This is the conclusion of a two-part story. Copyright is held by the author.
I DEFER to Jay to run the code and turn to the interns and students and explain that Connie is in EMD — electromechanical dissociation. That is, her heart has electrical activity yet no effective contraction or pumping.
Jay says to me, “Lewis, I was down the hall and a nurse asked if I could look in on her, that she had become unresponsive. Is she on your service?”
“Yeah. She was supposed to have been transferred to rehab late this afternoon. She’d had a stroke.”
“What? No. Sickle cell.” Scanning the on-lookers in the room, I ask, “Who was taking care of her? What nurse?”
From the back of the room, Joel, an ashen young man takes a half-step forward and answers, “It was me, we had just finished packing her stuff for the move when she fell back and sort of gasped. She was fine until then . . .”
I place Joel in line to participate in the chest compressions and turn to Ron and ask, “What’s the differential for EMD? Use laymen’s terms as you explain the possible causes to Liv and Maurice.”
Having just been relieved from compressions, Ron is short of breath yet nonetheless offers an analysis. “Most likely cause for her is a PE. Blood clot to the lung. Less likely are fluid around the heart, a collapsed lung, bleeding and an elevated potassium level.”
“So, Sarah, what do you think is most likely?” I ask as I recall how, hours earlier, she had wrapped her arms around Connie and wished her well.
Her lower lip trembling, Sarah stutters as she replies, “I’d guess PE. But, aside from giving IV fluid and epinephrine, I don’t know what else can be done.”
Chest compressions continue and Jay, positioned to monitor the femoral pulse and EKG monitor, asks the charge nurse, Helen, to continue to administer sequential doses of epinephrine. As the efforts continue I see that Sarah’s face has clouded. I tap her on the shoulder and instruct her to break away and gather any family into a conference room. She looks at me expectantly and I say, “Tell them that Connie’s very sick and we’ll know more shortly.”
Jay asks that compressions be halted and he now feels a weak femoral pulse at a very slow rate. However, there’s no increase in heart rate with atropine and her blood pressure is not measurable with a cuff.
“Let’s try the Zoll, Jay,” and I ask Helen to retrieve this external pacing device.
After the pads have been placed on Connie’s chest I turn it on and see that, with each firing, her chest twitches. Jay shakes his head and says, “It’s not working. She’s lost her pulse again. Resume chest compressions. Lewis, I think we need to call it soon if – “
Interrupting him, I turn again to Helen and ask, “Do we have a transthoracic pacer on the crash cart?”
Jay states, “Lewis, if the external pacer, the Zoll, didn’t work there’s no reason to think sticking a pacer in her heart will.”
“Helen?” I ask.
She looks from Jay to myself and hesitantly replies, “Yes, I think so though, since we now have the Zoll, it’s been a while since we’ve tried this.”
“No, Lewis,” Jay says, shaking his head, “this is ludicrous. Let’s call it.”
Liv, delivering chest compressions, sweat dripping onto Connie, stops upon hearing Jay’s comment.
I instruct Maurice to take over compressions and then turn to Jay and reply, “Not yet. Five more minutes, Jay.”
With reluctance, he replies, “That’s all. Go ahead, Helen. Find the pacer kit and place it on the end of the bed.” As she rummages through the bottom drawer of the crash cart I glance out the room’s window into a park across the street where leafless trees are silhouetted against the darkening sky and have dendritic branches as though torn free of neural connection. I fear that Jay is right, that Connie is dead.
“Dr. Lowery? Lewis?” Helen asks.
“Here’s the kit.”
“Thank you.” Then, pointing at Ron, I tell him, “come stand beside me and I’ll show you how to insert the pacer.” He is startled but when I hand him a packet of sterile gloves he slips them on and then holds his hands aloft and apart from him. The solemnity with which he approaches slipping on the sterile gloves and how he now holds his hands upward remind me of when I was an altar boy assisting the priest in preparing the host.
I quickly cleanse the skin where the pacing wire will be inserted and then put on sterile gloves myself. Using sterile technique Helen opens the packaging of a long needle and hands this to me. I attach a 10-cc syringe to the needle and hand it to Ron.
