The Rent

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