Balls and Walnuts
more than you ever wanted to know
The Big Sleep
I wrote this one several months ago and I’ve been sitting on it ever since. What else can I say, by way of introduction? I’ve seen a lot of cancer lately, and several of my older patients — favorites, many of them — have left me.
***
It was my second year in training — we call that the R2 year, but really, it’s the first year of residency — and I was post-call on a Thursday afternoon. My patient, an elderly black man scheduled for a laryngectomy on Friday, never showed up in clinic. In those days, we would bring in the big surgical cases a day ahead of time. The evening before surgery we would do all the pre-op labs, X-rays, and consultations, everything necessary to spiff the patient for his operation.
My patient’s no-show would leave us with a nearly empty surgical schedule for Friday. My chief and my attending were not happy.
“Have you called him?” asked my attending.
“Yeah,” I said. “He had no ride and he had no money for the bus. He didn’t have any friends who could bring him, either. He says he wants to wait anyway.”
“He can’t wait,” she said. “Why don’t you see if he’ll come in if someone picks him up?”
You can probably guess the result. Yes, he would come in, and yes, I was that someone. I’ve often wondered if that changed me somehow — if, by picking him up and bringing him into the hospital, I felt like I owned his fate. It was my responsibility. In any case, it’s safe to say he became special to me.
After his operation, he communicated mostly by pantomime. He had a writing tablet but had trouble with it, perhaps because of arthritis. We weren’t doing immediate voice rehabilitation in those days; he would have to wait for his electrolarynx. Somehow, I managed to figure out that he was bored as hell on the ward. The other patients kept the one TV tuned to a Spanish language channel. He wanted something to read.
After a one-sided conversation, I decided to bring him two of my favorite paperbacks: Raymond Chandler’s The Big Sleep and Farewell my Lovely. I’m not sure if he read them; on these open wards, you kept your possessions in your bedside table or they were soon pilfered. I know he appreciated the gesture, though.
***
I’ve never been good with death. Maybe Dean’s right (in a comment he made here long ago): we’re culturally crippled when it comes to death. When people die in serious movies, it’s the stuff of melodrama. Think Terms of Endearment. Children never die (which is why South Park’s “Oh my God, they killed Kenny!” shtick has such a visceral punch the first time you see it). Barring melodrama, good guys never die. Death, that’s for evil people.
We can’t even say death. Hence The Big Sleep. Hence a jillion other euphemisms (and, hence, the comic power of the Monty Python Dead Parrot sketch).
When I was in first grade, my dad’s parents flew across the country to attend my brother’s Bar Mitzvah. My grandfather, already in his 80s, said to me, “In a few years, I’ll be coming to see your Bar Mitzvah,” whereupon six-year-old me said, “I doubt it. You’ll be a dead duck by then.”
Some time after that, another first grader died in an accident. I didn’t know him; he was in a different class. But when our teacher told us that this boy had died, I waved my hand. I had something to add to the discussion, you see. Something important.
The teacher pointed to me and I said, “It’s not so bad. He’s going to get his name in the newspaper!”
I think I was punished for both of those incidents, but I don’t remember anyone bothering to explain to me what I had done wrong. In those days, the punishment was supposed to speak for itself. You done wrong, kid. Don’t do it again.
Point is, I was worse than clueless on the subject of death.
***
My patient had a long and troubled recovery. He developed a fistula (an abnormal passageway between the throat and the skin) which delayed initiation of radiation therapy. He had been a big-time smoker and alcoholic and was, as we docs say in our ever-so-polite way, piss-poor protoplasm. Remember our discussion of “blame the patient”? Whatever went wrong, we would blame the patient. Fistula? Not because of any problem with surgical technique. Your patient was malnourished, Dr. Hoffman. What did you expect?
He retained an almost constant air of bemusement. Once, when we were concerned about his depression, my attending had the bright idea of introducing him to one of our laryngectomy successes, a Hispanic fellow who could talk up a storm with his electrolarynx. The idea was to show my patient the light at the end of the tunnel. Unfortunately, our success story only spoke Spanish, which left my patient more befuddled and depressed than ever.
We laughed about it. Did you see the expression on his face? Priceless.
He healed eventually but suffered a stroke. Consult Internal Medicine; he became an ENT patient in name only. Not our problem any more.
He would never make it home.
***
So few deaths have affected me. It’s pathetic, really. My dog Chi Chi’s death busted me up more than the deaths of any of my grandparents (and that dog hated me. Go figure). I hear of the deaths of classmates from high school or college and I feel nothing at all. My father-in-law’s cancer diagnosis upset me, but I didn’t cry over his death. I didn’t even go to his funeral — my wife went by herself.
