I.C. Cordes submissions arise spontaneously whenever I have something on my mind. Usually they are concrete lessons in airway management, but recently I have done a lot of airway training and that tank is a little dry. Hence, this is another foray into metaphysics as I stumble toward the twilight and navigate Erikson’s 8th stage of psychosocial development.
A Short, But True, Story
The department was characteristically chaotic at the transition between the day and night shifts. I found the UH-1 attending in the SRU and took turnover on the stable but sick patients in beds 3 and 2. When we stepped into SRU-1, I witnessed a young man laying on the gurney, intubated, with a grotesquely swollen head wrapped in a blood-soaked turban comprised of Kerlix and ACE-wraps. The monitors revealed a sinus tachycardia, an adequate O2sat, and a blood pressure of 108/76. The patient was bleeding freely from his nose, mouth and ears, with eyes that were swollen shut, the lids purplish in color. The day attending quietly informed me that he had sustained a self-inflicted gunshot wound two hours earlier and had an unsurvivable head injury. Neurosurgery had evaluated the patient and informed the family of the prognosis, and no further resuscitative efforts were to be undertaken.
A young woman sat at his right shoulder crying openly to such a degree that her hair and shirt were wet. A middle-aged woman stooped at his left shoulder staring intently at his face. Her eyes were red and swollen, but now dry. She was dressed in a plaid print dress that was thin with wear. Several feet from the foot of the bed stood three men in workmen’s clothes staring at the floor, occasionally murmuring to one another, their body language palpably, painfully transmitting a desire to be anywhere other than where they were.
Suddenly the older woman assumed an expression that could only be described as urgency. She grasped her son’s hand and leaned closer to his face and began singing a hymn in a high, cracked voice that carried the twang of Appalachia. As she sang, the patient’s heart rate began to slow, the QRS complexes on the monitor widened, and over a period of a minute or so his vitals spooled down like an unwound clock…and he died. His mother stopped singing and moved around the bed to embrace the inconsolable sister. The men shuffled their feet and looked away. At that moment there was nothing more to be done in that room and the day attending and I stepped through the curtain into A-Pod. My eyes stung, and my throat felt so thick that I didn’t dare try to speak. The UH-1 doc said, “Well, that was weird.” And it was.
It was weirdly prescient. How did his mother know that the end had come? Her singing clearly preceded any change in his clinical picture, but the sequence and temporal association between the two was undeniable.
It was weirdly beautiful. Her voice was hoarse, grating, and heartbreaking in its grief, but it was perfect in the moment.
It was weirdly suggestive of the supernatural, as though she suddenly came to full acceptance of the futility, and sought to give her son permission to go now that hope was exhausted and pain was all that remained. And, he responded.
It was weirdly affecting. I was the father of small children at the time and was almost overcome with the realization of how invested I was in my daughters’ well-being, and how fragile and beyond my control that well-being was.
My contact with this case lasted only a very few minutes, but it is weirdly significant to me, still. It reminds me that we are surrounded by mysteries we cannot hope to understand, and this should keep us humble. It reminds me that we work in a setting where the depth of emotion that is evoked and expressed every day in our presence can either be fended off, or be allowed to wash over us and soak us to the skin. While the latter strategy is often difficult, it develops one’s humanity to bathe in the humanity of others. This may particularly be true when the others are strangers who enter our lives through happenstance – it reinforces how common is our predicament whether we are the doctors or the patients, the parents, brothers, sisters, friends, witnesses, or passers-by. I can't say that feeling for my fellow man has made my life easier, but it has made it richer. Feel deeply.
I.C. Cordes is written by Steven Carleton, MD PhD, Professor of Emergency Medicine, University of Cincinnati Department of Emergency Medicine and instructor of airway education at the Airway Course.