“Ron, enter the skin about two centimetres beneath the xyphoid process, the lowest part of the sternum, and 1 cm left of her midline. After penetrating the skin pull back slightly on the plunger and then, as you advance, aim for the posterior aspect of her left shoulder. Within several centimeters you’ll be in the right ventricle of the heart.” His hands are surprisingly steady as he punctures the skin and advances the needle and then there’s a gush of dark blood into the syringe.
“Stop, remove the syringe and drop it onto the bed. OK, slip this wire into the needle. Further. Good. Now remove the needle without removing the wire. Stabilize the wire. Hold it with your left hand at the skin and don’t let go.” I then attach the exterior end of the wire to a pulse generator, set the rate on 60 per minute and dial up the delivered amps. “Maurice, stop CPR.”
Jay and I study the EKG monitor and we can see a spike followed by a wide wave-like form confirming that the lead is correctly placed within the right ventricle and is activating the heart muscle. But, is the heart pumping?
“Can you feel a femoral, Jay?”
I then palpate for a carotid pulse and there’s none.
Jay glances at me and then his wristwatch and declares, “That’s it. 6:17 PM as time of death. I’m sorry, Lewis. Thanks everyone.” With that pronouncement, Jay and another resident physician leave the room as quickly as they had arrived. Maurice and Liv move hesitantly toward the doorway and then stop and wait for me. I slowly pull off my gloves, toss them into a trashcan by the bed and join them before turning back for a final glance.
Ron remains at the bedside and continues to hold the pacing wire in place as I’d instructed. The nurses, Helen and Joel, glance puzzledly at him as they begin to gather up the scattered debris from the code — discarded gloves, bloody gauze pads, needles, syringes and plastic wrappings tossed onto the bed and floor. I wonder about the intangible detritus. Over the next days to years, with their world awry, would Connie’s family break into pieces or would they stagger initially to regain sure footing? Would her death be a black hole which collapses upon itself sucking in those who loved her?
I gently say, “It’s over, Ron. Let’s go see the family.”
As we watch from the doorway, Ron releases the slender wire protruding from Connie’s chest, tidies her gown and pulls a sheet up to her chest. Then, after using a clean gauze to wipe the saliva and petroleum jelly from around her mouth, he tries to close her eyelids but they pop back open. I walk back into the room and show him how to deflate the balloon to the breathing tube and slide it out of her mouth. With my back to the others except for Ron, I remove the plastic bag from my pocket and pull out the rosary beads. He watches as I wrap the beads around Connie’s left hand. I thank the nurses and Ron and I shuffle into the hallway. When I turn to him his shoulders are slumped and his eyes are red and moist. He is sniffling and wipes his forearm across his face. I touch his elbow and then motion for him, Liv and Maurice to come with me.
The door is closed. I knock twice and enter trailed by the others.
Sarah along with Connie’s mother and father, siblings, other adults and a hospital pastor are seated in a cramped room. Two children are perched on an end table. Her parent’s eyes are beseeching and when I shake my head it’s as though a grenade has exploded. All the family but the children tumble to the floor.
Their wails wash over us, knocking us back on our heels, and I don’t know what to do. Sarah crouches down beside Connie’s mother and is able to lift her up to a chair. The hospital pastor similarly assists the father. After a few minutes of continued sobbing the mother looks to me and asks, “What happened?”
“We don’t know. I wish we did. We think she may have had, after the stroke, a blood clot form in her legs. The clot may have traveled to the lungs causing her breathing and heart to stop.”
After further explanation of our efforts I suggest with trepidation, avoiding the word “autopsy,” that a post-mortem examination might help us understand why she had died.
Connie’s mother quickly responds, “No, she’s suffered enough.”
Cautiously pleading, Connie’s father says, “But, Karen, honey, this may give us —”
“Luke, no. No more.”
During all of this, Ron, Maurice and Liv have been plastered against the wall. When the pastor asks for all of us to close with the Lord’s Prayer I motion for the three of them to step forward and I clasp the hand of Liv on one side and Ron on the other. I glance at Ron and his eyes are closed as he silently mouths the words spoken by the priest. In the past, I’ve taken solace from this ritual but it now seems so empty. Is it that I no longer believe? Or that I’m unforgiving? Mostly, this display of deference seems to be an affront to Thomas and Catherine and — and now Connie — and how senselessly they died.
