Medicine out of the Box

Every now and then something happens that haunts you.  The episode plays over and over in your head like a television rerun you’ve seen a dozen times.  But, while the TV show began to bore you on the second replay, your memory’s rerun still gets to you.

I have no idea of how many motorcycle accident victims I have seen or cared for since becoming a physician.  The number is at least in the hundreds.  I wouldn’t be surprised if it were a few thousand.

I also don’t know how many terminal patients there have been on whom I’ve had to discontinue life support.  It’s not the kind of statistic one likes to track.

There are so many of these patients coming through the doors, holding our attention for such a brief time that we usually fail to give them a second thought.  That sounds hard, I know.  It seems cold.  After all, families are attached to each one of these young people.  They weep in the background of the intensive care unit, suppressing sobs as they try to catch anything in the air that resembles a hope. . . 

Somehow, dispassionately, we must take care of the paperwork.  We try to let them down gently, finding the words to tell them the worst has happened.  But pressing us forward is the cold realization that we must move the body to the morgue quickly to make room for yet another brain-dead victim of the traffic maze.

But every now and then something happens….

I can’t even remember how many trauma admissions we had that night or when this young man was brought in.  I think we were busy, though.  I believe he came in while we were in and out of the operating room taking care of the injuries we could do something about.

This young man was in his early 20’s.  He had been drinking with his friends and was out riding the motorcycle he loved.  Then, as they always seem to do, he lost control.  I never learned anythingn more to the story than that.  I’m not sure anyone really knew.

It was clear that he had suffered a fatal head injury, even accounting for the alcohol still in his system.  A CT scan was performed of his head, and it confirmed our initial impressions.  There was no simple clot inside the head which we could remove to release pressure; it wasn’t that easy.  No, his brain had been shattered.  There was nothing the best neurosurgeon in the country could do on his best day ever.  This was far beyond repair.

Sadly, his body was otherwise fine.  I don’t mean that it was merely uninjured.  I mean, it was perfect–healthy, strong, vigorous, bursting with life.  And, because he had no external injuries, he didn’t even have a head bandage.  He simply lay there in the intensive care unit, looking as though he were merely napping.  The only signs that something wasn’t right were the endotracheal tube coming out of his mouth and the intravenous catheter inserted in his lower neck.

It didn’t take long for him to be processed through our system.  By early morning, a nuclear medicine cerebral blood flow study confirmed that there was no blood flow to his brain.  The brain was dead.

This simplified our approach, because there aren’t many arguments about what the options are at this point.  There are two basic rules that direct us: 1) dead brains don’t grow back, and 2) you only get one brain per life.  Once a brain is gone, it’s gone.  That’s life.

This seems to happen at least once or twice a week at our hospital.  In fact, it happens with a fair frequency throughout the country.  Fifty years ago, it wasn’t so routine for several reasons.  First, back then it would have been unusual for a patient not to have suffocated at the scene of the accident or during transfer to the hospital.  Now, because our ambulance and helicopter personnel are so well-trained, they can provide and protect the airway and keep the simple catastrophes from happening.  Second, even if such a patient survived to make it to the hospital twenty years ago, the doctors wouldn’t have been able to see the horrible damage to the brain because they didn’t have computerized tomography.  Back then, they would have performed some less precise studies like arteriograms or even have drilled some holes in the skull “blindly” looking for a blood clot to evacuate.  After several days of intensive effort, it would have become apparent that nothing was happening upstairs, that the brain wasn’t functional, that it was quiet.  They would have done at least a couple of electroencephalograms tosee the electrical silence.  And finally, they would have had a huge ethical dilemma.  The brain appeared dead, but the body was still working.  What were they supposed to do?  In the past, this individual would have been hospitalized indefinitely.  Nursing care would be provided every day with no goal of recovery in sight.  Over the years, the patient would become a familiar sight, a fixture, a mascot for the ward.  Family visits, at first frequent, would gradually taper from daily to weekly to monthly.  Finally, only a card would arrive on birthdays and Christmases.  After a while, the family would only think of the enormous financial debt they had accumulated, wrecking their generation’s hope for a normal existence.  The usual mechanism that could bring a merciful end to this continuous heartbreak was an accident: the ventilator’s alarms would fail to announce a disconnection of the patient from the machine; a medication error would stop this patient’s heart even though it was intended to help someone else’s; or the room he occupied would be forgotten during a major power failure, and the breathing would stop.  Comically, by then, the people charged with his care would no longer know anything about his case.  Just that he was there.  His ultimate means of exit would become a ward joke.  A sorry, sick, sad joke.

