How We Die (3 page)
Authors: Sherwin B Nuland
As I walked onto the division, the intern, Dave Bascom, took my arm as though he was relieved to see me. “Help me out, will you? Joe [the student on duty] and I are tied up down the hall with a bulbar polio that’s going bad, and I need you to do the admission workup on this new coronary that’s just going into 507—okay?”
Okay? Sure it was okay! It was more than okay; it was wonderful, exactly the reason I had returned to the division. Medical students of forty years ago were given much more autonomy than they are allowed today, and I knew that if I did the admission routines well, I would be granted plenty of work on the details of McCarty’s recovery. I waited eagerly for a few minutes until one of the two nurses on duty had transferred my new patient comfortably from the gurney onto his bed. When she went scurrying down to the far end of the hall to help with the polio emergency, I slipped into McCarty’s room and closed the door behind me. I didn’t want to run the risk that Dave might come back and take over.
McCarty greeted me with a thin, forced smile, but he couldn’t have found my presence reassuring. I have often wondered over the years what must have gone through the mind of that high-pressure boss of large, tough men when he saw my boyish (I was then twenty-two) face and heard me say that I had come to take his history and examine him. Whatever it was, he didn’t get much chance to mull it over. As I sat down at his bedside, he suddenly threw his head back and bellowed out a wordless roar that seemed to rise up out of his throat from somewhere deep within his stricken heart. He hit his balled fists with startling force up against the front of his chest in a single synchronous thump, just as his face and neck, in the flash of an instant, turned swollen and purple. His eyes seemed to have pushed themselves forward in one bulging thrust, as though they were trying to leap out of his head. He took one immensely long, gurgling breath, and died.
I shouted out his name, and then I shouted for Dave, but I knew no one could hear me in the hectic polio room all the way down the corridor. I could have run down the hallway and tried to get help, but that would have meant the loss of precious seconds. My fingers felt for the carotid artery in McCarty’s neck, but it was pulseless and still. For reasons I cannot explain to this day, I was strangely calm. I decided to act on my own. The possibility of getting into trouble for what I was about to attempt seemed a great deal less risky than letting a man die without at least trying to save him. There was no choice.
In those days, every room housing a coronary patient was supplied with a large muslin-wrapped package that contained a thoracotomy kit—a set of instruments with which the chest could be opened in the event of cardiac arrest. Closed-chest cardiopulmonary resuscitation, or CPR, had not yet been invented, and the standard technique in this situation was to attempt to massage the heart directly, by holding it in the hand and applying a long series of rhythmic squeezes.
I tore open the kit’s sterile wrapping and grabbed the scalpel placed for ready access in a separate envelope on top. What I did next seemed absolutely automatic, even though I had never done it, or seen it done, before. With one surprisingly smooth sweep of my hand, I made a long incision starting just below the left nipple, from McCarty’s breastbone around as far back as I could without moving him from his half-upright position. Only a little dark ooze leaked out of the arteries and veins I cut through, but no real flow of blood. Had I needed confirmation of the fact of death by cardiac arrest, this was it. Another long cut through the bloodless muscle, and I was in the chest cavity. I reached over to grab the double-armed steel instrument called a self-retaining retractor, slipped it in between the ribs, and turned its ratchet just far enough to allow my hand to squeeze inside and grasp what I expected to be McCarty’s silent heart.
As I touched the fibrous sack called the pericardium, I realized that the heart contained within was wriggling. Under my fingertips could be felt an uncoordinated, irregular squirming that I recognized from its textbook description as the terminal condition called ventricular fibrillation, the agonal act of a heart that is becoming reconciled to its eternal rest. With unsterile bare hands, I grabbed a pair of scissors and cut the pericardium wide open. I took up Mr. McCarty’s poor twitching heart as gently as I could and began the series of firm, steady, syncopated compressions that is called cardiac massage, intended to maintain a flow of blood to the brain until an electrical apparatus can be brought in to shock the fibrillating heart muscle back into good behavior.
I had read that the sensation imparted by a fibrillating heart is like holding in one’s palm a wet, jellylike bagful of hyperactive worms, and that is exactly the way it was. I could tell by its rapidly decreasing resistance to the pressure of my squeezes that the heart was not filling with blood, and so my efforts to force something out of it were useless, especially since the lungs were not being oxygenated. But still I kept at it. And suddenly, something stupefying in its horror took place—the dead McCarty, whose soul was by that time totally departed, threw back his head once more and, staring upward at the ceiling with the glassy, unseeing gaze of open dead eyes, roared out to the distant heavens a dreadful rasping whoop that sounded like the hounds of hell were barking. Only later did I realize that what I had heard was McCarty’s version of the death rattle, a sound made by spasm in the muscles of the voice box, caused by the increased acidity in the blood of a newly dead man. It was his way, it seemed, of telling me to desist—my efforts to bring him back to life could only be in vain.
