I trudged hesitantly up the stairs, flipping through my stack of sign-outs that contained the basic information on every patient in the hospital, since it was my job that night to take care of them all. I had never even heard of Mr. Fitzgerald while he was alive, which is why I wanted to know what was wrong with him, in case the family had any questions about his death.
Only five minutes earlier I'd been asleep, when the nurse stirred me awake, asking me to pronounce Mr. Fitzgerald dead. I had never done this before. Not as an intern. A hundred questions ran through my mind at once. Was I supposed to pretend I knew the patient? Was I supposed to give the family words of reassurance, tell them that he had fought hard, that he was finally relieved of his pain? Maybe I wasn't supposed to say anything at all. I was at a complete loss.
The stairwell echoed with my footsteps as I found the former patient's page. Seventy-nine years old, pneumonia, do not resuscitate. It was all the information I had. Not much to go on, but then neither was my past experience with this sort of matter. In medical school, we were taught how to preserve life, not what to do if we failed.
Certainly, I had learned a thousand physical ways to tell if a person is dead. The skin becomes blue, then white. The limbs begin to stiffen -- a process commonly known as rigor mortis. There would be no pulse in the wrists or carotids, the iris would dilate and breathing would stop. The patient would show no response to pain, and no reflexes could be elicited. An electroencephalogram -- the charting of electrical activity in the brain -- would show a straight line, as would an EKG.
The list went on and on. But what was I supposed to do? What actions should I perform? There is a formal checklist for everything in medicine -- even for this -- but as I walked up those stairs, I could not remember one for the life of me. Or for Mr. Fitzgerald.
I began to sweat a little, and not only because my pale, undernourished body was laboring up its third flight of stairs at 2:43 in the morning. There were going to be people in that room who had not only just lost a loved one, but who needed closure for what was most likely a long period of waiting and suffering. What they did not need was to have me clumsily poking at random around their lost relative's body, mocking their pain with my inexperience. And even worse was that I'd be the only one in the room who never knew Mr. Fitzgerald at all.
A chill wind enveloped me as I climbed past a window, abnormal for an autumn San Diego night. I wondered if Mr. Fitzgerald's grandchildren thought it grew cold every time someone died.
In medical school, you learn a lot of science. While humanistic qualities are certainly desired by med schools, they are still not considered as valuable as, say, the memorization of all 27 ion pumps in the nephron of the kidney. So while I knew every single thing that constituted the physical state of death, emotionally I knew about as much as any grandchild.
I reached the top of the stairs and came onto the former Mr. Fitzgerald's ward. The sense of death, I thought, permeated the floor. I was not prepared for this.
I had only faced a dead person once before, during my fourth year of medical school. Up until then, death was just something we'd learned about as a negative end point, a failed treatment. No emotions had ever been connected to it. And therefore, I had never been prepared to deal with any emotions that might come up at the inevitable time when one of my patients finally passed away.
That time came while I was on overnight call for my sub-internship. One of my patients -- Mrs. Forman, an elderly woman with advanced stomach cancer -- passed away. The nurse who summoned me from my call room must have recognized the glazed look in my eyes as I approached, so she pulled me over to the side.
"You've never done this before." It was more a statement of fact than a question. "Just do everything I tell you," she whispered, pushing me into the dim, silent room. To say I was scared to death, under the circumstances, would not have been appropriate. I was frightened, but no longer alone. Like a little angel sitting on my shoulder, the nurse stayed by my side to whisper in my ear.
"Listen to the lungs," she said. My only experience with death until this point had been the anatomy lab cadavers that, after being soaked in formaldehyde for so long, hardly even looked like, let alone smelled like, humans. However, what I saw before me was simply a small, wizened old woman, with thinning white hair and veins bulging from her tiny frail hands. She smelled of old yarn. And while she didn't seem in perfect health, what she looked like most was a person with stomach cancer, only asleep.
The nurse pushed my stethoscope hand to Mrs. Forman's still chest, but I was unable to hear anything. Hmm. I'd run into this problem before on physical exams, and knew that with persistence, I would eventually find the sounds of her breath. I moved the stethoscope around, searching for a better spot, until my angel whispered again.
"You're not going to hear anything."
Oh, that's right, I thought. She's dead.
