Death has always had a special horror for me. I know I’m not alone in that feeling. I realize that we’ve all been “dead” for the eternity before we were born – and will resume that state after our relatively short lives are over. But knowing that fact doesn’t allay the innate horror that wells up from deep within our brain when we see death firsthand, since we identify with another’s death which mirrors our own that will occur at an unknown but too-sort time in the future.

There’s nothing we can do about death, except stave it off. I guess that’s one reason I entered medicine – to fight the good fight that we all wage against the grim reaper. Non-physicians try to elude the reaper. As a physician I could fight it. A noble endeavor, perhaps.

So a physician’s first encounter with a patient’s death is similar to a GI’s first contact with the enemy, a horribly strong foe that will kill us all eventually. It humbles us and impresses us and first impressions are lasting. The death encounter lives on in each physician’s active memory.

My first encounter with death occurred in Glasgow, Scotland in 1970. I had started my first clinical rotation as a medical student at the Royal Infirmary. I’d been assigned to the cardiology ward, which was a huge open room with tall ceilings and natural light. Our patients’ beds were lined up against the walls and there was no privacy, except for transluscent curtains that the nurses could draw around a bed for privacy. The patients, mostly older gentlemen, seemed quite accustomed to this open ward situation and were very considerate of each other’s peace and quiet. After the nurses administered the bedtime medications, each patient turned out his light and was still.

I was assigned to do an intake history and physical exam for a distinguished-looking 80-year-old Scottish man. He’d had a sudden crushing chest pressure that felt “like there’s this elephant that’s come sit on my chest.” We partially relieved his pain with nitroglycerine and morphine. But it was clear that he’d suffered a massive myocardial infarction (heart attack) and was having serious cardiac rhythm problems and congestive heart failure. He was dyspneic (short of breath) when lying down, his lungs filling with fluid. So we propped him up and gave him oxygen, lidocaine, digoxin, and diuretics. This relieved his dyspnea such that he could speak. Through all this, he remained an incredibly good sport. He maintained a twinkle in his eye and, perhaps because of the narcotics, he proceeded to regale his American medical student with stories of is life. He told me about his his clan – his wonderful wife (who had died a year earlier), their children, and grandchildren.

The next morning, after our ward rounds, I met some of his extended clan who’d gathered around his bed to wish him a speedy recovery. Later that night I made evening rounds on that ward. It was entirely dark now, except for a curtain that had been drawn around my patient’s bed and lit from within by his wall light. The ward was completely still, except for a nurse who was softly singing a Scottish melody behind his curtain. Thinking this a bit odd, I peeked inside the curtain. My patient was dead!! And his nurse was cleaning his body. I was horrified, since I’d just spoken to him earlier that day and he had been so alive. I was shocked and angry. Death had won. And I immediately thought to myself: “Why is this nurse singing? Doesn’t she have respect for the dead?” That thought vanished when she felt my presence and turned to me, smiled sweetly and whispered in her thick Scottish brogue “He had a fine life, didn’t he now.” All I could do was nod my head in agreement. I just listened as she continued her song. I think it was a lullaby.

She looked like a little kid. She was black and very, very young. I recall that she was 14 years old. She was equally very, very pregnant. And she was my very first delivery on the Obstetrics ward. As a 4th-year medical student, I had observed and participated in several vaginal deliveries and Caesarean sections. But she was to be my patient. She was assigned to me. I was to deliver her baby, with an attending or chief resident assisting. I was responsible for her.

The reason I had so much responsibility? This was a public charity hospital and she was as poor as she was young. My being assigned to her was an example of our tiered medical system. She was on the lowest tier – and she got me. I was her short straw. But I wasn’t really looking at the bigger medical-social issues. In fact, I welcomed the experience. And she was to be my only patient...for 36 straight hours.

So we came to know each other pretty well, between contractions, which had begun earlier that day. Her contractions were not Braxton-Hicks this time. She was in active labor when her Mom brought her to the hospital that day. But her Mom could only stay a few hours and had to go home to rest before going to work the next morning. Her Mom was the sole support for the family and feared being fired if she missed work to attend her granddaughter’s birth. That was really sad. So my young lady had no moral support. No family or friends were there with her. And I never met her boyfriend. So by midnight it was just her and me... and her baby trying to be born.

Her contractions became more severe and closer together. I was surprised by how she endured the agony of the contractions in silence. No screaming, like the adult women elsewhere in the delivery ward. She intermittently gritted her teeth and grimaced. I got a washcloth and repeatedly wiped the sweat from her brow. Otherwise, I was not helpful at all.

After many hours of active labor, it became clear that her delivery was not going to be easy. She was too young. Perhaps her pelvis was too narrow for her baby’s head: cephalo-pelvic disproportion. This was years ago and we practiced primitive medicine by today’s standards. We had no ultrasound, just x-rays. So the Obstetric Resident assigned me to bring her to x-ray. I wheeled her on a gurney down the hallway and into another area of the hospital, up a steep ramp, into an elevator, and over to radiology.

We measured the baby’s head and her pelvis. We applied a formula and she did not automatically qualify for a Caesarean section. But, in retrospect, that would have been easier. That night was hell. Her baby’s head had become wedged in her pelvis and was progressing slowly down the birth canal. I made other trips to x-ray with her, wheeling her through the silent dark hallways in pain.

