Great article from the Atlantic this week, How Not to Die.

The line about, “‘Do you believe what we did to that patient?”, that gets said a lot.

Doctors know what happens in hospitals. Patients learn about what happens in hospitals by suffering through it. That’s why doctors and patients make such wildly different decisions for themselves for the get-go.

“What Doctors Want from End of Life Care” Jad & Sean discuss end of life care on The Brian Lehrer Show

Whenever I am consulted by doctors to come see their patient and make recommendations, I must write a History and Physical, or H&P. This has essential components, some of which are useful and some of which are generally glossed over. An example:

Chief Complaint: leg wound
History of Present Illness: Pt is an 83 year-old black man with a past medical history significant for diabetes, hypertension, gout, end stage renal disease, and polyneuropathy who has developed a slowly growing ulcer on his left lateral ankle for the past three months. He states that this started after he bumped into the corner of a doorway and has been getting worse over time. He has been seen in the diabetic foot clinic for the past three months and this ulcer has failed conservative management including regular debridements, daily dressing changes, and oral antibiotics (14-day course of Cipro).
Past Surgical History: multiple operations for bilateral arm arterio-venous fistulas for dialysis access, appendectomy, ex-lap with bowel resection for diverticulitis
Past Medical History: hypertension, diabetes mellitus type 2, gout, end-stage renal disease, diabetic polyneuropathy, glaucoma, bilateral carpal tunnel syndrome
Social History: lives with grandaughter. Married. Disabled. Scooter locomotion. Denies EtOH, Tobacco, Illicit drugs.
Review of symptoms: Pt endorses shortness of breath, intolerance to cold, pain in both hands, pain in both hips and ankles, decreased feeling in his legs. Pt denies fever, chills, headache, confusion, anxiety, depression, cough, angina, nausea, vomiting, diarrhea, constipation, rash.
Physical Exam:
Vitals: 97.9F 92 150/80 18 96%RA
General: NAD AxOx3
HEENT: edentulous, MMM, PERRL, SSTrachM
Chest: RRR S1S2 -MRG
Lungs: CTAB
Abd: S/NT/ND +BS, Obese, healed surgical scars
Ext: RUE with clotted AVF, LUE with AVG and palp thrill, BLE with 2+ pitting edema to knee, decreased sensation in stocking distribution to mid-calf, PT/DP signal on doppler, LLat malleolus with 2x2x1cm ulcer with exposed bone, soft on probing.
Labs: CBC nml. BMP nml except Cr 9.6
Imaging: 3-view L ankle with findings consistent with osteomyelitis of left lateral malleolus
Assessment & Plan: 83yoAAM with osteo of L lateral malleolus and non-healing ulcer in setting of DM, HTN, ESRD, MWF HD
- intravenous antibiotics and Infectious Disease service consult. Question of dosing in setting of dialysis.
- Ankle-Brachial Index of BLE
- Betadine-soaked gauze to wound with daily dressing changes
- will follow-up study results and discuss debridement versus amputation with patient.
- thank you for this consult

And that’s pretty much it. From putting down the phone to seeing the patient and signing the note, this can take as few as 20 minutes. And when you’re busy, it can’t take any longer. When my boss or other members of my team read this, it takes less than 3 minutes. Add another two minutes to look at the x-rays themselves, and then a consensus is reached. “Book him for a BKA on Tuesday. Get medical clearance from the primary team.”

BKA = Below the Knee Amputation of the leg.  BKA is a BFD.

That decision-making process and the insane speed of it should make you uncomfortable, but that’s surgical decision-making. The man has microvascular disease that will forever prevent him from healing appropriately. He’s already had an excellent shot at healing that foot and failed – trying again is just wasting time. And worse, as that infection spreads it could cause a blood infection and become a threat to his life. The foot is coming off one way or another. There’s really no point in dilly-dallying. And surgeons don’t.

But this man will have to live with one leg. Everything in his life will have to adjust around this, and there may be goals and dreams he had for himself that he gives up on because, in the dreams, he walks his granddaughter down the isle instead of drives her there. And understanding all of that comes from his social history.

