I have only and exactly three things in common with every other human who has ever existed on this earth.
I was born.
I have breathed the air of this world around us.
And, someday, I will die.
Regardless of past or present, here or across a vast ocean, I can choose another human at random and know that I share these things with them, irrevocably and unchangeably. If we are at odds in every other conceivable way, in looks, gender, ideology, who or what we love — the ways in which we are uniquely human are too numerous to list — then, even still, we have this in common.
We have this bond, this moment of entering existence, of existing, and of the knowledge that there will inevitably be a moment of exit.
Once we’ve moved past the first two commonalities, we tend to let the third slip our minds, intentionally or not. Granted, there are some of us that live in fear of the moment of our death, compensating by living frantically, as though in our haste we might somehow skip right over it — we just simply ran out of time today, sorry, we’ll have to reschedule.
Some of us wish for it, for reasons sound or flawed. Some of us chase it. A few of us catch it.
But I think for most of us we’re just simply too busy living to be concerned about dying.
Until it steps in front of us, and forces us to raise our eyes and focus.
~ ~ ~
He had tripped and fallen earlier in the day, not hard and not far, and had only grazed his head on the edge of the table as he went down. But it was enough, after more than eight decades, to wiggle loose some fragile skin of an artery, deep in his brain. He complained of a headache, and went to lie down. And when his family went to wake him for supper but could not, they called the ambulance.
He seemed peaceful, lying there on the gurney, breathing evenly and slowly, his vital signs stable, his hands folded gently across his stomach. But the CT of his head showed a vast, secret bleed, one that would not stop and could not be fixed with surgery. He had fallen asleep for the last time.
There were easily fourteen or fifteen family members in his room, gathered around his bed, holding his hands, talking to him, touching his face, laying their hands on the thin fine gray hair just above his ears, when suddenly the monitor alarm flashed yellow. Desat, 88%. 87%. 85%. 80%. Now it flashed red. 78%. 75%.
He had stopped breathing. His cognition had been the first thing to go, his breathing was now the second, and his heartbeat would be the last. Suddenly, for his family, it was real.
The hue and cry was immediate, visceral, and agonizing. They screamed, and cried, and begged, and wept, and begged again, and grabbed at him, almost violently, desperately holding on to the shell of him that was left.
There is a phrase that carries the same pitch, the same tone, the same rhythm, regardless of language:
no. don’t go. don’t leave me behind.
We moved quickly to draw the curtain and close the door to his room, both in an effort to offer them some privacy, and to muffle the sounds of their grief. It is one thing to know, in an abstract way, that people die in emergency rooms. It is another thing entirely to be a patient in room A and learn that your neighbor in room B is breathing his last.
I walked over to check on my patients and their families. Across the hall, a man and his wife sat at the bedside of her elderly mother. It was the small hours of the morning, and my patient, mostly deaf and pleasantly demented as she closed in on nearly a century of life, was sound asleep. The other two, however, looked past me to the doorway where shrieks and sobs could still be heard.
“Do you want me to close your door?” I asked gently. “I recognize that this is upsetting for some people, and it’s ok if you’d like it to be quieter in here.” I tried to phrase it in such a way as to give them permission not to participate in this unintentional but communal ritual of grief. It’s ok to shut death out today.
But they shook their heads. “No,” replied the daughter, “it’s all right. It’s not upsetting us. We’re ok.” Her tone conveyed a deep sympathy for the other family, and then her gaze moved back over to the figure in the bed. And in that gaze was the awareness that her own grieving was held back by only the thinnest thread of time, that her mother was only a step or two away from pressing a coin into the cold and empty flesh of Charon‘s hand.
I crossed the hall and entered the room adjacent to the grieving family; only the cinderblock interior wall divided this room from theirs. My other patient, a middle-aged man with an obstructing kidney stone, sat upright on his gurney. His girlfriend sat beside him, holding his hand, their gaze focused intently onto the floor in front of them, deliberately avoiding looking at that wall.
“Would you like me to move you guys to a different room?” I asked. “I know the noise can be distressing, and I’d be happy to move you to a quieter area of the ER.”
But they also shook their heads. “No. We’re all right. It’s just….” and the girlfriend trailed off, and glanced at him, and then at the wall. She was imagining the day when she would grieve like that for him, or, even worse, a day that he would grieve like that for her.
She shrugged, helplessly. “I just feel so sorry for them.”
~ ~ ~
ER patients behave differently when they realize that someone else in the department is actively dying. Call lights ring less frequently, requests are made with apologies attached, family members are quiet and withdrawn as they pass through the hall, to and from the waiting room.
It seems to be the only time that we gain a universal perspective that someone else’s suffering far exceeds our own; that ours is trivial when compared to death.
Many years and time zones ago, the nurse on the other side of the quad from me punched the code blue button on the wall, jumped onto the gurney, and began frantic chest compressions on a patient who had arrived nearly four hours earlier complaining of a cough. Given a low triage priority, he was placed in one of our numerous hallway beds, not “sick” enough to warrant one of the few precious rooms in our perpetually full ER.
When his vitals were finally rechecked, they found his oxygen level to be dangerously low, his pulse dangerously fast. Suddenly a “sick” patient was pulled out of a room, the patient with the “cough” was wheeled in, and as the nurse reached for the cords to put him on the heart monitor, his eyes rolled back in his head and his heart stopped.
The end result was that we never had time to wheel the patient to the critical care area of the ER, and the team coded him in a tiny room, the doors wide open to allow all necessary staff in, in full view of all the roomed patients, hallway patients, and their families in the quad.