"Now shine your flashlight in her eyes." I did so, and after several moments the nurse bent over and lifted the lids, so I could actually evaluate the pupils I was pretending to evaluate. They looked right through me, as if calmly assessing something very far away, something the rest of us could not see.
"Feel for a carotid pulse." I put my fingers to the paper-thin skin of her neck and held them there, waiting for further instructions.
"Good. Now, nod to the family and say you're sorry." I did my best impersonation of all the warm, caring doctors I'd seen on television over the years. "Now tell me to follow you and leave the room." I did, and we were out. After I signed all the forms she told me to sign and wrote all the notes in the chart just as she instructed, my angel kindly pushed me off toward my call room and the awaiting bed. I was so disoriented, I didn't even remember to thank her. And as though it had been a dream, the next morning I didn't remember anything at all.
I searched in vain for that wonderful nurse as I scanned the 11th floor, but of course I was an intern now, 3,000 miles away from her and from medical school. Instead, I was met by a 24-year-old nurse who merely pointed at Room 1128 and went back to her bag of pretzels.
Unsure of everything except the fact that a dead person awaited me behind that door, I knocked softly and entered. Indeed, there lay on the bed a thin, balding, elderly man connected to about 40 tubes, plugs and IVs. Strangely, all the usual humming, sucking and beeping was missing; the room was eerily dark and still.
It struck me that only recently this man had been alive, just as I was. Ten minutes ago I was asleep and his cells were reproducing, his synapses firing and his ion pumps doing whatever the hell ion pumps do. But for some reason, at 2:37 a.m. they stopped, and when they did, he became very, very different from me. He became an inanimate object. He became devoid of life.
Which is why, as I stood framed in the doorway, the one thought I had that shone above all the others was, simply, "Boy, this sure is creepy." I mean, after all -- this guy was dead. For the first time since my medical training began, it occurred to me just what it meant to be dead. No one had ever discussed this with me before. Mr. Fitzgerald was turning cold and blue. His joints had become stiff and his flesh was becoming hard, like raw meat. I looked at my shaking hands and realized that, for the first time in my short-lived internship, I was freaking out.
In all of medical school, you're never once given the time to think about death. After all, we were devoting our lives to preventing death. Once the patient died, you had failed. So why devote time to learning what it's like to face a dead man, when that time could be spent learning a new way you could have kept him alive?
What they hadn't considered in med school, however, was that at some point, every doctor was going to have to face the death of a patient. And when that happened, the med student -- or intern, or resident or attending -- was also going to have to face the feelings that went along with it. Not just the feelings that perhaps you could have done something more, but also the feelings that every human being, doctor or not, shares when faced with the bad side of mortality. The feelings of the cold stiffness creeping from the deceased person's body into yours; and the feeling of your own fragility that goes along with it. I looked down at my hands again; only living things shake.
The soft rustling of the family members brought me back to the quick realization that, all of these thoughts aside, I still did not have any idea of just what I was supposed to do here, but that I had better figure it out soon. I tried to remember that night as a fourth-year student, but the details, hazy at the time, were all but erased in the present.
So I did just what had gotten me through my internship so far -- made a concerted effort to look like I was doing what a doctor was supposed to do. I calmed my hands, walked to the patient, frowned knowingly and palpated a few things. Then I listened to a few others. I shone my pen light on various body parts and put my stethoscope on different ones. After several minutes of fidgeting around the body of Mr. Fitzgerald, I gave one last somber nod to the family, gravely shook hands with each person, and told them I was sorry.
I waited for the questions, the wailing, the begging for a miracle. But none came. Instead, they each thanked me quietly, and let me go on my way. I found myself lingering near the door, wishing that they would ask me a question, that there was in fact some way I could do more. But the chaplain had already arrived and was speaking soothingly with the distraught wife. And the others, her children I supposed, were hugging and reassuring her.
I stepped away quietly to figure out just what one writes in the medical chart in this situation, and found myself wondering what medical school could have done to more adequately prepare me. Certainly, I could have done a better job of memorizing what sort of exam to perform. But from an emotional standpoint, perhaps facing death -- as a doctor, a family member or even a patient -- is something that can't really be taught. Perhaps, when it comes to this Great Equalizer, the one thing we will all someday hold in common is that we must all approach it simply as human beings.