The Social History is the most neglected part of the H&P. Most physicians in the hospital are so uninterested in this that a field of people exists to deal with it for them. These are the social workers. I remember working in the Children’s Hospital ED when a young mother brought in her son for a broken arm. The story of how it happened made sense. The kid was acting normally. The mother was obviously very upset and shaken. I asked them some questions, did my exam, wrote my note in 20 minutes. I went to speak with the ED physician caring for the kid.

“Can you get a Social Work consult for the kid in room 6?”
“Why?”
“Just want to make sure something funny isn’t going on.”
“I don’t think he needs it. Mom seems fine. Kid seems fine. Story fits.”
“Yeah, but her clothes are dirty.”
“Fine, I’ll order the consult.”

So the social worker came, spent an hour with the family, and found out that the Dad was out of the picture, that they had lost their home and were sleeping in the living room of a friend’s house, that he wasn’t making it to school as a result, that Mom was about to loose her job, and that Mom was afraid that her boyfriend was hitting her son.

I’m really glad the social worker came. The social information was the most important part of that entire kid’s life. It was the kid’s life. I’m happy to see him and set his arm, but the contribution of my cast is a bandaid on his bullet wound. But the way things are now workload-wise and time-wise, it’s no longer your doctor that gets the luxury of sussing this out with you and placing your problems in the context of your larger life.

But yesterday, I had that luxury.

I came into that 83-year-old gentlemen’s room. He was very fat – I’d say 280 lbs on a 5’10″ frame. He wore a maroon Champion sweatshirt under a black zip-up jacket. He had tan Dickie’s pants. I didn’t recognize his boots except to say that they had walked through everything at least once. He had a black cabbie’s hat and a pair of blue, ribbed cotton gloves on that had faded across the backs from the Sun. He breathed heavily and his voice had a wet sound to it. He had an old face but a young look about him, his eyes wide open expecting anything to happen. His lower jaw was smaller than I expected and I assumed he had lost his teeth some time ago. His legs were frog-splayed out in front of him, the way most people who have spent more than a month in the hospital have learned to place them. His blue scooter was parked in the corner of the room with the front basket filled with the essentials (coffee mug, kleenex, fishing magazine, coca-cola bottle, phone charger). He had a small, flip-open phone always in his right hand.

This is my routine: I ask if I have the correct room and if this is Mr. Suchnsuch. I tell him my name and that I’m with the Surgery team. I ask if he knows why his doctors asked me to come by. I ask him to tell me what he knows about what’s going on. And then I ask the questions to fill out my H&P. This time, I didn’t do my 20-minute drill. And I’m glad.

Tell me about yourself.
Oh, I’m all right.

Where’d you grow up?
I was was born and raised in Mississippi, in a town 30 miles out of Jacksonville. You heard of Jacksonville? I grew up in a house, just me, my mom and sister. My Daddy was no good. It was a three room house. My mom had a lamp which she would use to chase the bugs and cats out at night. Cats would still come in though because you had to leave things a little open for air. We didn’t have any fans. Sometimes I’d sleep outside on the porch to try an’ keep cool. But I never turned to stealing or anything. I always worked. My Dad was no good and my mom didn’t have anyone to help support her, so I had to work real young to help ends meet. I had a job that paid $5 a day. Not $5 an hour. No! Five. Dollars. A. Day. And it was a good job to have then. I had to walk three miles to work and I only had me one pair of shoes. When I got holes, I’d have to get some banana leaves and let ‘em dry first. Then I’d put them leaves in my shoes and that’d last the day. People don’t know how to work anymore. They just do drugs and cry about it.

You keep touching your hernia. How long have you had that?
Oh I have a couple of kids but they’re no good. My one son that did work worked himself to death in Kentucky. He had a hernia down in his belt. I kept asking him “when you gonna fix that?”. “Aw, my bills back up. My bills back up.” So he never got it fixed. One day it got bad and he was vomiting his food and stool out his mouth. He died after six, seven hours. So I thought about getting this here fixed but my doctor told me that if it isn’t bothering me, then I could just leave it alone. It hasn’t been bothering me for 30 years, since before you were born probably!