Because of improved emergency care, the scenario our young man’s body was facing became a more frequent problem.  Individual human suffering became a social problem, and the issues were debated extensively.  They are still argued hotly, but fortunately, many of the ethical concerns are more consistently resolved.  In fact, most states have legislation which helps to resolve these situations.  The concept of brain death is accepted and used in daily practice.  There is no longer a need to continue fruitless agonizing care under these circumstances.  When the brain is dead, you’re dead.  

I asked for the family to be brought up to the conference room so we could tell them of the situation.  I had a lot of other patients I needed to take care of, so I wanted to expedite things.  Once they were assembled, the nurse and I walked in and quietly shut the door.

There was the father standing across the table from me.  A big man, probably a farmer or a factory worker, with a tough, leathered face that had seen its share of sunbaked Texas days.  His grip was strong, but his heart wasn’t in his handshake.  He sensed that I was bringing bad news.

The mother turned out to be sitting next to me, most of her face buried in a pile of handkerchiefs.  But I could see that her face wore the colors of sorrow: grey hair and red eyes.

There was an older brother by his father and a quiet worried sister at the other end of the table.  That was all I could make out of the immediate family.  There were even more friends, neighbors, cousins, and grandparents around.  The whole room could have had twenty or thirty people in it.

I spoke to only two.  Mom and dad.

“Has anyone talked to you yet?” I asked, trying to get my bearings.  I never know where or how or what to do to get this talk started properly.

They shook their heads, some yes and some no.  The usual response.

“Well, as you know,” I continued, “he had a very bad accident on his motorcycle early this morning.  The major–in fact, the only–injury he received was one to his head.  We have performed a CT scan–that is, a special X-ray study that shows us what’s happening inside the skull–and that showed us that his brain has been horribly destroyed.”

I paused here because I thought that the words that I had just uttered were strong, and I waited to sense their impact.  The mother was trying to catch her sobs in her handkerchief; she wanted to hear every word I said.  She was hoping. . .

But I had no hope to give her.

“I’ve had our neurosurgeon, Dr. Wright, look at your son and the X-rays with me.  He believes that this is a devastating injury to the brain.  In fact, it is so bad that he can’t do anything to fix it.

We have just finished doing a nuclear medicine study which looks at the blood flow to the brain.  What that shows us is that there is no blood being pumped to his brain.”

I paused.  She was starting to let out one of the sobs she had tried to hold.

“His brain is dead.”  I finished tersely.  “That means he is dead.”

She was heaving with sobs.  Dad had brought up a hand to suffocate his mouth as water welled into his eyes.  The rest of the crowd seemed to exhale a collective gasp and collapse into each other’s arms, leaning on shoulders, pounding on walls.

I let this go on for a few moments.

I usually feel awful about this time.  It hurts so much to see such an assembly of sorrow and to know that I just now made it happen.  It’s so deep and so personal for them, and I’m just some stranger, some guy sitting there watching.  It would be such a relief to start crying with them because I’m usually choked up just being there.  But they don’t want that.  They need me to be strong for them for a while.  It would be weird for this stranger, this unknown doctor, to start crying over the death of their youngest son.

They gradually regained composure.

I continued my job.  

“Because we are able to artificially breathe air into his lungs, his heart is still beating and the rest of his body is still alive,” I explained.  “However, because his brain is dead, he is legally dead, and I will stop the breathing machines.  Before I do that, I want to know if you have thought about donating his organs so that they can live on in other people and help them.  If so, I can have you talk to our transplant surgeon.”

