Code Gray: Death, Life, and Uncertainty in the ER - Tapa blanda

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Farzon A. Nahvi is an ER physician at Concord Hospital in Concord, New Hampshire, and a clinical assistant professor of emergency medicine at the Geisel School of Medicine at Dartmouth. Prior to this, he worked as an ER physician and clinical assistant professor of emergency medicine at the Mount Sinai Health System, NYU Langone Health, NYC Health + Hospitals/Bellevue, and the Manhattan VA. He is a graduate of Cornell University and NYU Grossman School of Medicine. He has written for The New York Times, The Washington Post, The Guardian, Daily News (New York), New York magazine, and other publications. In April 2019, he testified as an expert witness before Congress in the nation’s first Medicare for All hearing.

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Chapter One: Death’s Herald

ONE DEATH’S HERALD

At the tail end of an overnight shift, in a small community hospital in one of New York City’s outer boroughs, our little healthcare army—about a dozen nurses, three patient technicians, one physician assistant, an indefatigable medical scribe, and myself—reeled as the red phone rang. The 1980s-era corded phone had no caller ID, but none was needed. The red phone was death’s herald, and calls from it always meant that someone had died or was dying, and that person was on their way to us.

The charge nurse grabbed a notepad as she listened to the muffled voice on the other end of the line. Static made it difficult for her to hear, but she squinted her eyes and peered ahead intently as if the voice were a blurry image she could not quite see. Two decades into the twenty-first century and we somehow still lacked a reliable phone connection. I read her transcription in real time as she scribbled her notes:

43yo F. Pulseless x 30 mins. CPR in progress. Intubated. ETA 6 mins.

Each of us sighed and began preparing for our arrival. The ambulance was bringing a dead woman to our emergency room. Beyond that, the death of this particular woman was without recourse—she would remain dead.

This was no criticism of the skill of the paramedics or of ourselves, but simply commentary on the limits of the human body.

Some dead patients can be brought back to life. Centuries of rigorous scientific research, crossed with centuries of ingenuity, crossed with the occasional wanton good luck have endowed us with such magical tools as endotracheal intubation, central intravenous lines, and epinephrine. We can breathe for people who have stopped breathing, refill a tank of blood for those who have dipped down to “E,” and even trick a defeated heart into beating once again. Through the miracle of modern medicine, a very small number of dead patients can be resurrected and go on to tell the story of that time they came back from beyond. That is, of course, the holy grail. There is no better feeling than doctor-as-resurrectionist.

This particular dead patient, however, would not give us such satisfaction. This patient, we all knew, would remain dead; that verdict was already made, and even the best that medicine had to offer could make no appeal. Our patient was without a pulse for thirty minutes and counting. After such a long duration of the heart failing to beat properly, the brain loses oxygen for too long a time for any meaningful chance of recovery. When the brain has died, the rest, of course, is a futile exercise.

Nevertheless, we donned our gloves and prepared our equipment. Perhaps there was a communication error and the patient was pulseless for three, not thirty, minutes. Maybe there was indeed a pulse, but the paramedic simply could not feel it. Maybe the patient was found at the bottom of a frozen lake, making her a rare exception to the normal rules that govern when, precisely, it is that death becomes irrevocable (“you’re not dead until you’re warm and dead,” the teaching goes). Or maybe I was relying on science too much and a miracle would occur. After all, one thing I have learned from working in the emergency room is that nothing is as certain as it may seem.

The only certainty that remained after the red phone rang was that our ten-hour overnight shift would now extend well into the morning.

As the sound of the arriving sirens grew louder, any uncertainties that did remain began to evaporate. From the speed that the ambulance drove into the loading bay and the ambiguous sound of determined voices coming from inside the truck, it was clear no miracle had occurred. We were to receive another dead body that, with or without any chance of recovery, we had to act upon.

As the automatic doors opened and the frigid winter air rushed through our emergency department, the patient was wheeled in on a stretcher.

Each player scrambled to execute their role—plugging in wires, inserting intravenous lines, and cutting off clothes with trauma shears. Contrary to television depictions of such moments, there was no shouting. Outwardly, there was barely any palpable drama at all. Our team functioned in silence so that the paramedics could fill us in.

• Me: Okay, guys, talk to me, what’s going on?
• Paramedics: Hey, Doc—we got a forty-three-year-old female. She was complaining of abdominal pain and chest pain to her husband during the day, then she felt short of breath so she called 911. When we got there she was totally normal, walkie-talkie—she looked fine actually. We got an 18-gauge IV in the left antecube and started giving her some fluids, but then she suddenly collapsed. She was pulseless, EKG was in asystole, so we started CPR, tubed her, and gave her five rounds of epi.1

Winston and Lewis were two of the best paramedics I knew. They were the good guys you hated to see, the type of guys who have waded through scenes of blood and vomit with nothing but surgical gloves and grit. The type of guys who seemed to always bring good energy and bad news. I trusted them entirely, and notions of a communication error or a missed pulse rapidly vanished.

• Me: How long has she been pulseless in total at this point?
• Paramedics: Almost forty minutes now.
• Me: Did you get a pulse back at any point or was she pulseless the entire time?
• Paramedics: No pulse at any point.
• Me: Sounds like you guys did everything—what else is there to do?
• Paramedics (still out of breath, sweating from the last half hour of nonstop movement, visibly defeated): Ah, shit. The paperwork?

