A Study in Death

It's been a while since my last post and I've been stewing over a few things, so it feels the right time for another. There seems to be another upsurge in discussion of doctors’ health, more specifically mental health, in the past few weeks. It’s an important topic, partially because it’s often overlooked, more so because it’s not discussed. Doctors are people. We all carry our own experiences, our own strengths and weaknesses, our own scars and banners. There are those of us that manage complete detachment and those of us with so much empathy that it’s overwhelming. And we will each deal with adversity in our own way. But unlike the population at large, we see and are involved with far more death. I’m not saying we’re the only profession that does, far from it. But pronouncing death, as much as sustaining life, is an integral part of being a doctor.

No one will argue that death is an emotionally charged moment. It is moving in so many different ways and affects people sometimes unexpectedly, sometimes predictably. I don’t want to talk about the reasons for death here, I don’t want to talk about the specific cases or the hospitals; I want to talk about death and it’s involvement in my career. I’ve learned that there are episodes, single points in time that will stick with me, that I carry with me, that are learned scars on my heart that I hope, somehow, make me a better doctor. Some of these vignettes are not easy to read; they certainly are not easy to write. But if someone were to ask me about death, this is what I remember.

I started to get the sense that I wanted to be a doctor when I was in high school. I loved science (and I was good at it). I had done intensive research, competed in science fairs, but I knew I wasn’t a lab person. If I had been, I probably would have become a Scientist (capital ‘S’). I have friends that are Scientists. Their intelligence astounds me. I didn’t have the attention span for it. And it was in the middle of this development that I lost someone dear to me. It was not the first death in my family, but it was the first time I’d been so close to it. My grandmother had become unwell about 4 years prior and subsequently, she had a rapid onset of Parkinson’s and was wheelchair bound. We, as a family, went through various stages of care, but ultimately, my grandmother was in a nursing home only a few minutes from our house and my high school. Final cause of death: Pneumonia. Not uncommon, and it was, thankfully, a very quick end. I remember the night my dad picked me up from practice after school and told me where we were going. I remember saying goodbye. I remember the stages of grief my mother, my aunt, my uncle went through. I remember the next day was Halloween. I remember the funeral was on the East Coast, because it was autumn and the leaves were changing. I remember thinking that this was how you were supposed to do it, the whole death thing.

When I was in medical school, we were relatively insulated against death. I think there was the feeling that death isn’t what we were in med school to learn; we were there to learn about saving lives. Right? We had communications courses or practice, but the difficult scenario was more along the lines of telling someone that their procedure was cancelled or something had gone wrong. Learn how to say the word cancer without cringing. Learn how to have someone yell at you without crying. Tough spine, stiff upper lip, thick skin. Perhaps my focus on surgery at the time put me in the mindset. It was still very ‘old boys club.’ And we knew that as females we were in for an uphill battle. No room for tears. No room for weakness. And yet, one of the most profound rotations for me was in a peripheral hospital on the palliative care team, aka ‘pain team.’ (Not because what they did was painful, but because they were the pain management team… seemingly). We did dry rounds on Monday, Wednesday, Friday. We didn’t have many patients, so we all knew them very well. And on my third week, we lost a patient. It was mentioned at the end of the dry round. I will never forget the heavy sigh from out consultant, the careful nod, and heartfelt murmur of, “Good for him.” I will never forget using the same line myself.

Another thing that isn’t necessarily taught in med school is pronouncing death. Breaking bad news is one thing; declaring a body inert is, in fact, a procedure with legal ramifications that must be learned. As an intern, I remember hoping not to be the first one bleeped to do it. What if you do it wrong? In honor of the first intern to have that duty, I salute you, sir. I memory of your timid entrance into the room, your nervous smile to the family, and your skill at blessing the patient with the sign of the cross and saying, “I pronounce you,” I will be eternally grateful. (If you’re not aware, that is not what you are legally required to do). And God bless the CNM that caught you by your ear and threw you back into the room to do it properly. Someone had to do it. And we all learned from you. It’s something that I became relatively good at over the course of the year. I remember having to do it 5 times in one night. I remember running into the priest in the middle of the night, and he looked at me with a tired smile and asked, “Are we winning?” I think I told him I’d seen him too much that night to call it winning; I’m pretty sure he agreed.