Who do you live with now?
My grandaughter. Her mother, she’s no good. Child was born with sores from her knees to her hips. So we took her in an’ raised her. She’s going to beauty school!

You and your wife?
Yeah. She had a stroke. She’s in a nursing home now. She’s doing better than me! She has good days and bad, her mind comes and goes. But we been married 53 years! You can’t say that, can you! I don’t know where we’re going to live. Nursing home is $780 a month. We got a house in The Pines but we can’t live in it.

Why Not?
Why not? It’s one o’clock in the afternoon is why not! You try walk to my house right now, well, you’ll get robbed! I got robbed there in front of my house. Took my truck and my bills. Hate to say it, but I think it was my son that told them when I was going out to be there. But drugs got him. Drugs ruin everybody. So I don’t have nothing to say so to my kids now. All of them, crime and drugs. I never did no drugs and I never went to jail.

In the chart:
“Social Hx: lives with grandaughter. Married. Disabled. Scooter locomotion. Denies EtOH, Tobacco, Illicit drugs”

Doctors can be really funny, especially when they slip something into an otherwise serious affair. I laughed out loud when I came across the following:

Bouwman DL, Morrison S, Lucas CE, Ledgerwood AM. Early sympathetic blockade for frostbite–is it of value? J Trauma. 1980 Sep;20(9):744-9.

Under Results….

“Despite intensive efforts at rehabilitation for alcohol abuse, repeat cold exposure occurred in the winter of 1977-1978 after the patient imbibed the same brand of whiskey, in the same neighborhood, while wearing the same pair of shoes.”

Awesome.

There will forever be experiences beyond the edge of the map of what you know. For most people, a lot of that content goes unexplored. For doctors, there is no telling when a yeti will come down from some dark mountain or the kraken from an unexplored sea, and drag us into the darkness.

“What are you saying, doc? Is it cancer? I don’t want cancer. I was gonna buy a house!”

This is one of the monsters I knew about before I started exploring the edges of my map, the ones that kept me up at night, made my palms sweat. I knew there were more out there, scenarios I had not imagined, could not dream of. But these were the ones that were in my mind. How do you tell someone they have cancer? What do you do with someone in a death panic?

You will come to these places in your life, I am certain of it. And I don’t know what you will do when you get there, but I think you might find out what I found out. What I still find out, each time.

It’s not the end of you. It’s not the terrible, earth-shattering horror you thought it would be. You will come through it, and you will have to figure out what it means for your life, and who you are going to be on the other side.

That fellow with the cancer? He was panicking and clawing at me to save him. He came to the office bright and excited to tell me how he had lost the weight we were working on. How he had got a rowing machine and was thinking of buying a house. Death was not on his mind that day. And I did my best to cobble a shield for him, to soften the blow of what we were not sure about but both suspected. I couldn’t tell you what I said, not exactly, and to be honest I was clawing for something myself.

After he failed the chemo, after months in the hospital, after going to hospice to die and losing ground from the wheelchair to bed, after getting back in the wheelchair and then starting to walk again, after being sent home from hospice because he was “too healthy,” after all of that and the thousands of moments that I cannot imagine, he came back to my clinic, smiling. He told me what I said to him that day.

“Doc, you said, ‘none of us knows what will happen from here. I am healthy now, but I could get hit by a bus on my way home from the clinic. There’s no use in being afraid of what might happen. We will have to see what will happen.’ And doc? A lot of people have died that wasn’t supposed to since I was diagnosed with cancer, and I’m still here, enjoying every day I get. So that’s what I’m gonna keep on doing.”

I can’t tell you what’s past the edge of the map, and I won’t tell you not to be afraid of it. But when it drags you out into the darkness, remember this: If this thing cannot be avoided, then do your best to face it bravely.

The intern does not know that he is a doctor.

This is not unfair to say of interns. I was an intern last year. I remember it well.