Her baby finally made it. He cried right away and seemed ok. But he was covered with blood and slime and his head had been molded by the tough delivery. He was not a Gerber baby. I clamped and cut the umbilical cord and waited for the placenta to be delivered. Meanwhile, a maternity nurse whisked him away to cleanse and warm him in a baby blanket. The nurse brought him back looking less disgusting and pretty cute. But his mom was virtually unconscious from exhaustion. So I held her baby for a while, admiring his perfect little hands. It was morning now and his mom woke up and I handed him to her, wished her good luck, and left.

I've always thought that I’d be cool in an unexpected emergency, but one never knows. Perhaps the only way to deal with the unexpected is to expect it.

It happened a long time. I was a medical intern at Denver General Hospital's Emergency Room. It was about 2 AM. A middle-aged (young, in retrospect) man arrived in a screaming ambulance with a classic myocardial infarction (heart attack), his first. He was wheeled in, gripping his chest in pain. We provided relief with morphine and a sublingual nitro and he appeared stable, with a nice regular sinus heart rhythm on the electrocardiogram. We supplied extra oxygen to him via a nasal cannula. Those were the days before emergency coronary angioplasty, so this was about all we could do for him. The ER team assigned me to accompany him up to the 9th floor Coronary Care Unit (CCU). It was ”scut work” (boring errand without responsibility) that interns become used to doing.

We transferred our patient to a wheeled gurney for his little ride upstairs. A nurse hooked his cardiac leads to a portable monitor that I’d placed on the gurney beside him. I chatted with our patient, a really nice guy and a robust fellow who seemed quite blasé about the situation. I’m a little ashamed to say that I can’t remember his name. But I do remember that he had a family and worked construction. He asked me if I thought he’d be able to work the next day.

I wheeled our patient over to a service elevator with the help of a young nurse - a petite, newly-minted RN. She pressed the button for the 9th floor, the location of CCU. As the elevator doors shut, the three of us were alone together. It happened immediately. The portable monitor began whining and showed a flat line. I checked whether the cardiac monitor's leads were plugged in. They were. Meanwhile, our patient seemed to have fallen asleep. I yelled “Heh” directly in his ear and pinched him. No response. I felt for his carotid pulse.

No pulse. “OH SHIT!!!” I thought and yelled at the same time. We had no defibrillator with us. So, I started pounding on his sternum as the elevator stopped and the doors opened on the third floor, revealing a housekeeper with her mop and bucket, who just stared at us: a wildly frantic nurse and doctor pounding on this poor fellow on a gurney. The doors closed and the elevator proceeded upward, all seemingly in slow motion. I was giving his chest ineffective chest compressions from beside the gurney with its siderails up. The nurse couldn’t feel any pulse, so I jumped on top of him and repeatedly compressed his chest while sitting astride him. The elevator stopped again. Nobody was there. The elevator then proceeded upward, seemingly in slow motion. The door finally opened on the 9th floor. The young nurse hauled us out into the deserted hall and pushed us down the long corridor, the gurney careening out of control and bouncing off a wall on the way.

We burst through the swinging doors of the Coronary Care Unit, both us screaming: “DEFIBRILLATOR!!!” I stayed on top of the gurney while a CCU doc put in an oral airway and began bagging our patient to get him some air. I glanced at the monitor: flat-line. Another nurse wheeled a defibrillator over to us. I turned it on and it seemed to take forever to charge the defibrillator’s capacitor. “Let’s use 200 hundred joules”, said the CCU doc. He placed the paddles over our patient’s heart and said “All clear!” We jumped back as the charge ripped through him and his back arced off the bed. Flat-line. The nurses gave him an ampule of lidocaine and bicarbonate through his IV that we’d inserted in the ER, and I jumped back on and resumed chest compressions. Flat-line. “Use 400 joules!” I yelled and the capacitor was allowed to fully charge up to the 400 mark. I jumped off as the ER doc shocked him again. This time I smelled charred flesh. I hopped back on and began cardiac compressions again. “We’ve got a rhythm!!!!” a nurse yelled gleefully. “And a pulse!!!”

I climbed off the gurney and watched him closely. He was still unconscious. By this time, a CODE BLUE team (cardiac arrest in the CCU) had assembled as we transferred him to the CCU bed. My job was done and I made my way back down to the Emergency Room to continue my shift.

I never saw that man again. That’s often the way it goes in the Emergency Room. But the young nurse who’d pushed us down the hall gave me the follow-up I didn’t want to hear. He’d had lived for another 2 weeks, but never woke up. His brain and heart had been irreversibly injured during his cardiac arrest.

Thereafter, I brought a defibrillator with us on all such transports, and kept the paddles ready, gelled, and charged. My ER mates thought this was a bit dangerous and daft. But the patients didn’t realize it, and it made me feel better. Of course, transport after transport went uneventfully.

Then, months later, it happened again. Our patient coded in the elevator. I saw him go into ventricular fibrillation on the monitor. Before he fully lost consciousness, I yelled, “STAND CLEAR!” and zapped him with a full 400 joules. His ventricular fibrillation reverted directly back to sinus rhythm. I acted nonchalant, but my heart was pounding with excitement and pride. But my patient wasn’t pleased with me. “What the hell!!! He said. All I could say was “Sorry.”

Ever after that, I brought a charged defibrillator along with each cardiac patient we transported to the Coronary Care Unit. But it never happened again.