They looked at each other and shook their heads no.  There was no doubt.  I wanted to make sure that they understood that there really was an opportunity to help others here, but it seemed they were convinced.

“No,” his mother gulped, “he wanted to keep his body perfect all the time.  I don’t think he would have wanted it all cut up.”

“I understand,” I lied, wondering how committed to bodily perfection he could have been while drunk on a motorcycle.  “In that case, we’ll be turning off the ventilator in just a few moments.  Would you care to see him before we do?”

“Uh, Doc,” the father said, hesitantly.  “I’d like to be there when you do that.”

This was an unusual request.  Most people don’t even think of asking and would probably refuse if the opportunity were offered.  It’s emotionally a very rough time for a relative.

But I didn’t want to stand in the way of whatever they felt they wanted at this point.

“Are you sure?” I asked.  “I mean, it’s all right, but it might not be easy to handle.”

“No, I’m sure,” the father said, his eyes wet.  “He’da wanted me to be there for him.”

Well, I thought, I really can’t argue with this request, unusual or not.  They may have had some kind of pact on this type of thing.  People are different.

“Fine,” I consented.  “Do you have–“

“–I wanna be there, too!” the mother blurted, cutting off my sentence.

As soon as the words escaped her, she began sobbing heavily again.  It wasn’t clear she meant it, or she just said it tobe included with the commitment the father had offered.

The room crowded around her, trying to comfort her.

“Oh, no, Ma,” the father said, “I don’t think you should. It’ll be too rough for you.”

“No, no,” said the sister and some friends.  People were holding her, stroking her hair, reassuring her.

She just shook her head back and forth as she sobbed.  She wasn’t happy with them.  No one was understanding her.

“It’ll be OK,” the father said.  “I’ll be there with him.  You just stay here and rest with Stacy.”

She was weeping heavily now, shaking her head no, trying to get up.

“I . . . want . . . to . . . be . . . there.”  She blurted out the staccato words between sobs.

People looked at each other.  Concern and skepticism registered on their faces.  They shook their heads at each other.  They tried to close in on her some more.  She collapsed in her chair as she wept.

She kept sobbing, shaking her head back and forth.

“No, no, no,” the crowd murmured, moving closer.

Suddenly, she erupted.

“Dammit!” she yelled, flinging people away from her.  

The room was paralyzed with rapt attention.

In the sudden silence, she cried with desperate conviction: “I was there when he took his first breath!  I’ll be there when he breathes his last!”

The room dissolved as tears swelled into my eyes.  A choking ball gagged the back of my throat.

That was it.  A life.  A mother’s love.  From first to last, it embraces us.

I don’t know how I kept from crying.  I darted a look to the nurse.  She was struggling, too.

“Alright, alright,” I soothed.  “It’s OK.  Why don’t you two come with us?”

The four of us–mother, father, nurse, and I–walked out of the room and shut the door.  We tramped stonily toward the intensive care unit and entered.

There was no noise between us.  A stunned silence seemed all around me, despite the beeping of electrocardiographic monitors, the sighing of the ventilators, the hubbub of nurses and technicians at the bedsides.  I should have heard these, but I didn’t.

Instead, her words were echoing too loudly within my head for anything else to be heard.  For some reason, there was a strength in her statement which obsessed me.  Its image was so overpowering.  That a mother should hear her infant gasp for his first taste of air.  She then holds him close to her, nurturing him, watching him grow.  She teaches him how to live his life–that strong is good and weak is wrong, that truth is right.  She sees him enchanted by a puppy, and she wistfully celebrates the loss of each milk tooth.  He starts school and loves baseball and learns that girls are pretty.  And then she discovers his dreams–he wants to do something special with his life, he wants to be somebody.  And she’s sad that he must go but she’s proud of this because she put him there.  He is hers, she made him, he grew inside her and came from her.  Then he will have his own children.  Her grandchildren.  And she will see it happen all over again. . .

