Thursday, October 16, 2008

Titrate until comfortable

Autumn has arrived.

The leaves are falling like colorful snowflakes. The sweet, sharp smell of autumn's decay reminds me death is inevitable, an unpleasant thought in the spring--makes sense in October. An occasional large raindrop splattered the ground.

I walked past the Park Manor Nursing Home as I do every day--large windows frame the elderly bathed in fluorescent lights, gazing out at the fall blizzard of leaves. I imagine the smell of isopropyl alcohol, of antibiotics, of death delayed too long. I am glad to be outside.

I have seen a lot of people die, even helped a few along the way. A good death in a hospital is rare.

Somehow I want my students to know this.

The doses of morphine were now high enough that the nurse assigned to the dying young man in the adolescent ward would no longer administer it. Titrate until comfortable was the order. I titrated.

His mother was at his side. His lungs were now near useless from cells that no longer recognized boundaries.

He stopped breathing. I went in to pronounce him. Until I pronounced him, the state of New Jersey would continue to recognize him as alive. I put my stethoscope to his chest.

The state of New Jersey was not alone. His mother quietly, adamantly told me he was still alive.

It was almost dawn. It had been a long night. I hope my face did not betray my frustration, but I kept silent.

A moment later, the dead boy's chest heaved in a last agonal gasp, a deep groan shuddering his body, his bed, my soul.

"Now he is gone," she said gently. "Now you can listen."

She was kind when I had forgotten what kindness meant.

I want my students to know this.

I no longer practice medicine. I teach. I probably have seen more people die than anyone else in Bloomfield High.

I had a man bleed to death under my hands, his heart ripped apart by bullets. We pumped on his chest to keep the gathering crowd satisfied. He died anyway.

I gave mouth to mouth to a baby whose parents begged me to keep her alive until someone figured out what obscure metabolic disease wracked her body. We got her back. 12 hours later, her specialists confirmed they had enough tissue to make a diagnosis. We let her go, 12 hours too long.

Lester's valve gave way from rheumatic fever. 6:30 AM, just before shift change. Some of us cussed at his timing. Lester was 6 years old.

Dying is not easy. Dying is not comprehensible. Dying is what we all are going to do. We do not do death well in this culture.

I want my students to know this.

I teach biology. We call it the study of life. In our culture, we tend to think of life as discrete packets called "organisms", which go about their business until they die, when other organisms make sure that the parts of the dead organism get back into the game.

We don't actually talk about life. If we did, we'd be (justly) accused of talking about religion.

My mom died at home. I titrated her until she was comfortable.

On the weekend she died, her oncologist was away. I needed to boost her morphine. The covering doc resisted my frantic efforts to increase her dose.

I am a retired doc. I know how to hurt other docs. Appealing to a doc's sense of humanity might work, but threatening his time works even better.

"Tell me the code to the morphine pump, or I am going to call you every half hour until she dies."

He told me the code, and my mother died two days later.

She laughed the day before she died. I want to laugh the day before I die. I want each of my students to laugh hours before they die.

As I walked home today, thinking about autumn and death, I knew apples would be waiting for me.

As I walked up my porch, I smelled them before I saw them. A crate of apples from the orchard that holds my sister's remains sat on the porch. The apples will taste wonderful, as they always do.

Teaching biology to students who live on concrete can be maddening. Food today is an abstract concept. Death is something that happens in hospitals, that happens in processing plants. What matters is presented as some reward in the future for their hard work.

I rarely assign homework over the weekend, but I might assign it tomorrow.

Get an apple. Go outside. Sit down. Close your eyes. Listen. Sniff.

Then take a bit of the apple.


Louise Maine said...

Do your students love your stories. Mine love the ones I tell. I can be brought to tears if I let it.

I was not a doctor but was a paramedic while pre-med/bio in college. Not the same I know but plenty of stories still. To wait until the last agonal breath though the monitor is asystole. I hated nursing homes. I especially hated that there my grandfather would not remember me no matter how often I visited and it was maddening to watch him deteriorate.

We just walked our 4 dogs down my in-laws lane caught between the soybeans and the corn drying on their stalks waiting to be harvested. I love the smell of Fall even more than Spring. Nature celebrates in this season and yet we who have lost this lesson, see our Fall so differently.

Clay Burell said...

One of my best reads in quite a while. And we really don't do well with death in this culture.

doyle said...


I think they like stories--I hope so, anyway.

Tomorrow I am getting some clams for eating and for bait. Clams are alive. They're not so alive when I'm done.

Not sure how to make this all fit--last week I ate a clam about (or perhaps older than) my age. Tomorrow I am taking my 9 year old nephew fishing, and if we get a croaker or two, we are eating them.

And I'm equivocal about all this.

I asked each of my children to slaughter a fish they each caught.

They did. They know where food comes from. And they each still fish.


There you have it. I praise/blame you for an erstwhile doc revealing what all docs know, few docs talk about.

And we don't do death well in this culture. I suspect it's because we don't do life well, either.

Always good to see your words here.