Alone in that room with a corpse, I looked into its glazed eyes and saw something I should have noticed earlier—McCarty’s pupils were fixed in the position of wide black dilatation that signifies brain death, and obviously would never respond to light again. I stepped back from the disordered carnage on that bed and only then realized that I was soaking wet. Sweat was pouring down my face, and my hands and my short white medical student’s coat were drenched with the dark lifeless blood that had oozed out of McCarty’s chest incision. I was crying, in great shaking sobs. I realized, too, that I had been shouting at McCarty, demanding that he live, screaming his name into his left ear as though he could hear me, and weeping all the time with the frustration and sorrow of my failure, and his.
The door swung open and Dave rushed into the room. With one glance he took in the entire scene, and understood it. My shoulders were heaving, and my weeping was by then out of control. He strode around to my side of the bed, and then, as if we were actors in an old World War II movie, he put his arm around my shoulders and said very quietly, “It’s okay, buddy—it’s okay. You did everything you could.” He sat me down in that death-strewn place and began patiently, tenderly, to tell me all the clinical and biological events that made James McCarty’s death inevitably beyond my control. But all I can remember of what he said, with that gentle softness in his voice, was: “Shep, now you know what it’s like to be a doctor.”
Poets, essayists, chroniclers, wags, and wise men write often about death but have rarely seen it. Physicians and nurses, who see it often, rarely write about it. Most people see it once or twice in a lifetime, in situations where they are too entangled in its emotional significance to retain dependable memories. Survivors of mass destruction quickly develop such powerful psychological defenses against the horror of what they have seen that nightmarish images distort the actual events to which they have been witness. There are few reliable accounts of the ways in which we die.
Nowadays, very few of us actually witness the deaths of those we love. Not many people die at home anymore, and those who do are usually the victims of drawn-out diseases or chronic degenerative conditions in which drugging and narcosis effectively hide the biological events that are occurring. Of the approximately 80 percent of Americans who die in a hospital, almost all are in large part concealed, or at least the details of the final approach to mortality are concealed, from those who have been closest to them in life.
An entire mythology has grown up around the process of dying. Like most mythologies, it is based on the inborn psychological need that all humankind shares. The mythologies of death are meant to combat fear on the one hand and its opposite—wishes—on the other. They are meant to serve us by disarming our terror about what the reality may be. While so many of us hope for a swift death or a death during sleep “so I won’t suffer,” we at the same time cling to an image of our final moments that combines grace with a sense of closure; we need to believe in a clear-minded process in which the summation of a life takes place—either that or a perfect lapse into agony-free unconsciousness.
The best-known artistic representation of the medical profession is Sir Luke Fildes’ renowned 1891 painting entitled
The Doctor
. The scene is a simple fisherman’s cottage on the coast of England, where a little girl lies quietly, seemingly unconscious, as death approaches. We see her grieving parents and the pensive, empathetic physician keeping his bedside vigil, powerless to weaken the tightening grip of mortality. When the artist was interviewed about the painting, he said, “To me, the subject will be more pathetic than any, terrible perhaps, but yet more beautiful.”
The Doctor
. The scene is a simple fisherman’s cottage on the coast of England, where a little girl lies quietly, seemingly unconscious, as death approaches. We see her grieving parents and the pensive, empathetic physician keeping his bedside vigil, powerless to weaken the tightening grip of mortality. When the artist was interviewed about the painting, he said, “To me, the subject will be more pathetic than any, terrible perhaps, but yet more beautiful.”
Fildes clearly had to know better. Fourteen years earlier, he had seen his own son die of one of the infectious diseases that carried off so many children in those late-nineteenth-century years shortly before the dawn of modern medicine. We don’t know what malady killed Phillip Fildes, but it could not have bestowed a peaceful ending on his young life. If it was diphtheria, he virtually choked to death; if scarlet fever, he probably had delirium and wild swings of high fever; if meningitis, he may have had convulsions and uncontrollable headaches. Perhaps the child in
The Doctor
has gone through such agonies and is now in the final peace of terminal coma—but whatever came in the hours prior to her “beautiful” passing must surely have been unendurable to the little girl and her parents. We rarely go gentle into that good night.