But suddenly–now–it’s over.  Too soon, sadly.  Before the future could follow

Now, she will hear the last breath leave his lungs.  She feels she must.  It makes it whole, complete.

A beginning.  An end.  A life.

My eyes were watering as we approached the bed.  This isn’t supposed to happen to doctors, I thought, and I gritted my teeth to fight it.

But it was so hard.  I kept thinking of my wife’s love for our children, how much they have meant to her, how much they mean to us.  I couldn’t imagine what it must be like to be living the tragedy I was witnessing.  How could you lose your boy?  How do you live through that?  I didn’t want to imagine it.

But I was there.  I had to see it.

We arrived at the bedside, and suddenly I could hear the rest of the room.  The drone of background conversations from other bedsides was overlaid by the beeps and the sighs which identify the machine life of intensive care.  I heard his EKG monitor and his ventilator right next to me.

After they assembled around the bed, I wasted little time.  I automatically looked at the clock: 2:45. Without looking at his parents, I went to disconnect the ventilator tubing from my patient’s endotracheal tube.

As I pulled the plastic tubing apart, I heard a soft puff leave the endotracheal tube.  His last.

I quickly shut off the power switch on the ventilator so the alarm would not sound.

And then there was silence.  No breath.  Just the beep. . .beep. . .beep of his EKG.

No breath.

We listened.  She listened.  It was quiet.

No breath.

None.

His mother crumbled, choking on her cries.  The nurse caught her in her arms.  The mother shook her head no, no, no, and moved to leave.  But she couldn’t do it alone.

I looked at the nurse and nodded.  She turned to help the mother away from the bed.  She was ushered out of the unit without turning back, supported by the nurse’s strong arm.  The mother had done what she needed to do.

I looked at the father across the bed from me.  His eyes were glued on his son’s face.  I guessed that he was wishing his son would awake, finding it impossible to believe that this could be happening, that his son was really gone.  I couldn’t imagine what his father was thinking about while gazing on his son, but I didn’t have to wonder for long.

“Breathe, Tommy,” he said, hesitantly at first.  Then, more boldly, “C’mon, breathe!”

I froze.

“Tommy!” he yelled, “Wake up!  C’mon, Tommy, breathe!”

A few heads turned.  I looked quickly around the unit as if to reassure everyone that things were alright.  I was mildly chagrinned by this unexpected outburst.  What had begun as an unusual request could now become embarrassing.

“Wake up!  Wake up!  C’mon, Tommy, c’mon!”  He reached his hand toward his dead son’s shoulder as if to arouse him.

“Breathe, Tommy, breathe!” he yelled, and started to pull up and down on the shoulder.  As he did so, however, the EKG leads became jostled, and the arrhythmia detector on the monitor began pinging its alarm.

With that, the father stopped his shaking and followed my eyes to the EKG monitor.

“What-?” he paused.  I reached over his shoulder to turn off the alarms.

 

“It’s just the alarms going off because the wires got shaken,” I said.  “It’s not from his heart, it’s from the shaking.  His heart is starting to stop.”

As I watched, the heart rate slowed.  Each beat seemed to find it harder and harder to come through.  As the rate slowed, the electrical complex widened.  Normally a sharp, crisp spike of electricity zipping through the heart, his complexes became shorter and wider as the currents slowed in their course through the nerves and muscles.  Agonizing, struggling, his heart kept up its flagging pace for all it was worth.  Occasionally, a burst of electricity would emanate from some other region of the heart, identifying an impatient cell with pacemaker-like abilities stepping in to fill the electrical void.  But these were futile, wasted efforts.  With a gradually dwindling supply of oxygen, his heart was doomed.

The father watched the monitor over this passage of time with me, not understanding the physiology, but grasping its import.  As the complexes started to disappear from the screen, he turned toward the bed with grief clutching his face.

“Breathe . . .” his voice cracked; the command was a whispered plea.

But nothing happened.

