I sit on my front porch, the smoke of a cigarette lazily curling around my fingers. I’m not a smoker, but from time to time I bum one off a neighbor when I’m feeling particularly stressed. An old habit from an old girlfriend.

My patient, Simon, is dying. Bacteria have riddled his body, already ravaged by chronic illness, and he has been dying slowly for months. Last week, with the input of his loving family, we withdrew all medical care on him, and I’ve been watching him die for days. This morning I heard the first telltale sign of the death rattle. I’ve never heard it before, but it is a chilling sound. The Reaper is standing in the room with me, and I can see his hand on Simon’s shoulder. I have been with death before, but not like this.

Simon’s room is beautiful, papered with carefully hand-lettered signs. “Simon, we love you.” “Go with God.” “Happy Birthday From All Who Love You”.

His brother, Joseph, approached me today. Joseph and his mother are concerned that by not giving Simon fluids by mouth or IV, we are making him less comfortable while he dies. From a purely medical standpoint, I know this isn’t true – at this point, hydration will only cause his lungs to exude more fluid, drowning him in his own secretions. He’ll be far more comfortable without, but I couldn’t find a way convey this.

And then, Joseph laid his hand on Simon’s head. “I’m so sorry, brother. I love you so much.” Simon, who barely focuses on anything any more, turned his head to look into his brother’s eyes.

So I decided to take the middle ground. I started extremely low-dose IV fluids – so low that I hope it won’t make a difference – and increased the pain medications in case it makes him more uncomfortable. But I know full well that more pain medications will hasten his death by decreasing his drive to breathe. He’ll die faster now, and that decision must stay with me.

I sit on my front porch, the burden weighing heavy on my shoulders. Joseph and his mother may sleep easier tonight, believing Simon to be more comfortable, but I won’t.

I just sit, and watch the trail of smoke drift up towards heaven.

The Emergency Department was absolute bedlam. In the space of a few hours multiple trauma codes, medical resuscitations, and psychotic patients were brought through our doors. One patient literally bled pints of blood onto the floor before we got her to the ICU, almost exsanguinating in just a few minutes.

One of the drunks tried sprinting through the doors until security restrained him. He was surprisingly articulate in his verbal abuse for a guy with an alcohol level of 450.

People were being pushed around on gurneys and stashed into the hallway simply to make room once they had been stabilized. The level of chaos was audible in the noise of the department. Everyone was working with a purpose.

Walking by, I overheard a woman say to her boyfriend “Wow, this is like that show ER!”

I wheeled around and smiled a bit.

“Ma’am, this is ER.”

Reading this post from an old friend (hi Al!) reminded me of my favorite Mommy Line call ever.

Now, Mommy Line calls tend to vary from stupid to stupider.  Why?  I don’t know – but questions like “Can I drank while pragnint?”  or “I think my water just broke and I’m having contractions, but can I stay home and finish watching Cougar Town?” are a dime a dozen.

One night the good Dr. F was fielding calls, and the conversation transpired as follows:

So, I’m 40 weeks pregnant, and I keep getting this feeling like I have to poop.

Ok, well, sometimes that can be a sign of contractions.  Has your water broken?

No.  When I feel like I have to go poop, I go sit on the toilet, and I do.

Do… what?

Poop.

Ah. Let me get this straight, just so there’s no confusion.  You feel like sometimes you need to poop.  And when you feel that way, you do, in fact, poop.

That is correct.

… you should probably just poop.

“Code Sepsis, here now“.

Her blood pressure was tanking as a result of a systemic infection, a condition known as sepsis.  Sepsis can kill, and quickly; the most important thing to give is intravenous fluids fast, and plenty of them.  Traditional IV lines are too small – the equivalent of using a garden hose to put out a fire.

A central venous catheter is used instead, where a large bore tube is placed.  Unfortunately few veins in the body – only deep ones – are large enough to support this type of tubing, making central line insertion a potentially very dangerous procedure.  The risks of popping a lung, hitting an artery, or triggering a deadly heart rhythm must be carefully weighed against the benefits.

I remember my first central line – it did not go well.  In fact, it did not go at all.  I knew enough to know that I didn’t know anything, and got cold feet before I had the chance to seriously hurt the patient.  Let me be the first to tell you, sticking a huge needle in someone’s neck is really intimidating. And these needles are huge.  Think Nicolas Cage in The Rock (great F’in movie) and you’ve got a rough idea of the size we’re talking.  Looking back on it, it was a smart choice.   Plenty of time to learn.  No reason to go cowboy too early.

Back to the present.  When I teach medical students to do procedures, I walk them through every single step of the way, and then have them teach it back to me.  Not just in broad strokes, but the nitty gritty.  Why?  Because if you forget to put on your sterile gown – or you put it on in the wrong order – well, then, you’ve screwed the pooch just as much as if you missed the vein, haven’t you?

