The house pager goes off with its irritating little warble; I answer it. It's the oncology floor: the patient in $room just expired. No code blue, no family here. I'll be right there.
My first visceral response is a flash of irritation. People always die when I'm trying to sleep. But that fades, and quickly. I am not yet so hard at my core.
Out of bed, white coat and stethoscope, around the corner to the elevators and up to the floor. I try, usually, to find out at least why the person was in the hospital. Curiosity compels me more than anything. I glance at the chart, walk into the room where the nurse-extender is busy changing his gown. She does her job, I do mine - a meshing of gears. I listen to the chest, check the pulses, pry open the eyelids to peer into eyes that no longer window onto anything but blankness. My bare hands touch cooling flesh, waxen and doughy with death, lean on the sternum with my knuckles.
I always make the family leave; sternal rubs are brutal and can sometimes earn you a groaning exhalation/gasping inhalation of elastic recoil and stored air. It's not a breath, just a matter of physics, but it's cruel to make the family hear it.
It's half-ritual, half-habit, the order of things. We are instructed to do whatever we must to be satisfied that the patient has indeed died - but that should include heart sounds, pulses, and respirations. I always look at pupils too; I remember that from somewhere back in medical school. Besides, I never cease to be fascinated by the very lifelessness of the eyes.
I wash my hands before I leave - either with soap and water or with alcohol scrub.
The note is always the same:
FMR2 on-call pager
Called to bedside for death pronouncement. No code blue documented in chart. Patient is pulseless and apneic, unresponsive to voice/painful stimuli. Pupils fixed and dilated. Precordium silent. Time of death: _______. My condolences to the family.
If there is family there, I tell them how sorry I am for their loss. I am, too - genuinely sorry, regretful that these people, warm and real and breathing, have lost one of their number; as if the death of one diminishes the whole. Sometimes I offer Kleenex. Sometimes the chaplain is there.
But I always write my condolences in the note. It seems a fitting last sentence to the chart, which is destined for Medical Records and a home in the twilight oblivion of a database.
It is no effort for me to go back to bed, back to sleep; to file away another empty shell of a human being in an endless stream of experience that takes me away from the norm. He is the second death I have touched tonight; the first came into the ER asystolic after being pulled from the burning wreckage of her house. I had no part in her care, nor the pronouncement - but I walked into the room where the stench of charred timber filled the air, put on gloves (a homicide case!) and pulled back the blankets to look at her face. I can't explain why - I brushed it off as morbid curiosity, but I think somehow it is more than that.
In a world where death can be reduced to three lines in black ink on yellow paper, sometimes it's worth really looking at people.