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Keeping someone alive? I could do that. After all, that's what medical school taught us, ways to save lives. Give me a disease, and I could find the algorithm.
Death, however, was murky, messy, and confusing. An algorithm does not exist. There is no uniform response to provide grieving family members at bedside. Death was its own master, chose its own rules, and decided its own course. Death was something I would become intimately familiar with throughout the first rotation of my intern year during the upswing of the COVID Delta variant in our area.
I remember the first patient I pronounced dead. Compared to the other calls I received, it really was a simple request. "We have a patient on the ventilator who has passed, and we need a physician to come to pronounce the time of death."
OK, I thought. This would be straightforward. Easy. I'd been through 4 years of medical school. Of course I could determine if someone was dead or not. What kind of a doctor was I if I couldn't do the bare minimum?
Yet on my way to the critical care unit, walking through the empty halls of the hospital, I suddenly started to panic. All the lectures on COPD or CHF, or any other acronym, wouldn't help me now because they were already dead. I was never taught how to deal with the dead; I was taught to treat the living. I had no clue what to do when patients were beyond measures to be saved.
I called an upper-level resident on the way to ask for direction, feeling like an idiot as I asked them how to tell if someone was actually dead. Check ocular reflexes. Got it. Listen for heart and breath sounds, got it. OK, it would be easy, I told myself. It is just three simple words and a time. I walked through the big double doors into the quiet unit beyond, as the charge nurse approached me and guided me to the room, the sound of mechanical ventilators humming in the background.
I entered the patient's room, the lifeless body still attached to mechanical ventilation via the endotracheal tube. There were lines and IV poles clustered around them. I noted the flatline on the monitor, asystole, and the empty room around me, COVID restrictions robbing the patient of their last chance for family support, their last chance to say goodbye. I shamefully pulled the nurse aside, apologizing that I had never done this before and had no idea what to do.
"It's OK," he whispered. "I've done plenty and can walk you through it."
His comfort and support helped put me at ease as we checked reflexes, placed the ventilator on standby, and listened for heart and breath sounds. The still body on the hospital bed seemed so foreign to me, so far removed from the patients I remembered seeing as a student. I stood there a little longer with them, more for my sake than theirs, as if being there made their lonely passing somehow meaningful. I looked at their pale face one last time and quietly announced, more to myself than the others, "time of death, 22:30."
Cali Clark, DO, is an internal medicine resident.
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