Have you ever called one?

I’ve had patients that I was taking care of die before. You come in the next morning and someone says “Hey, did you know Mr. Johnson died last night?” I’d be a little sad, but it never got to me. When people asked me what it was like to work in a hospital and be around death, I thought it wasn’t so bad. I said that it’s just part of what we do. However, today was different.

I’m currently doing a month in the Pediatric Intensive Care Unit and a few days ago, a 5 month old girl was brought in who was found not breathing in her crib after having been left alone for 20 minutes. When I was doing the initial history and workup at 4 in the morning that day we knew things did not look good. She had been intubated, was getting air from a mechanical ventilator and the heart had been restarted and was now beating. Everything else was either gone or going. We did all of the usual things we do when we take care of sick kids and managed all of the lab values and respirator settings. At the same time, we got the social worker involved and the family asked about organ donation. After all of the chest xrays, EEG’s and echocardiograms, we still did not have any idea of what had happened. This morning during rounds we were discussing how organ procurement would work tomorrow or the next day. All of the donation papers were signed, but there were still flickers of activity on the brain metabolism studies, so we could not call official “brain death,” but we knew it was coming. Sure, she was costing money, but you can’t “unplug” someone with that kind of quantitative activity, so it was still going to be a few more hours or days.

This afternoon, while we were working on all of our usual duties, I noticed a flurry of activity down the hall and one of the residents came over and said “she’s dying.” When I got into the room, the attending was there and the monitors began to show flat lines, while the systolic and diastolic blood pressures started to go to the same value. The attending turned to me and asked “Have you ever called one?” I said I hadn’t. He then explained to me the official procedure. Listen at the four cardiac windows for one minute each. Listen to the lung fields. Feel for femoral and brachial artery pulses. Check the pupils for reactivity to light. When all of that is done, say the words. So, I did and then I said “Time of death, 3:03.” A couple of people holding papers wrote it down and the others started unhooking all of the equipment.

We were already going to have a meeting with the family in a nearby family meeting room, so we gathered these young parents there with a Spanish interpreter, an aunt, a brother, the organ donation lady who speaks Spanish, the attending, the resident I was working with to take care of her and myself. The attending was very empathetic and showed great care when explaining what had happened and how we respected their wishes to not go to heroic measures to resuscitate again. He reiterated that they are obviously caring parents who loved their daughter and that now she was in a better place. The interpreter translated all of this. The parents were shaking and barely keeping from completely breaking down. I couldn’t see mom’s head as it had been buried in her hands the whole time. Dad’s shuddering hand held hers and his other hand loving lay on her shoulder. He thanked the doctor and with a trembling lip, but steady voice, said that he knew we did our best and saw the care and attention we gave her every day and told us that he knew we never gave up or treated her any differently from the other kids with more hope for a future.

Then, the attending asked if they wanted to go and hold her or if any other family member wanted to go in and be with her. With the mother shaking her head, the father lifts his head and speaks in just a strong enough tone that it’s obvious he is doing everything in his power just to make words come out of his mouth. “No, we don’t want to remember her like this, with all the machines and tubes. Let’s remember her laughing and crawling and smiling and playing.” It was not a whisper; these weren’t words eeked out between sobs. He was a father, and he was bravely standing for something. That was when I lost it. I don’t cry too often, but I was bawling. Maybe it was because I speak Spanish and since the interpreter was not translating this, that it hit me harder. Everyone who spoke Spanish, the organ donor lady and all the family were all crying now. Like I said, usually I’m pretty stable at the hospital and I can remain cool even when it is a really stressful, sometimes disgusting situation, but this got me right to the core. Maybe it’s that I have a little one on the way. Maybe it’s that I took care of this girl from the moment she came to the hospital to the final point of calling it. Whatever it was, I now cannot say that I’m a hardened surgeon. And that’s a good thing. Innocence can’t be recovered, once lost, and no one should be in a hurry to go through that one-way door. I may have “called one,” but at least I know I can still call myself “whole.”