The Collapse of a Life

"3:51am, time of death" I announced.

Content warning: this essay describes the death of a parent.

“3:51am, time of death” I announced. Just 9 short hours after Frances told me she was proud of me for being a doctor, she was dead.

The previous day, Frances had come into the hospital from a community center miles away. As usual with the transfer process, we received little to no information about her care.

“Does anyone know why she has this drain, or what it’s from?” Our attending asked on morning rounds, with no response. “Okay, let’s make sure to get that drain out today – it’s just a nidus for infection.”

So after all the notes were done, and urgent orders were placed, I grabbed a pair of suture scissors and walked the five feet that lay between the resident station and her room. She was sucking on a tootsie roll.

“Shh, don’t tell anyone,” she said, as she saw me walk in.

“That’s alright, you can have a tootsie roll,” I smiled.

“I just love candy. Can’t get enough of it. My favorite are those jolly ranchers, but they’re harder to come by.”

After promising to raid the nurse manager’s station to look for jolly ranchers, I carefully cut around the drain exit site, prying the tube away from the scarred down tissue, and pulled it out quickly, plugging the hole with my finger.

But I wasn’t fast enough – straw-colored fluid poured out of the hole, and the single gauze I had brought to dress it with was now looking pathetic. I looked out of the see-through doors, hoping to catch someone’s attention, but there was no one in sight. If I moved, I would drench her bed in ascitic fluid.

“Hey, um, Frances. Do you think you could reach your call button? I think we need your nurse’s help for a minute.”

I felt stupid for not having brought more gauze and padding into the room with me.

“Oh, sure, sweetheart,” she said and quickly complied, not seeming to notice my poor preparation.

6 hours later she vomited blood.

At first, it seemed like nothing – her nurse wiped her mouth, and she sat up comfortably, switching the channels on the television. No alarms went off from her room as we called the gastroenterologist, the interventional radiologist, and the blood bank to get things ready.

But it was the calm before the storm. And we all knew it.

Things started to happen in rapid succession. She had one endoscopy, then another, and each attempt seemed to worsen the problem. The more we tried, the faster the blood poured out. We set up a convoluted compression apparatus that was strapped onto both ends of the bed, suspended in the air precariously, ominously.

It didn’t work. Was it dislodged? Was the balloon not inflated enough? Or, worst of all, could she be bleeding the other way – not out of her mouth, but into her stomach?

2 bags of packed red blood cells. Then 6. Then 12. Then I couldn’t keep track anymore. I called out what felt like arbitrary numbers and directions to the many nurses who had left behind their own patients to come help Frances.

“Shruti, what now?” Frances’ nurse, Alison, looked at me, waiting for me to make a call on the blood products. The tally marks on the wall that were meant to keep track of blood products swum around in my head, not adding up correctly. I knew the mantra – 1:1:1 – but I couldn’t make sense of the numbers. The blood pressure should have gone up, or at least remained stable as we flooded her body with more blood products, but instead it was going down. And I couldn’t see blood anywhere on her body, or on the bed, which meant it was all pooling inside her body.

“FFP next” I said, being able to tell, at least, that she had received double the number of red blood cells as plasma, and that we had some catching up to do.

“We can’t get the blood products in fast enough,” Alison said, telling me what I, too, was starting to recognize.

So then I was putting in a Cordis, a kind of jumbo-IV with a large enough diameter to be able to push entire bags of blood into her body in less than a minute. I had never done one before. But I knew the concept. And I had done enough central lines that, thankfully, I was able to throw it in on my first try.

But I knew, as soon as I placed it, looking up at her face, that she was beyond saving.

Earlier in the evening, a few hours before everything went wrong, I had called Frances’ husband to give him an update, and to ask him if they had ever discussed Frances’ medical care. Had they ever talked about what Frances would want if she were to become seriously ill? “We want everything done” he had told me, not really answering the question. I felt defeated, having heard those words far too many times, even in just a few years of experience.

I probed a bit more, trying to understand what he meant, and he said, “She’s always so full of life. She loves to laugh. Even with all the hardships she’s been through – she has such a joy for living.”

But now Frances was bleeding into every crevice within her body, swelling up so much that soon her heart wouldn’t be able to take it. This wasn’t living.

Hours, or maybe seconds later, her heart rate slowed.

“Dr. Kadir” my whole body tensed up as I called to my attending from the door, who had been conferencing with the GI and IR attendings for the past several hours, trying to find a solution to an impossible problem. “She’s bradying down – she’s about to code,” I said.

Dr. Kadir looked up at me, stony pain darkening her eyes. “We’re not coding her. She’s beyond saving,” she said.

Relief flooded my body. Frances’ consciousness and soul had long since left her body, which would have been harmed, beaten, and destroyed if we had performed CPR.

I went back into the room, and watched as her heart rate dropped lower and lower. It hovered in the 20s for an obscenely long period of time – her heart struggling, flailing uselessly as the rest of her slipped away. The blood pressure stopped registering, and we had long since silenced the ventilator alarms. Finally, mercifully, there was no rhythm on the monitor.

Alison palpated at her wrist, then her neck. She looked at me and I knew.

I walked forward, mirroring Alison’s motions, feeling Frances’ wrist, then her neck. I reached for a flimsy yellow stethoscope that someone had flung over the IV pole, hearing nothing when I pressed it to her chest. I could barely move her eyelids, but using two hands I pried them open, and saw two pinpoints of grey on a canvas of white – these were not eyes anymore. I shined a light into them anyways to complete the final step of the determination. Silly, pointless, important, and necessary.

“3:51am, time of death.”

---

Barely any time had passed when I started to notice the sun filtering through the transparent ICU doors. The day shift residents started to trickle in, some smiling, some grumpy — all completely unaware of what had just transpired.

Behind them trailed a man and a young boy, walking together yet apart. Frances’ family was here.

I rose from my chair and asked them into a private room.

They looked at me expectantly. Frances’ husband was not her son’s father. They probably lived separately — had they even arrived together? Had her husband prepared her son for what was to come? I looked at her son’s face, and its blank expression, and realized: he knew nothing.

His name was Daniel. He was 14 years old.

As the sun rose over the hills that morning, I told Daniel that his mother was dead. I can hardly remember what I said. Was this my first time telling someone their loved one had died? How many words had I said before I got to the most crucial one?

I watched him crumple onto the floor, and I stared at him as he let out a broken wail, the most terrible sound I have ever heard. I could only watch him, unable to say anything more, as my insides somehow lost sensation, and I stumbled over my breath.

For the first time in my medical career, I had to excuse myself from the room to compose myself.

When Daniel was finally able to stand up, we brought him in to see his mother. I didn’t watch. I darkened the shades on the glass ICU doors to give him some privacy.

Had he known how ill his mother was? That though to him, the death had seemed sudden, in fact her body had been slowly breaking down, being consumed by a chronic illness that, once it began, couldn’t be stopped?

For the rest of his life, Daniel will remember that day. And I will forever be a part of that story. I was the person to deliver death.

I will not forget it.