I remember the time I was called to an arrest for a patient that was NFR. The family was in the room and looked at all of us, crash cart in hand, and demanded to know what we thought we were doing. The nurse that called the arrest didn’t know the patient was NFR and she was behind us demanding to know what we thought we were doing when we started away from the room. I remember the time a patient was brought in by ambulance from a place an hour away, and the paramedics had been doing an hour of CPR with no success, and I knew the poor man was dead, but because the senior doctor didn’t want to stop until the family arrived, we continued compressing the dead man’s chest for another 20 minutes. I remember the time a family screamed at me, told me I might be an ok doctor but I was a terrible human being, because the doctor’s place was at the patient’s bedside when they passed. That patient was NFR as well, and I had been at an arrest on the other side of the hospital. They filed a complaint against me. It was the forth patient that had died that shift. I went home in tears.

I was working in a maternity hospital the night we lost a mother. My senior took me aside and told me that I had to support the new father. I bluntly asked her how to do that. Give your condolences, but remind him of his beautiful new son. His son was beautiful. And I’m sure he was and is very well loved. But at four in the morning, grief was more powerful, and I watched a man sob over his son. And I felt powerless. Four weeks later, and two weeks after I’d filed my report for the coroner’s inquest, I got a call from the occupational health office, just checking in, making sure I was “Ok” after that night on call… I’d already been on call ten more times, and we’d lost three babies in the NICU. I told them I was fine. We were having a normal day until paramedics pounded on the door to our NICU (how they got there, I’ve no idea), carrying a 25-week gestation baby, born in the ambulance on the way to the hospital. They’d hadn’t the equipment in their ambulance for a baby so small, but it was five minutes old and had the faintest and slowest heart beat. There was a resuscitation so that the mother could at least arrive (she was downstairs having the placenta delivered). When we managed an adequate heart beat through rather rigorous resuscitation efforts, I&V, drugs, I remember my consultant whispering, “Damn.” Later that day, I was privy to the conversation about outcomes for that baby, brain starved of oxygen for too long. The parents decided to let nature take its course. They were holding their baby when it passed away.

One week into a new job, and the entire team was in a handover meeting. An arrest call went out and there was some confusion as the bleeps hadn’t fully changed hands, the time of handover hadn’t been reached, a hodgepodge of people were called and arrived. I knew this baby, I’d been looking after it, it had become unwell overnight and apparently more so than expected. It was a one-hour resuscitation, and it was unsuccessful. But we had a debriefing one-week later. It was the first time in my career I’d actually had time or been asked to sit in on one. I ended up presenting a case study about that baby. I do not regret anything that was done in that resus. It was the first time I didn’t question an outcome. I don’t lose sleep over this one.

A child, two-years old, was brought into the A&E by ambulance at four in the morning. The ambulance crew has been attempting CPR; they’re not allowed to declare death, they have no other course of action. The child is DOA, full rigor mortis has set in. The consultant is phoned, and we are given permission to withhold resuscitation and declare death. I ask what it is I’m supposed to do. I’m told to inform the parents, get consent for the PM, and get as many of the PM samples as I’m able. I had never done any of those before. I’d never sat in on one of the bosses breaking the news to parents that their child was dead. It was four in the morning. I got on with it. I walked out of the room where I’d left the parents and was intercepted by another parent who wanted to inform me that their child had vomited again. I told them I’d be with them shortly, and started collecting samples for the PM. I saw eleven more patients before I ended my shift at eight in the morning. I couldn’t sleep all day.

One of the patients we all knew, a small child with charts that stacked higher than their head, a child whom had struggled with life from first breath, was in hospital with pneumonia. This time it was like so many other times. The parents knew the routine, the child knew the routine, and we all knew the story. I remember coming in to handover three days later and the on-call team informed us that the patient had passed away. I remember whispering, “Good for him.”