During that year, I remember assuming that things were being done that I did not personally verify. I remember looking forward to 6pm because that meant I was signing out to the night-float person and going home. And I remember not thinking about the patients on the floor when I was going to bed.

If you’re not in medicine, none of that should sound crazy. When I was waiting tables, tossing pizzas, checking coats at a fancy soireé, or recording vital signs, I never worried that other people were doing their jobs. “If they don’t do their jobs, they’ll get fired. No one is that stupid, therefore, it must have been done.” I certainly wasn’t thinking about tips and pizzas and urine outputs when I was falling asleep.

But if you are in medicine, that is crazy.

As an intern joining a residency and department and hospital, you can’t escape the feeling that you’re surrounded by dinosaurs who can’t shut up about the way things used to be and how no one takes responsibility anymore. This is evidenced by the 80-hour work-week and residents trying to have lives outside of the hospital, they say. And, appropriately, you view these people with extreme prejudice. They are dinosaurs. Just because they worked 100+ hours during their education doesn’t mean that (a) people that don’t do that are shitty doctors, (b) that you couldn’t have been effectively educated with fewer hours, or (c) that working people that hard was even good for the patients!

Armed with these insights, it’s easy to brush off what the Old Guard says about the hopelessness that is your education and future. But that doesn’t explain everything. It doesn’t explain why people only a year or two ahead of you in residency seem to think the same thing.

I remember the way my senior residents saw my actions during my intern year. The night-float person would be running late and I would start to get pissed off. An entire day of taking care of people and loving my job would be ruined by my anger at this person for not being on time so that I could go home. My senior would see me and ask, “What difference does it make if you’re here another hour?”

Are you serious! How does that question even make sense?! I would think but not say these things. But my seniors would see it in me, and they would make some uncomfortable facial expression and then go back to taking care of people. You notice, as an intern, that the seniors always seem to be at the hospital. As an intern, you just don’t get it.

But I now have the benefit of an intern year. And the thing that isn’t emphasized enough (or I didn’t hear when it was said) is that you really have to see things. Reading about peritonitis and guarding is tits-on-a-bull useless if you haven’t seen it enough times to recognize when someone has it and when they don’t. If you haven’t had the experience of treating a patient on your service for a week, doing everything you can to get them perfectly prepared for their surgery only to have it cancelled in the morning because someone didn’t notice their desaturations overnight, then you don’t understand. If you haven’t had a patient in the ICU start to code the second you turned your back on them, then you don’t understand. You need time to see these things, and the only way you get that time is if you spend that time.

And that’s the thing. You have to spend a year fucking it up. You have to see how close everyone can come to getting really sick. You have to live in fear of all the people who are doing their job just well enough so that they don’t get fired, because the worse case scenario is not that they get fired but that your patient dies.

And once you realize that – once you decide that it’s your responsibility that your patients are never left to the mercy of the weakest link in the chain, that you need to constantly double and triple check every order, that you need to be in the room with the patient to see why they aren’t eating, to see how they’re hunched over when they’re walking, to see how their pain is controlled – that’s when your dreams start to change. That’s when you start carrying your patients with you. That’s when leaving the hospital stops sounding like a reward and starts to feel like a gamble.

That’s when you start to become a doctor.

God bless Dr. Cox and his rants.

What do you want me to say? That you’re great? That you’re raising the bar for interns everywhere?

I’d be cool with that.

I’m not going to say that. You’re okay. You might be better than that someday. But right now, all I see is a guy who’s so worried about what everybody else thinks of him that he has no belief in himself. I mean, did you even wonder why I told you to do your own evaluation?

I can’t think of a safe answer. I just figured that…

CLAM UP! I wanted you to think about yourself! And I mean really think! What are you good at? What do you suck at? And then I want you to put it down on paper. And not so I could see it and not so anybody else could see it but so that YOU could see it! Because ultimately you don’t have to answer to me, you don’t have to answer to Kelso, you don’t even have to answer to your patients for god’s sake. You only have to answer to one guy, newbie, and that’s you. There. You are evaluated.

