The Dog Days of August

They teach you how to break bad news in medical school. One of the most common acronyms is SPIKES.

Setting Up - What would be a suitable time for us to chat with you and your family members?

Week 2 as a MICU senior started off with less fanfare than Week 1. I'd walked into that first day with a patient floridly bleeding from the mouth and nares, resulting in an early morning intubation. He'd circled the drain for two days before ultimately succumbing. Hemorrhagic Shock as a result of Disseminated Intravascular Coagulation, I'd written on the death certificate. The consecutive days were no better. A cancer patient who looked like he could have been one of my uncles, bleeding out from a perforation in his gut. I had to step out of the IR suite and update his son and wife every five minutes. He's losing a lot of blood. His heart stopped; they're doing chest compressions on the table. We brought his heart back, but he won't be able to survive surgery. There's nothing we can do now. The following day, I picked up a new patient who'd deteriorated acutely on the floor. Before I'd even had a chance to see him, his heart rhythm went haywire before slipping to brady to asystole. My co-resident spared me from having to do a third death exam as I called the patient's brother to break the news.

I picked up another cancer patient upgraded from the floor overnight. Doctors are notorious for being poor prognosticators, but there's a certain sense you develop with time. This man didn't have much time left. I called his sister every hour to let her know how he was doing. He was about to be transferred to the comfort care suite when his heart stopped. I called the sister myself to tell her the news.

I'd just finished filling out the death certificate and headed back to the call room, when I saw that there was a new message from my mother to the family group text.


Perception - Explain to me what you understand of the current situation?

I was in seventh grade when my father found a Yahoo Classifieds ad for a litter of Maltese puppies. Matisse was the runt of a litter of three. After years of three-against-one needling about a puppy, my mother relented. The littlest member of the family arrived in December 2003 and promptly urinated on the kitchen linoleum.

The Little Prince, we called him. He would sit elegantly on the coffee table rug with his paws crossed, expecting to be hand-fed his meals. As the years went on, his fur grew thin and his teeth fell out, but he remained the same playful, cheeky scamp who greets anyone who walks through the front door.

I've always been aware of his mortality, that there will be a day when he won't be there to greet my return. But it was an inevitability that never truly felt that way until he suffered from a bad bout of coughing fits in 2015. I'd cried in the medical school bathroom, then washed my face and returned to studying for my board exams. My parents found a vet who prescribed him antibiotics, and his condition improved. It was around that time that we learned he had heart failure. I brought my stethoscope home once and listened to that erratic beating until I couldn't stand to listen any longer.

Invitation - How much do you wish to know about the current situation?

I called my mother. They were already at the vet emergency room, where they'd told my mother that his labs were consistent with kidney failure. They confirmed that his heart was bad. My doctor brain was already processing this information, when my mother began to cry.

"Is it time to let him go now?"

The Doctor Brain spoke methodically and rationally. He's probably suffering from an acute exacerbation of heart failure. He's likely dehydrated from vomiting for four days, which is why his kidneys are doing so badly. He just needs IV fluids. It's too early to talk about putting him down. Yes, he should stay in the hospital for a couple days. We have 90-year-olds who come in like this, they just need a couple days to fine-tune everything and then they're stable to go home.

As soon as I got off the phone, I crumpled into tears. One of my co-residents asked if everything was ok, but I didn't answer. It occurred to me that he probably thought I was crying about my patient. Maybe he was wondering why I cry so easily, as he'd just seen me cry the previous week after I pronounced the cancer patient's death. I never see my colleagues cry. As disconcerting as it can be, you get used to that glassy look in the deceased's unmoving eyes, the hollow absence of sound when you listen to their chest. The part that can tear you down is that raw upswell of grief from family or friends, and even then, you can always retreat to your call room and proceed to document your clinical note of what occurred.

Knowledge - This is what we know so far.

By chance, I had a week of vacation scheduled in the middle of September. I drove 5.5 hours straight without stopping and, after a brief greeting to my mother, headed promptly to the bathroom to relieve my bladder.

As I sat on the toilet, a familiar scritching came from the door.

That was my impression that first day home. Other than the fact that he was shockingly thin--he'd always had a lean physique due to his finicky appetite, but not to the extent that you could see the sharp jutting angles of his pelvic bone--Matisse was the same dog. Snubbing the prescription renal kibble, bird-watching from the rug, curled up in a ball in his bed under the kitchen table, wagging in greeting at each of my mother's art students and the parents that came to pick them up. I was lulled into that fragile bubble of security I'd seen my own patients' loved ones seek solace in one too many times.

Thursday night, I finally witnessed the infamous vomiting spell.

Hours later, I texted my brother: "If you're able to, I would try to come back and visit in October. If he makes it to December, then great. But money is money."

