When There's Nothing More Your Doctor Can Do
Every shift in the ER can offer a chilling reminder of your own mortality. One doctor takes us inside a patient's final minutes.
From the neck up, Robert Gregory looked like an ordinary man, mild, scholarly, with thin wire glasses and bright eyes behind them.
From the neck down he was hardly a man at all. His body was enormous, so full of fluid that he could barely move. We had to lift him from the paramedic's gurney to the bed as he gasped into the oxygen mask.
His shirt was off. His skin was gray and damp. His hands and feet were blue. He felt cold to the touch, like a bag of flour in the refrigerator.
"I can't breathe, I'm so nauseated, help me." The words came one by one, between breaths, like beads on a string. "Help me," he said, again, and then he began to cry. He cried like he gasped, without restraint.
I asked him if he wanted to be on a ventilator. I asked him what he'd like us to do if his heart stopped. I had to get straight to it.
"I'm DNR," he said. "Just let me go. I'm so nauseated. I'm so afraid. Please help me."
"What would you like me to do?"
"Something for nausea. Something for pain. Oh my God."
So he absolved me: I would only have to watch. He was sobbing like a child, but he had the courage to give up nonetheless.
He was terrifying.
Primary pulmonary hypertension mostly affects women. Nobody knows why. Your immune system attacks your pulmonary blood vessels. The arteries become stiff and inflamed. The heart struggles to pump blood through them, and in a few years, it gives out. There's no cure. The failure begins with breathlessness, and it ends like it did for Robert. He'd called the ambulance himself. His nurses only came a few times a week—that day, they weren't there.
He should have been in a hospice. Instead, he was alone in his house.
It comforts us to name things. It comforts us especially when a disease is rare, when the odds are long, when the chances are great that it will never touch us. Something else, we think, but not this, and it's an uncertainty we embrace. His suffering was safely his. It had chosen him, like a celebrity, like a single star in the sky.
The hospital was full. The hospital is always full. It's a story that repeats itself throughout the country, because the struggles in America are much greater than we like to see. Hospitals like mine make you see them; they hold them up into the light.
There was no place to put him upstairs, no place for hours. Just the ER, in the afternoon, with a crowd waiting in the lobby.
For a little while, he stopped crying.
"Is there anyone you'd like us to call?"
"My mother is elderly. She doesn't drive. Please don't call her."
So we didn't call her. But he wanted to talk, and he didn't want to be alone, and we could see it.
I asked him what he did and where he was from, as if we were getting to know each other.
"I'm an artist," he said, his lips forming little circles, like rings in a pond.
"What kind of artist?"
"I paint watercolors."
Then he began sobbing again, opening and closing his hands.
So it was up to me—how much morphine to give him?
Once, when I was a child, I rode in a horse-drawn cart for a few miles down the coast of India. We were going to a hotel outside of town. We'd gotten into the cart in the dark, on a soft, hot, windy night, and set off briskly. The horse's hooves knocked on the dirt road, and the surf roared in the distance past the beaches. The moon was out among the clouds, and it was shadowy and exciting.
But after awhile it became clear how weak the horse was. It could not sustain the pace. We could barely see it in the dark. The driver whipped it, and whipped it again as it flagged, trying to get back to town a little faster, and pick up another fare. I remember grabbing his arm and asking him to stop. He looked at me, puzzled, and annoyed—as if to say, it's just a horse. Who are you?
Morphine. The question weighed upon me. Too much would kill him, not enough was worse. He was dying, but I didn't want to kill him. It's a primal thing, that decision. You want to do something. The desire is very powerful. You have to resist yourself: doing nothing is a greater form of discipline.
But that next step—pushing him over, and being done with it—is an even harder act. It requires a particular kind of courage. You can't be wrong. You can have no doubt. I was working, and there were many other patients to see. I spent only a few minutes on him. There were new hands to shake, tests to order. There were residents, and students, and EKG's to read. There were notes to type and questions to answer, and ambulances coming, and people walking by, and through it all the cellphone on my hip kept ringing.