In a few minutes, my team joins me in the nursing station where I scribble a note describing the code into Connie’s chart.
Ron asks, with a smirk, “So, Lewis, when asking them about an autopsy, why didn’t you mention the gold ball?”
I look up at him with befuddlement. An hour earlier I had to pull him away from Connie’s body, tearful, and then minutes later he recited the Lord’s Prayer with the priest and now he looks like the prick that I assaulted in the ED our first night on-call together.
“Gold ball?” I ask.
“Yeah, you could have told them about how sometimes following a death the body chemistries are such that a gold ball is formed in the patient’s stomach.”
“Why, Ron, would I say that to Connie’s family?”
“Because they’d become the rightful owners of this newfound treasure. If they understood this might occur then they’d be more likely to consent to the autopsy.”
Sarah appears stricken and both Maurice and Liv have cocked their heads, confused.
I pick up Ron’s backpack from a chair and, with two hands, shove it into his chest. “Not tonight, Ron, not tonight.” He staggers back a couple of steps and, without looking at the others, walks away.
Driving home that night I pass a cemetery where the tall and slender tombstones are of a uniform size and the top of each is emblazoned with a nighttime torch such that this reminds me of lit candles on a sheet birthday cake, waiting to be extinguished.
The next morning before work rounds I swing by Dr. Guttierez’s administrative office adjoining the hospital and find him at his desk. His door is open and he is crouched over an open textbook. As I knock on his doorframe, he looks up and grimly waves me in to have a seat. Before I sit he states, “I’m sorry, Lewis. I called in late last night to check in with the overnight resident and he told me about Connie.”
“It happened quick, we’re not sure what. PE most likely. We were all there.”
“Yes. Sarah, Ron and both of the students. Everyone is sort of bruised up. So, Dr. Guttierez, I have a favour to ask about this morning’s attending rounds.”
“OK?” he states, sitting back with his palms open, concerned.
“I know we need to talk about what happened when you round with us. Could we just go easy?”
Leaning forward he asks, “No pimping?”
During my work rounds with the team, Sarah and the students, when not speaking, look at the floor. Ron is frowning. When Dr. Guttierez arrives, he pulls us together into a conference room where, after sitting, he fires up a cigarette.
After a long moment, he says, “I’m sorry, Sarah.” She raises her head and he, after a long drag, adds, “You took remarkably diligent and compassionate care of Connie and your efforts are to be commended.”
“Not well enough.”
“We all tried very hard and I’m ultimately responsible for her care.”
I reach up to rub my right temple as he pauses before saying, “Let’s take a few minutes to discuss what, if anything, we might have done differently.”
Sarah’s eyes widen and Dr. Guttierez calmly states, “If indeed this was a PE, a clot to the lung, that led to her demise — and we don’t know for sure that it was — but, if it was then it formed in her leg despite receiving the low dose heparin started when she was admitted. Just like any other patient with a stroke she received the low dose heparin to help prevent a venous clot from forming during her hospitalization. So, we did what we could. Right?”
“I think we did. I hope so,” Sarah responds.
Dr. Guttierez pauses to study the lengthening ash extending from his cigarette and, just as we suspect it will fall into the floor he cups his hand, the hand holding the cigarette, and catches the ashes in his palm which he then drops into a waste basket at his feet. “Unless we were wrong from the beginning. Maybe her stroke wasn’t from her sickle cell. Maybe, before admission, she developed a blood clot in the veins of one of her legs and this clot broke off and traveled to her heart. And, because she has an undiagnosed congenital heart abnormality, a PFO, the clot shifted from the right to the left side of her heart and therefore went to her brain rather than her lungs. But, then, last night, perhaps the blood clot in her legs, which we’ve not effectively treated with the necessary high dose heparin, broke off once again and this time the heart shot it into her lungs. A PE. And she dies.”
