“I understand this is a very difficult decision to make at this moment ma'am. I have to ask you, though – would your husband have wanted to be placed on a ventilator?”
Even as my preceptor asked the question, dystonic beeps of various machines echoed through the room. Outside, the typical scurry of a busy emergency department bustled about with phone calls, nurses briskly walking from room to room, new patient arrivals, mingled with a blood-curdling scream from the psych room down the hall. My preceptor steadily gazed at the 89-year-old woman and offered a hand as she motioned to sit down into a chair. “We are here for you, and we are ready to go ahead with either decision. We can either start the ventilator and move him to the ICU, or we can make this room available for you and your daughter to say your final good-byes, should you choose to go that route. I have to ask again, though – how would you like us to proceed?”
The elderly woman pensively looked toward her daughter for support, then somberly shook her head. “No, he doesn't want to be on a ventilator. It's his time to go now.”
Acknowledging the woman's decision, he nodded toward the respiratory therapist, giving permission to cease the rescue breathing and remove the mask. He also gave orders for another dose of morphine “just in case” the patient was feeling any pain, and then he turned back toward the patient's wife.
“Take as much time as you need. There's no rush.” He then squeezed her hand, stood up, and turned to leave the room.
Slowly, quietly, the crowded room began to thin after him. A few nurses gathered discarded wrappers from the floor and stray gloves strewn across the room. The respiratory therapist collected the tubes and mask, then followed the physician. All was quiet, almost reverent, as the grieving wife and daughter held each other and rested their hands on the patient's hand. Tranquility descended into the room as the patient steadily drifted deeper into unconsciousness, as agonal, periodic gasping for air grew more and more silent, and the best medicine had to offer was a room and a place for stillness.
The best treatment in this case is the same as has been given through all of time – mourning with those who mourn, and allowing room for grieving. This wasn't anything like a shallow Hollywood drama unfolding in the ED, replete with screams of emotion and tortured souls lashing out at the staff. Instead, an aura of solidarity and acceptance surrounded the family as they gracefully experienced this event together.
Sensing I was intruding on sacred space, I migrated toward the door. Hesitating for just a moment, I lingered on the edge of the room, silently observing the death of a good man leaving his good family. In my first time witnessing a patient's death, I felt like I was learning more about living in those few moments of death than I learned about life in several years of school. I absorbed the scene before me for a few minutes more, then slipped out of the room.
Immediately the familiar chaos returned. Alarms. Voices. Footsteps. Phone calls. That blood-curdling scream down the hall. All of it was oblivious to the events in the trauma bay, continuing on without acknowledgement, refusing to pause even for a second, as the ever-present waiting room continued to fill. It took a few moments to adjust to the stark contrast, to return from a refuge of calm and enter the combat of pandemonium. I reorganized my thoughts, then grabbed the next chart.
Quickly following up on the 22-year-old female with abdominal pain, I noted her negative pregnancy test. The senior resident passed by and gave me approval to start with the finger laceration down the hall. I also noted the chief complaint of the next patient on her list and briefly thought through the “constipation” workup, then I washed my hands and grabbed a suture kit.
Lots to do. One thing at a time. For now, for the moment, I carefully stabilized my hand as I began numbing the finger of a young man who cut his hand at work, then started to suture. I was here for him. We were there for the man who just passed away. We were there for the man's family. It came to me that we only have a very, very brief time with the people who walk through the doors of the ED, yet that brief time can have a tremendous impact on their lives. We help those from cradle to grave, 12a to 12p, without weekends or holidays – servants at all times for whenever the emergency strikes.