Twenty or thirty people watched in mute horror for over an hour as the code team struggled frantically to save his life.
I was not on the code team; I floated around the quad, checking vitals, bringing blankets, helping everyone else maintain a holding pattern as all the normal activities ground to a halt. I watched the faces of the other patients and their families as the drama, violence, and noise of the code played out before them.
Many people stared, unable to look away. Others deliberately averted their gaze, unable to bear to see another human so badly battered by compressions, intubation, repeated defibrillation. One patient finally asked for a pain pill, his suffering obvious, and still he apologized for the asking.
Several of the hallway patients simply got up and left. Whatever their complaint was that day, whatever minor pain or discomfort had brought them to the ER in that late afternoon, whatever they’d considered to be “emergent” in their own heads was suddenly reclassified. Whatever it was, it wasn’t death.
It could wait.
~ ~ ~
Americans are not a terribly patient lot (pun entirely unintentional, yet unavoidable). We jump lanes on the freeway to try to get there faster, we get pissy at restaurants if our server doesn’t greet us within ninety seconds, we have been known to throw a punch if someone cuts into line ahead of us.
It is even worse for people sitting in the waiting room of an ER, sick, in pain, frightened, waiting for a room or a hall bed to come open so they can go back and see the doctor. It is infuriating to see others ‘jump the queue’ ahead of them, even if they understand the rationale (the chest pain is going to get seen before your hangnail, sorry). And anger builds as time continues to tick by.
The tiny clinic on the Indian Reservation where I worked at the beginning of my career had only an outpatient clinic and a six-bed ER, and the wait times for both could climb to four or five hours. A close friend and fellow nurse sat at triage one afternoon, apologizing again and again to angry, frustrated patients. I know the wait is long, I’m sorry. I know you’re hurting, I’m sorry. We have some very sick patients waiting to transfer to Tuba City, and then we’ll be able to bring you back. I understand that you —
And then the woman ran through the main entrance of the clinic, the pale, limp body of a small child held in her arms.
“She’s dead!” the woman shrieked, hysterical. “She’s dead she’s dead she’s dead oh god oh god oh god–”
My friend grabbed the child from the woman’s arms and ran with her, cradled against her chest, into the ER in the back.
The woman collapsed onto the floor of the lobby, still screaming.
In the movie The Princess Bride, Inigo Montoya hears a scream that is echoing across the countryside, reverberating in the ears of everyone in the kingdom.
He says, “Do you hear that, Fezzik? That is the sound of ultimate suffering. My heart made that sound when Rugen slaughtered my father.”
It is an apt description of the sound a parent makes when their child has died.
I have heard it three times in my career, and I hope I will never hear it again.
The waiting area of our little IHS clinic was silent for the rest of the afternoon.
~ ~ ~
I think it is natural for us to feel disconnected from strangers. In crowded areas, like hospital waiting rooms and overcrowded emergency departments, we do not or cannot make the effort to connect on any level to the people around us. We are focused inwardly, or constrained by the social dictates for personal space and privacy. We see the other people around us almost as competitors, fighting for the same doctor, attention, nurse, medicine, reassurance, care.
Our only saving grace, as morbid as it is, is that hospitals inevitably remind us of our own mortality, and in that single concept we have a universal connection to each other. No matter how hard we fight, or don’t, or how long we struggle, or don’t, or how many precautions we take, or not, death will come for us all. For you, for me, for the old man in the wheelchair, for the baby cradled in the carseat, for the young woman snapchatting her ER visit.
And sometimes, when that innate frailty is brought to the forefront, we suddenly realize we can connect to a perfect stranger, and that connection, that moment, that link — it is terrible and beautiful together.
“The mass we saw on your father’s liver is suspicious for cancer, but we can’t say that it definitely is cancer. You’ll need to see a specialist for a biopsy as an outpatient,” I explained, for the third time.
“But can’t you do the biopsy here? Can’t you admit him and do the biopsy tonight?” asked his adult daughter, for the fourth time.
I drew a deep breath and deliberately slowed myself down. She was asking – begging – because she was terrified. She’d brought her elderly father in for nausea and vomiting, and we’d discovered what was almost certainly metastatic liver cancer on a CT scan of his belly. But his symptoms were better, his vitals were stable, and the hospital was full. We couldn’t have admitted him even if such an admission were warranted.
I explained this to the daughter again, gently but firmly, as kindly as possible. I also tried to lower the pitch of my voice as much as I could — we were in a semi-private room, meaning that the four beds in the room were only separated by curtains. Everyone could hear everyone else’s conversation, symptoms, diagnosis, treatments. Nothing was private.
Eventually she accepted that her father would not be admitted, and I removed his IV and disconnected him from the monitor. She helped her father dress, and I handed them their discharge papers, their prescriptions for pain pills and nausea medications, and walked them to the door of the room.
I was startled to see the husband of the patient in the next bed over standing at the door, waiting for the man with the liver mass. He reached for the man’s hand, as if it shake it in greeting, and then enfolded it in both his own.
Tears were shining in his eyes. I realized he’d heard the entire conversation about the probable cancer, the terror of the daughter, the calm and quiet acceptance of the patient. He had felt the tenor of the room change, the sense of impending finality that had settled on this man, this perfect stranger. And perhaps he’d felt some awareness of his own final days, distant in the future if luck and health held out.
Holding onto that connection, he gently squeezed the man’s hand.
“May God bless you,” he said quietly. “Bless you both.”