In our silence he continues, “If this was the case then we missed it. If this was the case then only a contrast echocardiogram — not the routine cardiac ultrasound we obtained — would have led to early and full anticoagulation, thinning of the blood, and this may have been life-saving.”
“She did have some swelling in her legs when we admitted her but it was equal on both sides,” Sarah timidly replies.
“Good point. That goes against the scenario I described but not all patients with a venous clot have asymmetric swelling. Sarah, what I’ve described is probably not what happened. Her stroke was probably from her sickle cell. But, if we don’t think of a diagnosis, we’ll not make a diagnosis. When I’ve made mistakes in caring for patients it’s often because I’ve gone with the obvious diagnosis and paid scant attention to the other, albeit unlikely, possibilities. When a diagnosis seemed obvious I forgot to ask myself” — by now he’s enveloped in a cloud of smoke from which his voice emerges — “What could I be missing?”
Dr. Guttierez is right. If we miss a clue, if our reasoning is flawed, there may be horrendous consequences. But, I am so weary. Of shouldering this clinical responsibility. Of my headaches. Of Catherine’s and Thomas’s deaths and bewildering nightmares. I am so tired.
Over the years I’ve woven the rituals, parables and saints of my Catholicism into a rich and coherent narrative yet, since the plane crash, the tapestry has become frayed. Unravelled. As Dr. Guttierez speaks, I wonder what alternative paradigm, if indeed there is one, am I missing? Yet, even if another narrative allowed me to refocus upon the lives that Thomas and Catherine had led rather than their deaths they’d suffered, I’d likely reject this exercise as a betrayal of them. For it’s my despair as they die over and over which binds me to them.
One morning a couple of days later I awaken, startled, and facing the darkened window, I sense that someone else is present. Absent any thought, I blurt out, “Catherine,” and as I speak her name and lay in bed I recall how the media had converged to the backyard of a home in a Baltimore suburb. Above the smoldering and crumpled wreckage, they had photographed an open suitcase on a sloping rooftop and a UVA T-shirt dangling from the limb of an oak tree.
I have no headache that morning and rounds are uneventful. However, by midday conference, I began to have a throbbing in my right temple which escalates despite taking a Fioricet. I limp through the afternoon and, by early evening, voices become tortuously loud. I am nauseated and vomit in the restroom off the hospital’s entrance where I wouldn’t be recognized. After signing out to the on-call resident I drive home while a spike is being driven into my head. In my kitchen, I take another Fioricet and collapse on my bed, mercifully able to sleep. Around 10:00 PM I awaken and the pain and nausea have lessened. I have a sandwich and then watch TV at a low volume until I became drowsy.
That night I dream again of Thomas and Catherine. I visit Thomas at his house, as his physician, and I am accompanied by a young man, my assistant. We knock on the front door and Thomas ushers us inside. Somehow, to my bafflement, he has survived the crash. His brow is furrowed and I ask him, “How are you?”
“I’m doing fine,” he says and then, looking over his shoulder, says, “I have my sister with me so all is OK.”
“Your sister?” Then, in a corner of the shadowed room, I see a girl lying in a bed. I walk to her and turn on a lamp. Catherine. Barely recognizable, she is pale with wispy hair and her arms are boney. Her eyes are closed but her chest rises. I touch her fingers and they are cool. I pull back the sheets from her legs and they are mottled with a lace-like purplish discoloration. I am bewildered and say to her, “Catherine, I thought you had already died?”
She opens her eyes and softly says, “No, Lewis, not in the plane wreck, I survived that. But, later. Later, I committed suicide.”
I become distraught. Is she alive or is she dead? My assistant pulls me out of the house and I urgently ask him, “What did you see?”
He says, “Yes, Lewis, I saw Catherine, but she was not as substantial, not as vital or present as someone living.”
I grab him by the arm, whirl him around to face me and demand, “What are you saying?”
“I’m telling you that her presence was diminished. As is your own, Lewis.”
“My own? What do you mean?”
“You’ve also faded away. Like her, you also, have died.”