***

I don’t know why I’m so quick to forget this lesson. I have to evaluate medical students who rotate on the surgical services. Towards the end, they come up with their form and ask me if I’ll write something in their file. Usually, I do. I take their form, I write something half-assed and generic like “punctual, good fund of knowledge”, and call it a day. Looking back, only now do I realize how truly damning faint praise can be.

Maybe I should handle it differently. When someone asks me to evaluate them, maybe I should just look at them and ask, “When was the last time that you felt you did something extraordinary on this service? What have you done this whole month that went above and beyond the bare minimum of our expectations?”

I’m sure their answer would be the distant noise of field crickets.

And what about me? I’ve saved the worse for myself. White Turk, what is your self-evaluation after almost a full year as an intern?

1. I’m insolent. I regularly question all authority regardless of setting. I argue with my chiefs regarding appropriate management of the floor patients. I am a headache for my superiors.

2. I am not nearly as smart as I think I am or as good a doctor. A smart, good doctor would read more. A smart, good doctor would be embarrassed to not know everything about his patients.

3. I am too cocksure. I convince myself quickly that I know what a patient’s current problem is and then I stop thinking of things outside of that diagnosis. Because of that, I do not have the appropriate amount of fear that I am missing things, that something could go wrong, that someone could be hurt. This makes me dangerous to my patients.

There. Now it’s written down. So that I can see it.

I remember people trying to prepare me for this. “Come July 1st, you’re going to be the doctor. People are going to ask you what to do and you’re going to have to have an answer. It’s your decision now, doctor.”

Catch anyone in a moment of honesty and they’ll admit their terror at that expectation.

But the start of your year isn’t so bad, really. You’re a member of a team. The team is filled with smart people wearing coats with the longest of tails. Generally, your job is to accurately report what you find, let them decide what to do, and then you execute it. You’re the eyes and the arms, but not the brains. There is a wonderful comfort in that.

But when everyone is in the operating room and you’re the only one left on the hospital floors taking care of things, the comfort is gone. The pager goes off. You recognize the number for the ER immediately. You dial it and on the other line is someone saying, “Is this surgery? I have a patient down here that looks pretty bad.”

Shit. “Okay, tell me about them.” And now a human being with a possible surgical problem (what does that even mean? you could need surgery anywhere on your body for any number of reasons and how the hell am I supposed to know?) is being described in bullet points over the phone. You’re supposed to be writing this down. You’re supposed to already know everything this could be and all the tests you would need to tell ovarian torsion from appendicitis from ectopic pregnancy.

You’re the surgeon and you’re supposed to know.

So you go the ER. You look at their blood work and you look at their Xrays and CT scans. You see the patient. You ask them what happened. You put your hands on them. And they’re not dying. They have belly pain. It’s chronic. They’ve never had surgery before. They don’t have a fever. They do have an abdomen filled with stool, though, and they tell you that their last bowel movement was two weeks ago.

This person has constipation.

You walk out of the room and the ER resident comes to meet you, hoping you validate their impression that this is surgical and that calling you was the right thing. “So, what do you think?”, they ask.

“Tell me, when was her last bowel movement?”

“Uh, I don’t know.”
“I know that you don’t know. If you had asked, or if you had looked at the CT scan you ordered, you would know that this women hasn’t shat in two weeks and is filled with stool! You called me for constipation! I spent 30 minutes coming down here to do your job for you. Tell me, what’s the surgery you want me to do for constipation.” And then you stand there and stare at them. You stare until they apologize and slink back and tell their attending that’s the patient has constipation.

And for, like, a moment you feel good about how you’re so awesomely smart and they’re so epically dumb. You tell your coworkers about how you got called about this totally stupid consult and how you really let the ED have it and so on. You are elated that you actually knew something. You, the person terrified a moment ago that you would have no idea how to manage this mystery problem, not only knew what the problem was but knew whether or not it needed surgery! And you also slowly realize that what you learned as a focused fourth year medical student in your surgery rotations already puts you ahead of most first and second year residents in other specialties when it comes to surgical problems. You thought you were dumb! You’re not dumb – you’re smart!

