Sometime after midnight, the phone rang. The patient was crashing. With the complacency of bureaucratic work suddenly torn away, I sat up in bed and spat out orders: “One liter bolus of LR, EKG, chest X-ray, stat—I’m on my way in.” I called my chief, and she told me to add labs and to call her back when I had a better sense of things. I sped to the hospital and found Mrs. Harvey struggling for air, her heart racing, her blood pressure collapsing. She wasn’t getting better no matter what I did; and as I was the only general surgery intern on call, my pager was buzzing relentlessly, with calls I could dispense with (patients needing sleep medication) and ones I couldn’t (a rupturing aortic aneurysm in the ER). I was drowning, out of my depth, pulled in a thousand directions, and Mrs. Harvey was still not improving. I arranged a transfer to the ICU, where we blasted her with drugs and fluids to keep her from dying, and I spent the next few hours running between my patient threatening to die in the ER and my patient actively dying in the ICU. By 5:45 A.M., the patient in the ER was on his way to the OR, and Mrs. Harvey was relatively stable. She’d needed twelve liters of fluid, two units of blood, a ventilator, and three different pressors to stay alive.
When I finally left the hospital, at five P.M. on Tuesday evening, Mrs. Harvey wasn’t getting better—or worse. At seven P.M., the phone rang: Mrs. Harvey had coded, and the ICU team was attempting CPR. I raced back to the hospital, and once again, she pulled through. Barely. This time, instead of going home, I grabbed dinner near the hospital, just in case.
At eight P.M., my phone rang: Mrs. Harvey had died.
I went home to sleep.
I was somewhere between angry and sad. For whatever reason, Mrs. Harvey had burst through the layers of paperwork to become my patient. The next day, I attended her autopsy, watched the pathologists open her up and remove her organs. I inspected them myself, ran my hands over them, checked the knots I had tied in her intestines. From that point on, I resolved to treat all my paperwork as patients, and not vice versa.
In that first year, I would glimpse my share of death. I sometimes saw it while peeking around corners, other times while feeling embarrassed to be caught in the same room. Here were a few of the people I saw die:
1. An alcoholic, his blood no longer able to clot, who bled to death into his joints and under his skin. Every day, the bruises would spread. Before he became delirious, he looked up at me and said, “It’s not fair—I’ve been diluting my drinks with water.”
2. A pathologist, dying of pneumonia, wheezing her death rattle before heading down to be autopsied—her final trip to the pathology lab, where she had spent so many years of her life.
3. A man who’d had a minor neurosurgical procedure to treat lightning bolts of pain that were shooting through his face: a tiny drop of liquid cement had been placed on the suspected nerve to keep a vein from pressing on it. A week later, he developed massive headaches. Nearly every test was run, but no diagnosis was ever identified.
4. Dozens of cases of head trauma: suicides, gunshots, bar fights, motorcycle accidents, car crashes. A moose attack.
At moments, the weight of it all became palpable. It was in the air, the stress and misery. Normally, you breathed it in, without noticing it. But some days, like a humid muggy day, it had a suffocating weight of its own. Some days, this is how it felt when I was in the hospital: trapped in an endless jungle summer, wet with sweat, the rain of tears of the families of the dying pouring down.
—
In the second year of training, you’re the first to arrive in an emergency. Some patients you can’t save. Others you can: the first time I rushed a comatose patient from the ER to the OR, drained the blood from his skull, and then watched him wake up, start talking to his family, and complain about the incision on his head, I got lost in a euphoric daze, promenading around the hospital at two A.M. until I had no sense of where I was. It took me forty-five minutes to find my way back out.
The schedule took a toll. As residents, we were working as much as one hundred hours a week; though regulations officially capped our hours at eighty-eight, there was always more work to be done. My eyes watered, my head throbbed, I downed energy drinks at two A.M. At work, I could keep it together, but as soon as I walked out of the hospital, the exhaustion would hit me. I staggered through the parking lot, often napping in my car before driving the fifteen minutes home to bed.
Not all residents could stand the pressure. One was simply unable to accept blame or responsibility. He was a talented surgeon, but he could not admit when he’d made a mistake. I sat with him one day in the lounge as he begged me to help him save his career.
“All you have to do,” I said, “is look me in the eye and say, ‘I’m sorry. What happened was my fault, and I won’t let it happen again.’?”
“But it was the nurse who—”
“No. You have to be able to say it and mean it. Try again.”
“But—”
“No. Say it.”
This went on for an hour before I knew he was doomed.
The stress drove another resident out of the field entirely; she elected to leave for a less taxing job in consulting.
Others would pay even higher prices.
As my skills increased, so too did my responsibility. Learning to judge whose lives could be saved, whose couldn’t be, and whose shouldn’t be requires an unattainable prognostic ability. I made mistakes. Rushing a patient to the OR to save only enough brain that his heart beats but he can never speak, he eats through a tube, and he is condemned to an existence he would never want…I came to see this as a more egregious failure than the patient dying. The twilight existence of unconscious metabolism becomes an unbearable burden, usually left to an institution, where the family, unable to attain closure, visits with increasing rarity, until the inevitable fatal bedsore or pneumonia sets in. Some insist on this life and embrace its possibility, eyes open. But many do not, or cannot, and the neurosurgeon must learn to adjudicate.
I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action but an elevation of my own being: getting as far away from petty materialism, from self-important trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles…surely a kind of transcendence would be found there?
But in residency, something else was gradually unfolding. In the midst of this endless barrage of head injuries, I began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun. I was not yet with patients in their pivotal moments, I was merely at those pivotal moments. I observed a lot of suffering; worse, I became inured to it. Drowning, even in blood, one adapts, learns to float, to swim, even to enjoy life, bonding with the nurses, doctors, and others who are clinging to the same raft, caught in the same tide.