I wanted to turn away, and I did. But I felt his presence as the hours passed. I knew he was behind the curtain in the corner, crying and pleading. His begging was general, like that offered to a torturer, as the nurse sat with him, and held his hand.
So I compromised. I gave him almost enough.
It took hours for his terrible alertness to fade. But finally, inevitably, he became confused. And so he became less terrifying. The gulf between the watched and the watchers grew greater. His breathing slowed, his head started to fall back, his mouth began to gape. He'd gasp awake again, look up, blink a little. He moaned like someone who is dreaming in their sleep.
The nurse still sat with him, and still held his hand, but she had to get up and work also. She got the worst of it. A young woman, not yet thirty, and her life isn't easy; she has bills and children and troubles. I know this because the nurses talk to each other, and I hear it. They talk to me also, sometimes.
By then we'd turned off the monitor, so the alarms didn't ring.
The task had fallen to her: it was she who sat with him when she could, and looked straight at him, and tried to comfort him, as the hours passed, and the bright lights fell.
The end of a person's life occupies, at most, a single room. But it fills that room, and there is a sense of reverence within it. Everyone can feel it.
I felt it. But not as much as I would have when I was young, not even close, and that's something that's stayed with me also. If you're unlucky, the coldness of your own heart gathers strength as time passes, and forces a certain clarity upon you. You become part of the indifferences. Experience makes you stop seeing the cruelties of the world for what they are. It's something that you must resist, and something that you must remind yourself to resist. You have to cling to the knowledge that no one should be required to suffer like that, in a cubicle of an ER, among strangers.
Finally, he stopped gasping himself awake. His head fell back for good, and his mouth opened behind the mask. His glasses were still on. His breaths became farther and farther apart. His face slowly went blue, until it matched the color of his hands. I was there for enough of it.
A watercolorist—the mildest, the most harmless of men.
The hotel was a concrete building, and the nicest place for miles. It was lit up in floodlights, and there were floodlights down by the water too, illuminating the surf for a nighttime swim. It seemed miraculous, after the third class trains, and the heat, and the beggars everywhere.
We got out of the cart, with its faded tassels, its red and blue peeling paint, its worn cushions in the back. As the bellboys converged for the bags, we saw the horse clearly for the first time.
It stood there under the lights, utterly revealed, its ribs like the branches of a tree, its mousy coat worn hairless where the yoke rubbed. It was panting, gathering its strength again, and I stared at it as we settled the bill,. Then the driver shook the reins and clucked, and they moved off together into the dark again.
As a child I didn't understand that all the horses in that town were emaciated, fed just enough to work, pulling their carts along the beachfront past piles of trash for the tourists. I didn't fully grasp the poverty that it spoke to. I only knew how deeply the horse shocked me.
Now I wonder if I'd see it at all. I wonder if I'd look through it entirely.
I pronounced him dead, which is a little ritual from the past. I put my stethoscope on his chest and pretended to listen. I shined the light in his eyes. Then I picked a time, and the nurse wrote it down.
It was false precision—3:32 pm. Not 3:30. You don't round up, or down. You choose a number that looks measured instead of guessed, intelligent instead of mystified.
We covered his body, and moved it to the decontamination room to wait for the funeral home. The housekeeper came, and made the bed again, and wiped the floor. A new patient was wheeled in, someone with no idea of what had just happened there. Then the nurse, who had sat with him, and tried her best for him, stepped out into the hall. I followed her, and touched her shoulder, and said something to her—I forget exactly—but she shrugged me off and walked away.
Ten minutes later she was back, dark eyed, quiet. I knew she'd been crying, gathering herself again, and as I looked at her, I thought—she's so young. She has so much left to see.
Frank Huyler is an emergency physician living in Santa Fe, New Mexico. He is the author of The Blood of Strangers.
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