It’s only later, when you get over yourself, that you realize two things. The first is that someone didn’t know something, asked for help, and was rewarded with ridicule by you. That person isn’t any smarter now than they were before. That person only learned that they hate you. And now, if in the future they are treating someone who actually needs a surgeon, they may hesitate longer then they should to give you a call and the patient might be poorer for it.

The second thing you realize is that you are a moron. You’ve forgotten about psychiatric medications, about the up-to-date management of diabetes, about current trends in managing cystic fibrosis. And when you operate on someone with appendicitis and they have a host of other medical problems with which you’re unfamiliar, you’re going to page the doctors that specialize in those problems. And when that someone calls you back on the phone, asks you about your patient, comes to see them, and then politely points out the obvious thing you should be doing but have (assuming out of ignorance) missed, you’ll realize that you’ve just been taught something valuable.

From the intern.

Resitern is a tough gig when one of the patients is crumping at the time you are pre-rounding. You show up at 7:00 and sit down to gather your data. Look for overnight event notes, check the vitals, look for the labs. And just as you’re settling in, the intern you’re not covering for informs you that one of his patients may be circling the big drain.

“He’s up to 5L O2 and his sats still suck, can you come look at him?”

And so you hope the patients you were getting ready to see aren’t any sicker than he is (they all have cancer PLUS some horrible complication that landed them in the hospital, so this is a definite possibility) and you head over to see why this dude is in a hurry to do the mortal coil shuffle.

You walk in the door, and he looks great (WTF?). I mean, he still has cancer that is eating him up from the inside, and his ins/outs show he’s up 20L for the admission, but he isn’t trying to swallow a boulder right in front of you. He’s just taking a lot more breaths than you’d want him to. Through his mouth. Which incidentally is not where the nasal cannula which is pumping 5L of oxygen per minute is tucked.

This is a teachable moment, so you sprinkle a healthy dose of what is now obvious on him while trying not to sound like a dick. “You can crank that thing up all the way, but it isn’t gonna do a bit of good up the nose he isn’t breathing through.”

“Only one of my nostrils works.”

He heard you. He answered appropriately. He’s not dying. Not right this second, anyway. Maybe tomorrow. Maybe Wednesday.

“Sir, we think you have some fluid on you, and we think it’s making it hard on your breathing. I’d like to put a mask on you to help your breathing, if that’s okay, since your nose doesn’t work.”

“Shit, that’s fine.”

“Wonderful, we’ll have a nurse do that. And then we want to give you some medicine to get you peeing, get some of this water off of you. Are you having a hard time getting up to go to the bathroom with your breathing the way it is?”

“Oh hell yes, I’m a mess.”

“Alright, well, maybe we can put a tube in so you don’t have to get up. Just for a day or two, nothing too big.”

The nurse is there, setting up the facemask you asked her for. So she definitely hears him when he grabs your hand, pulls you in and asks

“Can they do it with a two-incher? Can they get that tube in?”

The nurse, she pretends to fumble with the plastic packaging holding the mask and the tubing as she is caught by a convulsion of laughter.

“Oh, yes. They are very good, they are professionals. They can take care of it with no problem.”

He grabs your hand again, pulls you in a bit again.

“The last time I needed one of those things, it took two of them 40 minutes to get it in. I asked them, ‘was it good for you?’ They told me, ‘well, you don’t get to go for a cigarette, but we can.’”

And now you’re more short of breath than he is, but you know he’s not dying and you still have 8 patients to read about and see and about 20 minutes to do it. And for the first time today you think about how much you love this fucking job.

My neurosurgery rotation is over. It was the most emotionally draining experience of the year and some of the hardest hours to work. I am glad that it is over. I will also miss it.