The rest of the unit had gone back to its business, the temporary disturbance abated.  As the quiet at the bedside returned, the hubbub of the surrounding area gradually began to come back to my consciousness.  The voices conversed with each other in various corners of the unit, a gentle swelling murmur.  Elsewhere, at the nurses station, the telephones were ringing.  Someone was stamping out patient labels on the addressograph machine.  All around, the monitors beeped in an irregular cadence, and the ventilators sighed.

Except here.

As the oxygen left his system, the boy’s cells became depleted of energy.  Muscle cells, losing the ability to keep themselves charged, became discharged as they approached electrical neutrality.  They began to twitch.  But it was uncoordinated, cell by cell or fiber by fiber.  It was not whole muscles acting in a smooth coordinated glide.  Rather, it was a subtle but grotesque shudder of death.  First, you saw something on his chest, his pectoral muscles.  Then the thigh, the neck, his cheek, a finger.  Nothing really moved.  It just seemed as though things were running under his skin.  Little lizards, thousands of them, scurrying under the epidermis.

His father stood transfixed watching the sight.  His face was a confusion of fear and hope.

He thought his son had heard him.

I groaned inside.  Once again, I had to dash his hopes upon the craggy rocks of dismay as I demystified the process.

“These are only muscle fasciculations,” I explained.  “When the muscles run out of energy, they twitch.  But it’s not him controlling them.  They do this on their own, like a reflex.  It doesn’t last long, and he can’t feel it.”  

As soon as I finished, the wave of twitching abated.  The last physiological gasp.  Gone.  Silence.

It was over.

I walked over to the chart and wrote the death note, mechanically looking up to note the time of pronouncement for the record.  Twelve minutes had elapsed since I disconnected the airway.

 

As I wrote, I mused on the ludicrousness of pronouncing a time of death with a precision of minutes.  It had taken roughly 12 minutes from the time of the last breath until his muscles had completely depolarized.  Likely, other less active muscles, like those in his intestinal tract, were still waiting to be discharged.  Even then, the cells themselves are potentially alive, potentially revivable if placed in the proper environment.  Some would die, sure, but others could live.  Some cells, the very slow metabolic ones like fat or bone, would continue to live for several hours, producing carbon dioxide continuously as they metabolized until they could burn no longer.  Some, I thought, would continue to metabolize on into the night.  The carbon dioxide production was measurable if one took the time and effort to measure it.

That’s how death is.  A slow and gradual slipping away.  Each cell hanging on as long as possible.  Just as it takes three-quarters of a year for an embryo to develop into a complete and physiologically independent human, death can take a long time, too.  Some patients seem to do it for months, lingering in bed with no hope of recovery because our technology can take them only so far, but not far enough.  Once the breathing stops and the heartbeat fades, the cells can’t hang on for long.  They capitulate, organ by organ, tissue by tissue, cell by cell.  A vast helpless army of billions, lay to waste.

But that doesn’t end it.  For as soon as the cells die, the bacteria living inside the body’s house start to digest and decompose the contents.  In a natural world, they would immediately begin the process of transformation, under the ground, feeding the burrowers and the roots.  And up from this decomposing dirge of death springs new life, seeking the sun, ready to feed new generations.

No, I mused, the chain of life has never been broken.  Rather, it cycles.  Up and down.  Parts of it grow and mature, while others age and wither.  We are merely carried by the current as the stream of life wends its way through time’s soil.

Closing the chart, I went over to the father.  The EKG monitor showed a flat trace.  He looked at me and nodded.  He shook my hand.  I don’t know why he had to thank me, but he did.

I walked him back to the waiting room.  The mother was slightly more composed at first, but when she saw her husband, the father of her child, she cried and buried her head in his chest.  His arms wrapped around her to hold her in their private world.

I closed the door and walked away.

As I heard her sobbing disappear behind me, her words came back to me.  Their symmetry held a special beauty amidsorrow.

I heard him breathe his first breath, and I’ll hear him breathe his last.

I couldn’t fight it any longer.  I darted down the nearest stairwell and paused on the first landing.  I saw no one.

There, like a cleansing rain, the tears poured out of me until the pain abated.