So, I started.  Anatomy examined.  Skin disinfected.  Gown on.  Sterile field.  Ultrasound guided.  Vein accessed.  Wire threaded.  Vein dilated.  Line placed.  Sewed in.  Finished.

Total time elapsed – 15 minutes.  Not great, but 45 minutes faster than the last one I did.  Next time I’ll be better.

She was 70, and her family noticed she wasn’t moving quite right.

By the time she got to the ED, her entire left side was paralyzed and her mental status was poor at best.  The massive, ongoing stroke was getting worse by the minute.  Her pupil was getting progressively more and more dilated.  Gurgling, choking sounds were emanating from her throat – a sure sign that if she hadn’t already swallowed a large volume of stomach juices and oral secretions into her lungs, she would soon.

First and foremost.  ABC: the axiom by which Emergency Medicine doctors live.  A is for Airway, the first and most important part of any emergent case.  She has officially failed to Protect The Airway, and it’s time for me to do it for her.

I’ve just finished my anesthesia rotation and for the rest of my career, I’m officially cleared to intubate when needed.  More importantly, I’ve done enough of these that I feel comfortable handling myself without guidance.

Equipment: check.  Always make sure your equipment works first.  It’ll save your ass when the clock is ticking and you suddenly realize your light doesn’t work.

Drugs: pushed through the IV.  Now she’s sedated and comfortable, and the paralytic quickly starts working.  I give her oxygen with an ambu bag because she can’t breathe for herself.  Completely paralyzed, her life is in my hands – a responsibility not to be taken lightly.

And so.  Scissor the teeth open.  Blade carefully inserted through the open mouth, tongue swept aside for easy visualization.  Vollecula pulled upwards and out.  Momentary pause –  I don’t see vocal cords.  Gentle pressure applied to the throat – ah, there they are – assistant’s hand placed just so to keep them in view.

“Tube please.”

Hands steady, I slide the endotracheal tube gently through the vocal cords.  I inflate the cuff to keep it in place, and hook her up to the ventilator.  Oxygen flows to her lungs.  Immediate crisis averted.  One of the nurses gives me a wink, “Doctor Z, you made that look easy!”

There is a particular satisfaction when you glimpse the beginnings of competency.  A month ago, I wouldn’t have known how to do this.  I’m far from an expert – but it will come.  I’ve got my whole life to practice.

Going back through my dictations today, I found this gem that I dictated at the height of exhaustion in the wee hours:

HISTORY OF PRESENT ILLNESS: This is a 30ish-year-old African American male who apparently was drinking heavily and fell asleep on the train tracks. He awoke when the train ran over his legs yet managed to call 9-1-1. Paramedics on scene report that he had a GCS of 15, was talking well and somehow moving all extremities, although they noted that his legs were not attached to his body.

And suddenly the surgical department realized – we need someone to cover the Surgical/Trauma Intensive Care Unit for the night.

Though some unfortunate planning on my chief’s part I ended up being the one who lost this particular Russian Roulette. I find myself amidst beeping monitors, medication drips, and unfamiliar patients.

Let me back up a moment. Intern year is all about uncomfortable firsts – your first prescription for narcotics, your first lab orders, your first blood transfusion, your first CT scan, your first crashing patient. All of these things are difficult in their own way. That being said, usually the degree of autonomy is matched to skill level.

Unfortunately, a mistake was made in the schedule and nobody was scheduled to run the trauma ICU tonight. Now, I’m on trauma this month, but there is a HUGE distinction between covering the regular floor and the ICU. The floor I can deal with. The ICU I simply do not have the experience to run.

Unfortunately I don’t have much choice, as I find myself here with pager on hip. Currently I have a gentleman on the razor’s edge of dying from his intracranial hemorrhage, another who chose to up and stop breathing about an hour ago, and one woman who is trying her best to grab the famous pink elephant.

I’ve got people I can call if I need to, and so far I’ve been pretty liberal with the phone-a-friend. But even though nothing has happened for the past hour, I’ve been lying wide awake.

If someone dies tonight… is it my fault?

Many of my stories happen at 4:30 in the morning.  Why?  Because that’s when I’m forced to make the choice: my sleep, or my patient?

This was a particularly nice 16 year old who lost control of his car on black ice, careening into a tree at high speed and breaking most of his ribs.  The crash caused his windshield to instantly shatter, giving him a few scattered cuts across his face  and one huge slice through his lip.

Ribs will heal on their own, but the lacerations to his face need sewing.  Now, I’m no plastic surgeon, but I am an ER doc and I sew up a lot of wounds. Importantly, the vermillion border – the demarcation between the lip and the face – is one of the most cosmetically important areas of the face. Even a millimeter of disunion is instantaneously recognizable by the human eye.