One of the strangest things about medicine is that things seem to have their own momentum. Often, things happen and it is not entirely clear why they do. The paramedics, myself, the nurses—we all knew this patient had no chance at survival. And yet staring at the sad, naked body on the gurney, her mouth agape, a breathing tube the size of a garden hose protruding from between her lips, our doing nothing would have felt unconscionable.

Winston and Lewis could have called a time of death en route, and they would have earned the right to do so. They tried to pump life into her dusky body and could have credibly said, “We tried, we could not get her back, so she is dead.” With the patient having just arrived to the hospital, though, and us yet to lay a finger on her, we had not yet earned that right. This was purely emotional reasoning—no matter what we did, the outcome would be no different. Yet it would feel inappropriate to get started on a death certificate without having so much as touched her.

I turned back to the patient. Her plump body was stripped nude to allow us to look for injuries and treat her with various needles, pharmaceuticals, and electrical conductors. Blood and plastic tubing oozed from her arms. Her naked body was slumped to the side, half falling off the gurney in a position so twisted that even I winced in discomfort.

The indignity of medicine can be profound.

A nurse instinctively readjusted her. “C’mon, let’s get you fixed up,” she warmly offered to the dead body as she grabbed her shoulders, straightened out her flopping neck, and half-draped her with a hospital gown. The remark was unconscious and reflexive. The indignity of death was casually met by the empathy of the living. We would not dare stand too near this patient in an elevator for fear of invading her personal space, but now we freely poked and prodded her naked body while covering it up and whispering kind reassurances to her unhearing ears.

A common misconception of medical professionals is that our natural emotions become replaced by a cool, calculating demeanor. Where someone else might feel sadness or panic, for example, a paramedic, nurse, or emergency room doctor is thought to block out his or her feelings and take action. The truth, however, is that those powerful visceral emotions are not replaced by an indifferent calm. They are simply papered over by it. In other words, under the surface of a calm operator there still exist very raw, very real, human emotions. They always make their presence felt—invisible but boiling, like magma below the surface of a dormant volcano.

It is a phenomenon I imagine we share with all those whose jobs bring them face-to-face with death—from firefighters to police officers and even combat soldiers. Panic is self-defeating, and it can be controlled, but no amount of training overrides the body’s highly evolved, instinctive reaction to death itself. We can slow our heart rates and bring a calm, algorithmic approach to our thought processes, but the pit of our stomachs will independently acknowledge death and keep a check on our humanity.

Such is the case whenever I am confronted with a dead body. A dead, naked body, of course, is an extraordinarily sad sight. Yet it is not sad in the way that death itself is sad—which is to say, sad because a human soul has extinguished. That particular sadness comes later. That particular sadness happens when speaking with the family or going through that patient’s belongings. That sadness comes from learning the human details that personify that body. That sadness comes from going through a patient’s wallet to search for a next of kin long after the person has died, and coming across a sandwich shop rewards card or a to-do list. That the now-dead patient was only two visits away from a free twelve-inch sub or had to buy cat food on his way home from work personifies that dead body. Index cards and Post-it notes transform. They turn sixty-two-year-old males with past medical histories of diabetes mellitus and hyperlipidemia, who suffered cardiac arrests from left anterior descending coronary artery occlusions, into men named Carl who used to enjoy roast beef sandwiches and loved their cats.

Before we get to that point, however, we are faced with nameless vessels. Devoid of any narrative or intention, an anonymous dead body is sad in a distinctly pedestrian, matter-of-fact way—a previously lithe, elegant body, reduced to limp flesh. Everything not securely fixed to the trunk—limbs, female breasts, male genitalia—flops around purposelessly with each chest compression like ribbons tied to an air conditioner at an appliance store. Hands that may have previously played the piano or legs that used to climb mountains become inert and rubbery.

In this way, an anonymous dead body ultimately evokes a deeply pathetic sadness. But they exist, and we are entrusted to do right by them. And so, while the dusky body in front of us simply lay there inert, it nevertheless demanded action.

• Me: Okay, thanks so much, guys. Alexandria, could you please start the stopwatch. Danny, could you use the GlideScope to confirm the ET tube is still in place?2 Daris, can you get a second IV on the right side, biggest one you could get, please—and let’s also draw off labs and check the glucose at the same time. Let’s continue CPR until the next epi and pulse check.

Death is bewildering on many levels. When I was a medical student, however, it was the medical treatment of death that I found particularly curious. The moments just before death can be wildly different—thousands of different diseases, each with dozens of different treatment options. But once that threshold is crossed—once “very sick” becomes “dead”—everything converges into a single pathway. Ultimately, there is one treatment protocol for death: CPR, oxygen, and a small handful of medications. Unlikely as it seems, whether the cause was a heart attack or malaria, the treatment of death is always the same. And so, just as death is the final landing place for all the divergent and individual lives that came before it, the medical treatment of death, too, is a final common denominator.

Like a group of honeybee worker drones, our little team was buzzing in action. A flurry of activity, but organized and with each honeybee knowing exactly his or her role. Despite understanding that we were trying to pollinate a stone, we nevertheless swarmed the lifeless rock.

• Me: Were you able to check the glucose in the field?3
• Paramedics: Yup. Normal.
• Me: Any past medical problems?
• Paramedics: None.
• Me: Any idea what might have happened?
• Paramedics: No clue. She was fine and then she collapsed.
• Me: Does she have any family?
• Paramedics: Her husband is on his way over right now.

Ah, okay, now this was why we were doing all this. Finally, here lay the justification for our otherwise futile activity. The dead woman would certainly stay dead, but we would still affect a life.