I’m beginning to wonder if I have a problem with death. Ya think?
I’ve only been to one funeral, the one held for my maternal uncle. What a pathetic affair! I was the only one in a suit, including the rabbi. The rabbi was the only one who had anything to say. “He could be difficult at times. Needy. But if we were ever short for a minion, he was always there for us.” Now, that’s really reaching.
The deaths in training: those were the ones which hit home.
***
If someone dies in the hospital, a doctor must determine that the prerequisites of death are present. As you probably know, it’s called “declaring” the patient.
When my patient died, I was on call. I had to declare him dead. You wouldn’t think it would be that big a deal, would you? After all, I had watched people die. Once you’ve witnessed agonal respirations, once you’ve heard the gradual silence, a dead body should be nothing to you. That’s what I told myself.
But I had never examined a dead man before. I had never listened for the absence of breathing, absence of a heartbeat.
Afterwards, I remember thinking, Don’t ever let yourself get this close again.
D.
Thank you for writing this.
It is hard to be that close.
My veterinarian friend helped me put down a number of horses, which was difficult. But she made the most terrible keening wail of stifled screaming during the euthanasia of a beloved stallion. Here we were all trying to hold it together and this sound just emerged. We weren’t even sure who was making it at first, or if it was human or mechanical.
At the end, when she had to determine if he had died, she stood up, put her stethoscope back around her neck, looked at us and said, “Sorry about that. I was too close.”
There’s a reason you try to disassociate yourself from painful things. It’s the work of trying to engage with the painful which creates a well-rounded person. I think. Perhaps.
Anyone who says that people go easily into death have never heard agonal breathing.
I’ve been present when people have died. My grandmother, mother-in-law, a cousin… and they were all very sick for a long time, hospitalized, and heavily medicated if not in a coma-like state. Things slow down, finally creak to a halt, and it’s over. The family stands around for a bit then leaves to let the hospital machinery of death take over.
My dad, however, was my first corpse. He was long-term diabetic and he passed unexpectedly during dialysis. They called Mom from work then, after she was there a while, she called us kids. He’d been gone about an hour by the time I got there. He was completely different in every way I can possibly articulate from all the other death’s I’d seen and it was one of the most unpleasant experiences of my life.
I don’t know how police and fire rescurer’s look at death every day, I really don’t.
Death is just so undignified. It makes no sense to me, I can’t wrap my mind around it and figure it out. Therefore I don’t respond to it well. I think because most of the time there is no control to how a person’s life ends. I think the best way to die would be in your sleep, unaware and unafraid.
Jeez…this is a heavy subject.
Thanks, folks.
And you’re right, Anduin. What we need right now is for someone to say, “Dood, yer bringin me down, man.”
🙂
“don’t ever let yourself get this close again”, is this why most surgeons are cold hearted? we laughed about it Did you see his expression. hope i never see you in the operating room.
I wonder about people like you, Dawn. I wonder how you can pop into a stranger’s blog, read one post, misunderstand it, and judge him for it. As we used to say in residency, strong work!
Hey Doug – despite my well earned skepticism when it comes to medicine in the US, you’d be one of the few doctors I’d trust, precisely because you are so honest about your thoughts.
For years, I worked in various photo labs where we processed photographs for the police, coroner, and hospitals. I cannot imagine having to see any of that in person, let alone have to deal with it on a regular basis.
I’m all for coping mechanisms, and I don’t think doing what it takes to keep yourself sane and working at a job that helps many people is cold hearted.
Thanks, Renee 🙂
And I am honest to a fault. I think it really bugs some patients — folks who want to be dictated to, who don’t want to hear even a shred of uncertainty from their doctor.
Death doesn’t bother me so much as the way it happens. I find myself trying to keep my own body in tact like loose marbles in a bag. No more cutting and hacking off of bad parts. No more mutinies lead my malignant tumors. I’m tired of seeing it too. Bullets in people’s brains. Cancer eaten through my father’s back. A man’s skull crushed by a car windshield as he jaywalked. One second they’re on this plane with me and then where do they go? I don’t mourn them either. I want death to be like when I was a child and it was the first of summer, the first day the swimming pool was open. I would climb the high dive, hesitate at the end of the board and fall into the chilly deep end of the pool. Then I would be gone.
Dood, yer bringin’ me down, man.
OK, Doug? It’s said.