I will miss Todd, a gentleman with a pituitary tumor pressing on his optic chiasm which has made him blind in all but half of one eye. I will miss Todd because Todd brought a chess set to the hospital and had it set up, daring someone to play him. On one particularly frantic day, I took the time to sit with this nice, three-fourths blind man with no depth perception, and SMOKE HIS ASS over 64 squares. Don’t you EVEN play Queen’s Gambit Declined against me, aight?

On Neurosurgery, I did my first lumbar puncture. It’s a procedure where I have a patient lie down on their side and then stick a needle into their spinal cord to collect some fluid for analysis or something. Depending on how sick the patient is, this fluid comes out under varying amounts of pressure. For my first time, I asked my chief to be in the room to make sure I did everything correctly. Our patient was in a coma, so I was able to talk through the procedure the entire time without alarming anyone to my newbiness. And I was lucky, because I got the fluid on my first try and didn’t have to hurt the patient too much.

“White Turk, what’s the opening pressure?” My chief has pen to paper waiting for my answer. I attach the column to the tube and watch as the spinal fluid slowly climbs past each number.

“It’s eleven.” And then I have my greatest idea ever. “Hey Chief?”

“What.”

“Is this spinal tap?”

“What are you talking about?”

“Just tell me, is this spinal tap?”

“I don’t know what you’re doing. What are you doing? What are you talking about?”

“Chief, just tell me, ‘Yes, This Is Spinal Tap.’ Just say it.”

“Grow up.”

“Dammit.” So close!

Neurosurgery, you weren’t all bad.

To look at her and guess, she’s in her eighties. I see her several times a day because her husband is in the ICU bed right next to the resident call room. If she was anywhere else, I wouldn’t see her so often, wouldn’t think about her so often, and would pretend she doesn’t exist.

But she does. And she is so alone. And I can’t.

Her husband is in that room. His body has failed him many times before and he has survived the surgeries to repair it. He has lived the last ten years on the borrowed time provided by synthetic patches and bovine valves and modern medicine. And blood thinners.

Finally, as had to happen, he fell at home. His body too slow to react and catch, his head too heavy to protect, his veins too fragile to hold, his blood too thin to clot, his skull filled with blood. His brain had nowhere to escape the pressure of the bleed. And as his wife rode with him in the ambulance, she kissed his forehead, told him that she loved him, and his last words were “I love you too.”

And because he had cheated it so many times before, he went to surgery a last time. “Surgery” is such a nice and tidy word that holds the place for actions that can be beautiful and lifesaving and barbaric and futile. In his case, the hair of his head was shaved off in awkward clumps, he was scalped, a hole the size of your open hand was made in his skull, and what blood they could find was vacuumed out before the pieces were reassembled. He was thoroughly monitored throughout the procedure. Catheters in his arteries monitored his blood pressure. A tube in his throat connected to electrical bellows kept him breathing. Large tubes leading to his heart gave him drugs and fluid to support his circulation. A tube in his bladder allowed him to urinate. A gown covered his body to keep him warm. His blood was drawn multiple times to detect the smallest changes in his condition.

It’s been days since the operation and there is nothing we can do to demonstrate that he’s still in there to hear us, to feel pain, or to hold together the memories that made him their father and her husband. You can say that he is alive, but it’s hard to mean it.

Her children can come to her and say that he’s lived a good life and that it’s time to let him go, but it’s hard to let him. It’s even harder when her grown children become angry and frustrated with how stubbornly their parents are both hanging on, how they just can’t accept the inevitable.

And so there she is, sitting next to his bed, resting her head on her forearm on his bedrail, waiting for him to open his eyes just once more so she can tell him all the things she hasn’t yet and ask him all things that, after 65 years, she still doesn’t know about him.

And she’s alone. I haven’t spoken to her yet because I am ashamed and afraid. I have never talked someone through another’s death and I can’t stop imaging all the questions she will ask me that I cannot answer. I don’t know how often people pull through. I don’t know if he can hear us. I don’t know. The people that do know, the people better trained and more experienced aren’t here – they’re in the OR trying to prevent this from happening again.

It’s either I talk to her or no one talks to her. And I have to decide if I’m really better than nothing.