The Doctor
has gone through such agonies and is now in the final peace of terminal coma—but whatever came in the hours prior to her “beautiful” passing must surely have been unendurable to the little girl and her parents. We rarely go gentle into that good night.
Francisco Goya, eight decades earlier, had been more honest—perhaps because he lived at a time when the face of death was everywhere. In his painting, variously called in English
Diphtheria
or
The Croup
, done in the style of the Spanish realist school and during a period of great realism in European life, we see a doctor holding a young patient’s head steady with one hand on his neck while preparing to insert the fingers of his other hand down the boy’s throat in order to tear out the diphtheritic membrane that will choke off his life if not removed. The original Spanish title of the picture, and of the disease, reveals the full force of Goya’s directness, as well as that age’s everyday familiarity with death. He called it
El Garrotillo
, for the strangulation by which it kills its victims. The days of such confrontations with the reality of death are long since over, at least in the West.
Diphtheria
or
The Croup
, done in the style of the Spanish realist school and during a period of great realism in European life, we see a doctor holding a young patient’s head steady with one hand on his neck while preparing to insert the fingers of his other hand down the boy’s throat in order to tear out the diphtheritic membrane that will choke off his life if not removed. The original Spanish title of the picture, and of the disease, reveals the full force of Goya’s directness, as well as that age’s everyday familiarity with death. He called it
El Garrotillo
, for the strangulation by which it kills its victims. The days of such confrontations with the reality of death are long since over, at least in the West.
Having chosen, for whatever psyche-shrouded reason, the word
confrontations
, I need to pause; I need to consider whether I, too, even after almost forty years of James McCartys, do not from time to time still fall into stride with the prevailing temperament of our times, when death is regarded as the final and perhaps the ultimate challenge of any person’s life—a pitched battle that must be won. In that view, death is a grim adversary to be overcome, whether with the dramatic armaments of high-tech biomedicine or by a conscious acquiescence to its power, an acquiescence that evokes the serene style for which present usage has invented a term: “Death with dignity” is our society’s expression of the universal yearning to achieve a graceful triumph over the stark and often repugnant finality of life’s last sputterings.
confrontations
, I need to pause; I need to consider whether I, too, even after almost forty years of James McCartys, do not from time to time still fall into stride with the prevailing temperament of our times, when death is regarded as the final and perhaps the ultimate challenge of any person’s life—a pitched battle that must be won. In that view, death is a grim adversary to be overcome, whether with the dramatic armaments of high-tech biomedicine or by a conscious acquiescence to its power, an acquiescence that evokes the serene style for which present usage has invented a term: “Death with dignity” is our society’s expression of the universal yearning to achieve a graceful triumph over the stark and often repugnant finality of life’s last sputterings.
But the fact is, death is not a confrontation. It is simply an event in the sequence of nature’s ongoing rhythms. Not death but disease is the real enemy, disease the malign force that requires confrontation. Death is the surcease that comes when the exhausting battle has been lost. Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception. Every triumph over some major pathology, no matter how ringing the victory, is only a reprieve from the inevitable end.
Medical science has conferred on humanity the benison of separating those pathological processes that are reversible from those that are not, constantly adding to the means by which the balance shifts ever in favor of sustained life. But modern biomedicine has also contributed to the misguided fancy by which each of us denies the certain advent of our own individual mortality. The claims of too many laboratory-based doctors to the contrary, medicine will always remain, as the ancient Greeks first dubbed it, an Art. One of the most severe demands that its artistry makes of the physician is that he or she become familiar with the poorly delineated boundary zones between categories of treatment whose chances of success may be classified as certain, probable, possible, or unreasonable. Those unchartable spaces between the probable and everything beyond it are where the thoughtful physician must often wander, with only the accumulated judgment of a life’s experiences to guide the wisdom that must be shared with those who are sick.
At the time that James McCarty’s life came to its abrupt end, the outcome of his heart’s misbehavior was inescapable. Although a great deal was already understood about heart disease in the early 1950s, the available therapies for it were few and too often inadequate. Today, a patient with McCarty’s specific problem may expect to leave the hospital not only alive but with a heart so much improved that years may have been added to his life. So much have the laboratory-based doctors accomplished that one of the approximately 80 percent who survive a first attack has good reason to think of a cardiac seizure as the shiniest silver lining of his life, because it has exposed a condition that might soon have killed him had it not been discovered while still eminently treatable.
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