The events that raise a welt in my experience of life are sometimes seemingly trivial. Being a parent seems impossible because it is a necessary part of life that one’s child gets hurt and that the parent will be the cause and that the cause might be seemingly trivial and that the child might remember it forever. The big, nontrivial injuries are what I am sure parents try to avoid and still they happen too. Bad things happen. Rents in the fabric. Often the little things take a turn for the worse…
Eventually a terminally bad thing happens. Today one of my patients died. He was very sick and was sick from the moment I met him. The little aching in his gut, the stomach ache, took on a life of its own. It changed from an annoyance to being his only sensory input, within hours. Before he could really understand what was happening, he fell out, collapsed. He had perforated an ulcer in stomach and leaked out liters of dilute acid into his abdominal cavity. We operated on him twice in 24 hours, an entire team of physicians and nurses came to his aid, to help. His kidneys shut down and we gave him emergency dialysis; his lungs stopped exhaling and we placed him on a ventilator; his heart gave out and we gave him epinephrine in his IV; etc. We never got him even close to coming back around. The shock took him.
One definition of shock, penned in the 1800’s by Samuel Gross, is ”the rude unhinging of the machinery of life”. I read that when I was a third year medical student and I have thought of it often. It is the best definition of shock I know. All the processes come unglued, the wheels are off. If we catch shock early it is often reversible, but there comes a point at which the rent is too deep, the unhinging. At that point, nothing works.
Standing at the bedside of a patient in this place is lonely business even though I have never stood alone at this kind of bedside. There are always many people around. We are all working, but I know that we are also all feeling the pull of the drain as the patient circles. We know what is coming and we remain silent in the knowing, we keep doing. In those moments, just being is too hard. We cling to our own lives while we helplessly watch another’s simply end. For the first decade or two of a career in medicine, this also happens unconsciously.
As I have gained experience as a surgeon and as a person, I see my role differently in these moments. As soon as I have that tug of the rope’s end in my own gut, I stop. I find the family and I tell them everything. Earlier we have talked and they already know that things are grim and I have told them about the possibilities, options etc. That is one conversation. The conversation I am talking about now has far fewer words. This conversation involves walking with them to the edge of a cliff and holding their belt while they lean over. The family is cursed with the same blood as the dying person. The vibration of the unhinging is rattling in them palpably. I can feel it. My job is to be. there. with them. I must have enough of me to be at their side, not talk them out of it and stop giving them hope of a different reality. If I don’t let them honestly have the feeling of that moment, they don’t get the understanding they need to let the person go in peace. If I help them look over the cliff, they find a way to say goodbye and even more miraculously, they usually find a way to not jump.
painting: Les Lyden