My brother booked a flight from Boston for the first week of October that night.

Emotions - I understand this may come as a shock to you. How are you feeling?

On Friday, I'd originally intended drive up to visit Graydyl after my haircut appointment, but after that awful night, I drove back home straight after. Matisse, too unsteady on his feet to go for his beloved walks, now looked forward to sitting outside in the sunlight in my parents' laps. I pulled out the faux grass rug he used to enjoy rolling around on and lay down, facing up into the cloudless sky. The baritone wind chime rustled in the breeze as my mother and I talked about everything and nothing. When her art students came that afternoon, my mother asked me to bring him upstairs to my room.

When I was in high school, he loved to lie on my bed and doze off while I worked on homework. If I left my desk for too long, he'd climb onto my chair and leave behind teeth-marks in the corners of my textbooks as evidence of his mischief. Those days ended when I went away to college. When I came back for winter vacation, I'd try to put him on my bed. He would jump right off and toddle over to my brother's room instead.

That afternoon, he didn't try to leave. He settled into his usual elegant sitting pose, and before long, he was curled up in deep slumber. I watched the rise and fall of his chest wall for a couple minutes before focusing back onto my research abstract.

These are the memories I want imprinted in my head. Not the whimpering as he shakes under our palms, the cry of agony as another bolus of white foam spills from his stained jaws, that stinging scent of stomach acid as our hands move to wipe the foam away.

Strategy/Summary - This is our plan moving forward; do you have further questions?

None of us know how much time he has left. Friday was a good day. By the time I reached my apartment on Saturday evening, another vomiting spell had returned. My parents had decided that they wouldn't take him back to the hospital again. Matisse was miserable in the hospital, away from his family and stuck in a kennel. He would rather be at home, even if it meant the inevitable would come quicker.

I called my mother on Sunday. They'd just come back inside after sitting outside in the garden. The stubborn little bugger had spit out his prescription kibble again. He would rather eat beef and chicken, even if it caused him to vomit.

"During the day, he's the same little master. He's still got that glimmer in his eyes," my mother said.

When my work schedule came out in May, I'd complained when I saw that my vacation weeks had been stacked so close together in September and October. It turned out to be for the best, as my next vacation two weeks away would overlap with my brother's return.

"Well, I hope he can hang on for a little longer," I said.

I heard my mom's voice break as we both began to cry. "We'll try our best."

White Night

First night of CCU overnight call.

It is my first time running a code.

The thing they teach you about CPR from the very beginning is that the patient--breathless, pulseless--is already dead before you begin. That nothing you do can make things worse.

It is a training-wheels kind of code. He has already gone through four codes in the span of six hours. My senior suggests I run the next one, because we already know at that point that he will likely not survive the night.

I call the two-minute pulse checks, hesitate on which orders to give... but in the end, it is medically futile to continue.

This is the second death exam I have to perform in my career. It struck me even that first time how vulnerable you are in the end. Naked, covered by a single gown or bedsheet, no jewelry, no material possessions, nothing.

But at least that first one had a family. I still remember his parents, his sister, the way his mother wept when they agreed to withdraw care. After the exam was complete, they entered the room, the curtains were drawn, and they were given the privacy of those final moments.

The thing that continues to gnaw at me is the loneliness of the man who has passed tonight. Previous notes document him stating that he has no social support, his family lives in another state, and he declined to provide any emergency contacts. There was one phone number listed in the chart. We called multiple times throughout the night, with no answer.

I think of my parents, my brother, my person, my friends from elementary school through residency. The man and I are separated by less than two decades. How do you get to the point where you have nobody?

I know the medical pieces to that story. Drug addiction, its wreckage on the body, untreated mental illness. I wonder if his parents are alive, or if he had a brother or sister. Perhaps they are sleeping in their beds at this hour, unaware that he has just passed.

Or perhaps, they didn't even know he had still been alive.

Quiescence

You say you're not the same person that you were ten years ago.

I won't dispute that statement.

The red blood cells in your vessels die every 120 days.
The lining of your gut regenerates every 5 days.
Skin cells rise to the sunlit surface every 39 days.

That face I look upon now did not exist a decade ago
Layers and layers sifting away like sand upon wind
Waxing and waning with each lunar phase
Moon after moon
Blood after blood
Life after life

But let me teach you a little something--

The neurons in your brain last for a lifetime.
Memories do not live or die,
but form in an ensemble of connected neurons
firing together at a sight, a sound, a scent;
And dissolve when the connection grows dormant.

When you were a newborn baby,
you were given a set number of heart muscle cells.
These do not divide
but simply increase in size
As your heart grows larger.

No, I have never seen you before.
But as long as you live, I lay buried within you.
Within this still-beating heart, you have the capacity to love.
Within these gyri, you have the capacity to remember.

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