On Friday afternoon my 94 year old patient I’ll call “Betty” kissed me on the cheek as I said goodbye to her for the day. She winked at me as I left the room, her elvish eyebrows arching high on her wrinkled forehead. We had just finished a care conference in which she had elected to discontinue BiPAP and supplemental oxygen. This meant that in a few hours her oxygen saturation would begin to fall as carbon dioxide built up in her blood. When I quietly stepped into her room early the next morning she was already unconscious and unresponsive, facing the ceiling with her eyes closed and her mouth frozen open in a small “o”. After checking her pulse I slipped out of the room, only to immediately turn back around and sit on her bed for another minute or so to hold her hand. It’s cliche as hell, but I had to tell her how much she meant to me and let her know that she wasn’t alone. Her mind had already turned internally, but I needed that moment for me. Thirty minutes later I was sitting in the residents lounge writing up my notes for the morning, and I got a page telling me that Betty had died.
I had spent the past two weeks following Betty and getting to know her. From her admission, when I found her unconscious and struggling to breathe, my first real doctor moment as a med student, to checking in on her on the floor and eventually the ICU, where she would wake up with a smile that lit up the room. It was easy to love someone like her. I didn’t stand a chance in the face of her razor sharp mind, radiant smile, and squeaky voice that piped up from the bed to ask me how I was doing every morning before I got a chance to ask her how she was doing. What I didn’t anticipate however, was how difficult it would be to stay objective and medical with her at the end. As a medical student, my responsibilities consist mostly of knowing my patients, figuring out what’s going on, checking up on them, and offering suggestions or ideas. Being a part of a conference in which someone who is one 100% cogent and deciding whether or not she wants to continue a treatment that, if withdrawn, will ensure her death in the next day or so, isn’t something I’m used to. Struggling to keep back tears as I kissed her goodbye, I felt a faint whisper of the power and importance of this kind of decision making. Talking about death is possibly one of the most important human moments we can have, especially in an era in which we can prolong life longer than ever before.
No matter how advanced medical technology has evolved, we still don’t understand what it is to live and die. It’s the ultimate fear of the unknown, and this fear can easily tempt us into simplistic and reductionist thinking. What happens when we die, what does it mean to pass time on this earth, what’s important, do we have free will, can we really live in the moment, what does it mean to lose your mind, how much responsibility can we shoulder, how much responsibility can we assign to someone else? We reflexively pass judgements daily based on our own unconscious answers to these questions, often without stopping to reflect on them.
Two weeks ago I was on an early morning on-call team that rushed up to the ICU to admit a patient, an elderly native woman who presented to the hospital for septic shock due to suspected pneumonia. Her blood pressure was tanking, she had a fever, and she was drifting in and out of consciousness. Her chart indicated that she was an uncontrolled type II diabetic with a history of alcohol abuse who was living in an assisted care facility. Looking down at this sick woman who had sky high blood sugars and bacteria coursing through her veins, I couldn’t shake the feeling that she had been poisoned. She had been poisoned by a capitalist colonial system that eviscerated her culture, impoverished her, and then enticed her with liquor and cheap fake food. That’s how I saw it through my unexamined lens. Then as we were walking to round on our other patients, one of the residents coolly commented that I was just witness to what happens when people don’t give a shit about their health. That’s how he saw it through his unexamined lens.
These moments happen every day. Today a diabetic Somali man on dialysis who was taken off the renal transplant list because he ran off to Mcdonalds while NPO (nothing per oral) for a scheduled procedure, or last week a 60 year old anorexic smoker with a history of alcoholism who refused to have her labs drawn. Judgement is quick, easy, and laid down with force behind closed doors. And I get it, I get how frustrating it must be to devote your life to prolonging the lives of others only to watch in disbelief as they seemingly throw theirs away. The thing is though, we have no fucking idea. We have no idea what it is to walk in their shoes, to live in their skin, and to wake up every day in their sick and increasingly obese bodies. I think we’re frustrated in part because we’re frightened of our own mortality, and it’s easier to assign blame and get angry than face the reality that our control is a facade.
This past Memorial Day weekend was perfect, 60s-70s and not a cloud in the sky Saturday through Monday. I had just taken my boards on Friday, so Saturday morning I decided to go out for a run, and I just kept running. By the time I got home I had run 12 miles, probably around 4 miles longer than I had run in over a year. I felt fantastic and that night I slept on marshmallows. So Sunday I did it again, and like a drug seeker I wanted more. Sixteen miles later I stumbled onto my front porch, but this time it was all I could do to keep my eyes open for the rest of the day. The next morning I discovered a sore knee that ended up taking 8 weeks to right itself. In the intervening months, I’ve kept running hard, rolling cigarettes, drinking whiskey on my porch, staying up late, and waking up bleary eyed to spend 12 hour days at the hospital. Self-destructive behavior takes all shapes and sizes, but it paints different pictures on different bodies.
My sore knee, chronic exhaustion, and the scar on my leg from taking a motorcycle down to avoid being broadsided are all symptoms of my own discomfort with mortality, and my own ways of dealing with it. Hopefully however, reflecting on the reality of death and learning from people like Betty, will allow me to better empathize with the decisions of others. I’m also hoping, as icing on the cake, it will allow me to continue to wrest every moment from this beautiful existence without destroying myself in the process. That’s why I love Minnesota; this state forces us to be alive. Give me the bike rides to work in dress pants and no shirt because of the impossibly hot and humid summers. Give me the contemplative fall where air is crisp and the leaves paint the city and country both with brilliant hues, only to lose those hues to a gray and impending cold. And give me the cold north winter where the black night burns your lungs and deafens your ears with its silence.