and hope of your holiday.