I arise early the next morning, haunted, and I have a dullness in the front of my head. I am straddling worlds and they are not so much alternating punches as tearing me apart. While having breakfast I scan The Seattle Times and on page one of the Metro Section I read about a middle-aged man whose daughter had recently succumbed to illness. He was found in a local park by an early morning jogger, hanging from a tree limb and shrouded in a hazy mist. The article included a photograph of a hand-written note folded in his shirt pocket and his ex-wife had allowed this to be published:
“Karen, our divorce then her death. I can’t live here knowing that she may be alone somewhere else. I never envisioned any of what has happened or what will. I still love you and the boys. I hope that you will forgive me and help them to understand. Thank you. I must find Constance.”
I am stunned and, pushing the newspaper aside, slump back into the chair. Would he find Connie the way, in my dream, I had found Catherine and Thomas? If so, I grimly muse, he’d kill himself. I arise, slip on my backpack and trudge down a couple of flights of stairs to the parking garage. While driving to work I recall an event from when I was 11 or 12 years old and away from home at a summer tennis tournament in College Park, MD. Along with the other players I was residing in a college dormitory and my room was on the fourth floor. Before playing a match one morning, my birthday, I took a call from my dad on the hall phone.
My father had always alternated from tyrannical to tender and I hold the receiver with trepidation. He says, “I am so proud of you, Lewis, and I just wanted to wish you good luck with your match this morning. Enjoy yourself as you strike the ball and the scores will follow.”
“Win or lose, I’m proud of you.”
“Also, son, we have you a birthday present.”
“A Beagle, a little puppy. And yours to name when you come home. Wait, hold on, here’s your sister. I’ll say good-bye now.”
I smiled as Catherine, then five years old, breathlessly shouted, “Happy Birthday, Lewis! Happy Birthday! He’s so cute!” Then, she was off. I replaced the receiver and slowly walked down the hallway to the circular stairwell and peered over the railing such that I could see through to the basement floor.
A heavy heart had grounded me for most of my early years yet, at that moment, the first I could ever remember, I felt thoroughly loved, blissful and buoyant. I leaned forward and, almost weightlessly, swung my left leg over the railing. An older boy suddenly came upon me, “Hey! Hey!” and he grabbed my arm and jerked me back. “Too close, man, way too close.” He then scampered down the stairs but the opportunity was lost. Now, many years later, I wonder if my death would have beckoned my father just as Connie’s had her own.
That morning in the hospital, news of the suicide is whispered from one to another. Sarah is stunned and, in the workroom, I sit and hold her hand for a moment. Maurice and Liv are huddled together and look expectantly at me. Ron is stone-faced. Attending rounds with Dr. Guttierez are quickly dispatched with as he, not addressing what has happened, is quiet and withdrawn.
After the noon teaching conference I wander into the hospital chapel and take a seat on the back row. A final visit. Cool, silent and dimly lit. Alone. I peer at the stain-glassed windows beyond the podium and recall, as a child, attending a Baptist Church when visiting my cousins. At the conclusion of each service, the pastor extolled believers to stand, walk the aisle and kneel in prayer with him at the alter to enter a “personal relationship with Christ.” Such intimacy was too intense for me. Yet, had I then not been so repelled would I now not be so alone?
I reach into my pocket yet the rosary beads are no longer there. I try to muster up the courage to believe that Christ had died to offer a path for believers to be with loved ones following their deaths but, I am unable. I no longer believe the assurance that those believing in him will not be snatched from his hand. Once, when visiting the Metropolitan Museum of Art in New York, I was drawn to Hieronymous Bosch’s “Christ’s Descent into Hell” but am no longer hopeful that he’ll come for me.
I leave the sanctuary and take an elevator to the top floor, walk to the end of the hallway and then climb a single flight of stairs to a rooftop observatory. The door is unlocked and, as I step onto the deck, I enter a dense fog and, like Thomas and Catherine, become lost in the clouds. I walk uncertainly across the platform until I reach the periphery. After reaching high with both hands and gripping the chain link fence I purchase a toehold with my left foot. Then, a dark shape crosses in front of me and I’m forcefully pulled down and back yet embraced securely so that I don’t tumble to the deck. Ron, grimacing, inches from my face, says, “Too close, Lewis, too fucking close.”