And so, 24 hours into my trauma call I was faced with a choice.  Let one of my less experienced colleagues fix his lip in a few hours, or take the time to do it now, myself?  My body was screaming from a difficult call night; 15 or so trauma codes in the last 12 hours, sleep deprived for a month, contorting my back to examine patients in c-spine collars all night long.  I felt the overwhelming, primal need to crawl into a corner and sleep.

I suppose, in the end, it was a false choice.  I went into this profession for a reason – to help people.  Knowing full well that these 30 minutes of my time would directly impact every interaction he has with people for the rest of his life… well, that’s time well spent.  The repair went wonderfully.  He’ll have a barely noticeable whitish scar through his lip.

What I’ve gotten used to in medicine is this:  most patients will never realize how important my small time in their life really was.  A missed diagnosis here, a well-repaired laceration there, a timely intervention when needed.  I think it’s a large part of why I went into emergency medicine – I want to be there for the important stuff.

When he gets out of the hospital, I’ll tell him.  ”Your lip looks great, man.  I’m glad you’re doing better.”  He’ll probably never know why I was more concerned about his lip than his ribs.

I remember all my first deaths.

The very first was our cadaver in medical school.  As first year medical students, we shuffled quietly into anatomy lab, nervous giggles escaping pockets among the crowd.  Lying cold, still, aseptic, was our body.  Charlie.   It’s an unsettling feeling, laying hands on a dead body.  There is a quiet dignity about death, a final stillness that is unmistakeable.  I remember stainless steel tables with stainless steel scalpels, and the subtle scent of formaldehyde barely masked by the cloying smell of wintergreen.  My hands shook violently as I made the first incision.

The second was the first death I ever witnessed in person.  Surprisingly, it took until my 4th year of medical school, on an ER rotation in Seattle.  He was an elderly gentleman who had shot himself in the head after downing a 5th of vodka when his wife divorced him.  His features were barely recognizable with all the damage.  He was intubated, paralyzed, and barely had a pulse on arrival.  CPR continued only for 5 minutes before he was pronounced dead; somewhat of an afterthought.  The only thing keeping his heart beating until he reached the hospital were the massive doses of epinepherine circulating in his bloodstream.  I remember being sorry for him, but not devastated – he was already DOA.

Last night, my patient died.

The page came: ADULT TRAUMA CODE ONE FIVE MINUTES OUT BY AIR

I sprinted downstairs and into the trauma room, a sea of faces greeting me.  My favorite nurses, our best physicians, waiting.   These are the most capable people I know.  They were ready –  I prepared myself for the survey.  As the trauma intern, it’s my job to perform the whole physical examination in front of everyone and call out significant findings.  All we knew is that the patient was a 70-ish woman in a car accident.

The medics rolled the stretcher in, and instantly the mood changed; suddenly silent and tense as we saw how bad off she really was.  For a second, the only sound was her quiet wailing, “Oh, Lord.  Oh, Lordy, my arm hurts.  Please, my arm hurts so badly…”

The moment ground to a halt.  I remember utter quiet as the seconds ticked by, as long as minutes.  Her forearm had three joints where it should only have two…

Silently, I took in the damage.  Horrific, tenting fracture to the left forearm.  Right wrist splayed off to the side, every bone in her hand likely shattered.  Right ankle sideways.  Left shin with shards of bone sticking out the front.  Amazingly, she was still talking and protecting her airway, the first thing ever said in a trauma assessment.

So I spoke.

“Airway… is currently intact.”

Time sped up, sounds and colors rushing in to fill the void.  What once was silence and stillness was bedlam and cacophany.  Everyone talking.  Everything moving.  I was lost in the exam, hoping against hope that if I could just find the one thing that was wrong, I could save her.  But there was too much.

Broken bones were quickly realigned, blood lost was quickly replaced, but we were waging a war against death and we were losing.  For every vein that we accessed, another collapsed.  For every unit of blood given, she bled two more.  I was struck for a moment by how beautiful it was, all of these people working in harmony to try to save one life.   Grim faces and furrowed brows desperate to help this stranger.  People at their best.

Blood pressure started dropping.  I had my hand on her pulse and felt it ebbing away, slowly, surely, towards that final quiet stillness.  I remember at one point looking up at the clock and realizing an hour and ten minutes had elapsed.   There was the chill, certain realization that nothing would stop this woman from dying.  My fingers felt her pulse getting weaker.  Slower. Fading.  A few minutes later, she was dead.  Everyone shuffled out of the trauma bay until it was just me and her.  I was struck by how cold she was.   Like Charlie.

And then the page came:  PEDIATRIC TRAUMA CODE ONE 6 MINUTES OUT BY AIR

Off to save a life, this time.

A question:  Can dirty clothes stay on the ground so long that they become clean again?