I don’t know if it’s universal, but any thought of death is something I immediately – and usually consciously – push to the back door of my mind to the point where it has to back into the rear yard and hide. This is a coping mechanism that may be unhealthy, but the only way this agnostic can cope with the concept of oblivion without getting the screaming meemies. My childhood nightmares were a bitch.
Thanks a bunch, dood. (is there an emoticon for sad resignation?)
So how does one behave/feel if one is “good with death”? Does it require strong religious belief? If it does, I’m screwed. Eh. I’m probably screwed anyway.
And how do we handle it so our kids aren’t as screwed up as we are? I’ve got diary entries from when I was 8 saying “sad day. Grandpa Cliff fell at work.” and two days later: “sad day. Grandpa Cliff died.” And what I remember is thinking that I was supposed to be sad, but I really wasn’t–more just uninterested.
We went to Carl’s grandmother’s grave last weekend, and my sons were visibly moved. As were Carl & his mom. I knew her for 8 years before she died, and I just kept thinking about her saying I had “kraeftige Beine” (when I was wearing a freaking size 4. argh.). I’m going to hell, aren’t I. But maybe I didn’t screw up too horribly with the kids.
I spent about an hour alone in a dimly lit room with my dead dad. I thought I had to and I kept waiting for it to feel natural. Death is part of life. Some people actually bathe their dead relatives’ bodies. I kept saying I can take this. (He’d been sick for a decade for gawd’s sake. This wasn’t a huge surprise.)
I couldn’t take it. I couldn’t drive the 45 minutes home, I stayed up for two nights afterwards and finally begged my neighbor for some valium.
It wasn’t sorrow. Well maybe it was in part. Mostly it was that he was SO DAMNED DEAD. Oh and the heating vent kept making the venetian blinds next to the bed move and I’d catch the motion out of the side of my eye and kept thinking oh, look, he’s moved after all.
And when my 17-yr-old dog was euthanized, the sliding from being alive to dead was astoundingly fast and easy (no agonal breathing) That was even scarier. And then she was SO COMPLETELY DEAD. It’s just so entirely DEAD. so NOT ALIVE. an absence of pulse is so PRESENT. (one of my favorite dumb med phrases)
Right.
lighten up, dood.
Sorry, folks.
Remedy soon to follow.
Sorry?
Dood, it’s not like you *invented* death. (or did you?)
Yup, that’s right. That’s me beneath the black cowl. So watch what you say about me behind my back.
And agents, publishers? You’ve been warned. I have a twitchy scythe finger. Hand. Arm. Whatever.
Do you think that people who have a strong belief that they are going to a good place after they die are less afraid of it?
One thing about seeing dead people and animals(in the actual, physical sense, not as in The Sixth Sense) is that it made me realize how unimportant the body is. When they’re dead, that body just isn’t them – they’re gone. It’s unsettling to see.
For this reason, I don’t want any fancy burial for myself. Donate my organs and do something ecologically sound, like cremation, green burial, or air burial or freeze-drying, if possible.
BTW, have you read Stiff or Spook? Both really good reads.
I think people with strong belief can convince themselves of anything; and, now, I haven’t read those books. More info!
I want to be mulched.
Don’t believe you. Everyone knows Death talks in CAPITAL LETTERS. And has no sense of humour. And probably isn’t Jewish.
Yes I like Terry Pratchett. (sigh)
So, I used to have this crazy great aunt… She held on to her husband’s urn for *years*. Oh, she kept talking about scattering his ashes somewhere he loved, but never quite got around to it.
Eventually, my folks had to take care of her: scheduling doctor visits, taking her places, helping her sell some of her antiques, talking to a realtor about selling her houses, letting my dad haul off the junk – and yes, *finally* dealing with my uncle’s ashes. “Oh, I’ll take care of it, ” she’d say…
They let the issue of the ashes slide for a while. When my mom finally raised the subject again, she was stunned when my aunt said “It’s done. He’s in your garden.”
Her rationale was that he’d really loved gardening, and he’d always loved my parents’ gardens – so in a fit of inspiration, she snuck over early that spring and dumped his ashes into the manure/mulch pile. Given that this didn’t come up until many months had passed, my aunt was probably right: her husband was at that moment evenly distributed across the garden.
I think it was right around then that they encouraged her to sell her car.
Hmm. Is death Jewish? Probably not. No sense of humor (in real life, that is. Pratchett’s Death is a hoot).
PS, I knew I wasn’t crazy. Senile, perhaps, but not crazy. Great senile minds think alike.