The Streak is Dead... Literally

Considering the amount of time I've spent in the Emergency Room, people are often amazed when I tell them I've never had a patient die. Honest. Actually, my life has been pretty much untouched by death entirely (touch wood, quick!). All of my family members who have passed away did so when I was too young to really get it, and no one has died in the past 15 years or so. Colour me lucky. And my patients... well, I guess they've been lucky too. I've had a patient or two die, but it was never while they were actually under my care. And only one of them was a patient that I'd actually had time to get to know beyond last name and chief complaint.

Even when people are supposed to die on my watch, they manage to hang in there until a new team comes on in the morning. A patient can be actively trying to die throughout the day but will miraculously stabilize at the exact moment I accept the code pager. And speaking of codes-- four code blues, four ICU transfers, three have improved well enough to come back to the floor. One is still in ICU, but doing better. No deaths. Un-freaking-believeable.

Basically, if you have a parent in the hospital... you want me on call. Not for my skills, but for my crazy good karma.

Now in all fairness, this might also be due to the fact that since becoming a resident I have actually spent very little time in the company of sick patients. Anaesthesia, Emergency Psych and Obstetrics don't often lose patients. And my time in family medicine was much the same. So the only time I was ever really in danger of losing a patient was during my hellish two months of general surgery and now, in my second month of internal medicine.

Which is why I was a little unprepared when I got called in the middle of the night to pronounce a patient on the hematology/oncology ward. We don't usually cover that ward on internal medicine-- those patients have specialized problems, and are usually handled by the specialists themselves. This was a young-ish guy (in his late 40's) who had developed a particularly unfortunate case of Graft-Versus-Host-Disease after a bone marrow transplant for a rare lymphoma. He had been doing poorly in hospital for over a month, and had acutely decompensated over the past few days. His death was expected to the extent that the attending hematologist had already gotten verbal consent from the man's wife for an autopsy to try to explain his recent rapid decline. All I had to do was pronounce the man dead and fill out the death certificate.

I knew the drill. I had seen it once as a medical student, and I knew the steps in theory. I entered the patient's darkened room and offered my condolences to the family. I then asked them to step out of the room for a moment while I examined their loved one. I turned my attention to the recently deceased. His mouth was fixed open in a silent scream, his head tilted towards the ceiling. Thankfully, his eyes were closed. His hands were cold and doughy. I was hesitant to touch them, feeling as though I were intruding on him at his most vulnerable. I felt for a pulse. Carefully, I peeled back his hospital gown to place my stethescope on his chest. I listened to the silence for a full two minutes, spurred by the irrational fear that if I rushed the process the poor man would sit bolt upright on the pathologist's steel table and I'd be interviewed on the evening news. I heard nothing. No breath sounds, no heart sounds. I tapped on the diaphragm of the stethescope to make sure it was working. It was. He wasn't. I pressed into his nailbed to assess response to pain. I reached over to rub his sternum but stopped-- his skin looked so fragile and delicate that I worried it would tear under my knuckles. Instead, I skipped to the last step. Prying open his dry eyes, I carefully touched a cotton swab to his cornea. No reaction. I gently drew his eyelid shut again.

I left the room. After a few more (likely contrived and artifical) words to the family, I retreated to the paperwork that accompanies death. I pondered over the offical cause of death for what was probably longer than I needed to. The autopsy would provide that information anyway... whatever I wrote would just be a guess. All I could think of was the coroner's talk we had received at the start of residency.

"Cardiorespiratory arrest is NOT the cause of death. Cardiorespiratory arrest IS death."

But I couldn't think of anything else to write.

By the time my shift ended at noon, I had been called to pronounce a second patient. An elderly man on the internal medicine ward with metastatic cancer, who had been bouncing in and out of the emergency room with severe nausea, vomiting and dehydration but determined to live out as much of his remaining days in the comfort of his home. Finally, he gave in and came into hospital to stay. He died with his family at his bedside, a jaundiced figure with a belly bloated with ascites and extremities that had wasted away to skeletal proportions. Although he wasn't 'my' patient at the time of his death, he had been under my care the week before during one of his shorter admissions. I knew him.

I don't know how many people I will have to pronounce during my medical career. I'd rather not speculate. But in the middle of the night in the darkened ward I laid to rest my first patient. And although I've already forgotten his name, his face will stay with me much longer.