Got to the hospital this morning at a little after 0700. Paged the rounding nurse. Dr. AO wasn't there, he was at another hospital, across town. "You can tag along with Dr. P instead," she says. So I did.
It was a better day than I'd anticipated, O Best Beloved. Dr. P was fond of letting me see patients and staff them, write notes. He liked to ask questions. He showed me little tricks for calculating creatinine clearances and things like that. He loved teaching, that was clear. It was a wonderful morning. And then Dr. P had to go do a procedure.
I got the senior nephrologist to follow, just as he was called down to the CICU. Patient had a blood pressure in the 40's. And then his heart stopped beating. Nobody'd talked to the family about no-code status, so they started full resuscitation efforts. CPR and all. We got down there and the epinephrine was keeping his blood pressure at 260/120 and his heart was ticking at 174 bpm, secondary to the drugs. And as they started to wear off it started to decline, but slowly. Very slowly.
That was when Dr. T, senior nephrologist, got the unenviable task of finding the family and explaining to them the essential futility of coding this man, their father or husband or brother or uncle, the man they loved. And they agreed, after a few minutes, the very end of which I heard, to make him a no-code, and just to continue the support he was already on. "A miracle could happen," says Dr. T. "But I think that at this point it's more likely that we'll let him just slip away. No more heroics." They nodded, sniffling. There was a chaplain and a student chaplain with them. Grief is their island, in the hospital, their province of familiarity. It's an unenviable job, like my own, to be a chaplain. But what job in a place devoted to healing the sick and comforting the dying is enviable? We may be like gods at times, but our feet are clay and glass, so fragile.
He came back and he told the nurses, and they turned off the extra IV fluids and they checked the pressors and they nodded. And the nurse who'd been running the code looked at him and said "Nothing more?" And he nodded, casually. "Nothing more. Just leave the pressors on." And everyone left the room.
I walked into the room, O Best Beloved, that big, spacious, sterile, comfortless room in the CICU of a new and modernized hospital in my hometown. I pulled aside the curtain and I walked in while the nurses were still setting up drugs and taking arterial blood gases and playing that his life was going to be something that could be saved. I stood out of the way, an uncomfortable figure in a white coat, the only one without a role to play, moving aside and trying to guess where the throng was going to go next. I listened to them talk, charting their code, their efforts, what they'd done and given, when his heart started beating again. I heard them comment on how strangely strong his pulse was, how it had been like that before the code, and slowly faded away. And then I ducked outside to make sure I wasn't left behind.
We ran into RT coming down the hall as we went back to the room, coming back from settling the family's decision so that it could be signed and charted. Permission, of a sort, to die. It's a cosmic sort of thing, signing a no-code, bowing your head to the will of the divine and acknowledging that we were not made to live forever. We were born to die. If we are lucky, we will do so in a manner befitting our station. "Wrong floor," he says, by way of making conversation. "Good thing, too. There's a crowd in that room." Soft, ironic chuckles drifted out around us in a cloud of wary humour. There is, after all, no such thing as a good crowd in a hospital. Either someone is dying or someone has something so interesting and rare that everyone has to see it.
They did paperwork, made calls, looked at the last blood gas drawn with a wry "I know it's futile, but here it is," from the nurse. I walked back to the room. It was quiet, the monitor alarms set to inhuman limits and turned off for all but the most life-ending of events. The hiss and soft thud of the ventilator had a flat and empty sound, absorbed by the aura of gathering death. There was a faint clicking as two vasopressor medications, maxed-out, flowed into veins that would have otherwise been without blood to sustain their shape. Veins, after all, collapse if they are not filled. Arteries do not - they stay round, and in the average American they crunch after death, given a sort of internal skeleton by the plaques rimming their linings.
Click. Hiss. Thud. The occasional gurgle of fluid changing locations in the NG tube that coiled down to his stomach to drain a muddy, greenish fluid. These sounds, and my footfalls on the grey-white tile.
They turn the monitor - still attached, still monitoring an artificially elevated blood pressure and sketching the irregular, far-too-fast beats of a heart whose true function could be anything but is most likely poor to none - they turn the monitor aside, O Best Beloved, face it into the shadowed corner. They draw the curtains over the glass doors of the room but leave the window blinds open to let in a grey, still, wintry light. Snow was falling outside, huge flakes and lovely ones that melted and died as they touched the warmth of the building, and I stood in the room alone with a man not really alive but not-yet-dead.
His eyes were slitted open, enough for me to see his pupils. I know from the nursing record that he wasn't conscious when they began to code, and I watched long enough to know he didn't see me then, but I couldn't take my eyes off those slivers of humanity for long. There were tubes and wires and needles connected to him, and the machinery ticked on its endless cycles. On vasopressors, you can hang on for days sometimes. Weeks. And sometimes not.
I didn't touch him. I was afraid to - afraid that my touch would dislodge something, disturb some delicate balance within him. Afraid that in touching his skin to see if it was still warm, I would begin the final run of dominoes that would ultimately kill him. Afraid that his skin would not be warm, that the chill embrace of approaching death would enfold me once again. Afraid, O Best Beloved, of that in-between state he lingered in, of the power of the medicine I am learning to embrace, of its potency in this hopeless, agonal existence we had helped to create.
I wish now, O Best Beloved, that I had touched him.
I left, after a little while, carried with me the memory of a man half-alive. I don't know his name or his diagnosis or why the nephrologists were the ones responsible for him. I know nothing about him but what I saw in those moments in that room, where it seemed so quickly that the sterility of the hospital washed into my soul. I left, brushed the curtain aside and closed it carefully as I stepped out, returned to rounding and seeing patients, laughed and joked and helped J in her frantic attempts to find out if someone was employed at the hospital or not. His father, you see, was suddenly attempting to die at another hospital in another city - thus rendering the original plan to transport him to our hospital relatively moot. It turns out he wasn't employed, and we never did reach him. I went back and had lunch, saw clinic patients with Dr. AO in the afternoon, discussed chronic renal failure and why our 16-year-old girl patient has proteinuria and postural incontinence, and where the overlap between urology and nephrology comes in. I came home early - 15:30 - and I folded laundry, went to dinner at the Indian restaurant, settled in and watched some Weiß Kreuz (Knight Hunters), and he was still in my mind, his eyes and the expression on his face. He has a commonality with the anaesthesia patients in my mind; his mien was that of a man asleep from surgery - not the grey and ashen, sunken expression I have come to associate with the elderly dead. Children do not turn so grey as their elders; their skin, while still growing ashen, becomes translucent in death. He looked asleep.
I do wish now that I had touched him. Maybe then it would be more real.