Modern Death: How Medicine Changed the End of Life

ISBN-13: 9781250160843

Media Type: Paperback

Publisher: St. Martin's Publishing Group

Publication Date: 05-01-2018

Pages: 336

Product Dimensions: 5.70(w) x 8.90(h) x 1.00(d)

DR. HAIDER WARRAICH graduated from medical school in Pakistan in 2009. He did his residency in internal medicine at Harvard Medical School’s Beth Israel Deaconess Medical Center, one of the main teaching hospitals of Harvard Medical School. He is currently a fellow in cardiology at Duke University Medical Center. His medical and Op Ed pieces have appeared in many media outlets including the New York Times, The Atlantic, the Wall Street Journal, Slate, and the LA Times among others.

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Modern Death

How Medicine Changed the End of Life

St. Martin's Press

How Cells Die

It had been the longest of months — in both the best and the worst possible ways. Brockton is a small town about a half-hour drive south of Boston, but in many ways it seems a world apart. As you move away from Boston, you can actually see rust accumulate on bridges, signboards, and fire hydrants. Boston carries a tasteful level of agedness, akin to a hint of silver hair. The red brick Federalist-style apartments of Back Bay, many built in the colonial period, have just the right amount of decay, which gives them a deep and rich texture. With Revival- and Georgian-style buildings intermixed, Boston is just rough enough to be photogenic. Brockton, on the other hand, is a town falling apart. Crooked goalposts stand half erect in fields with tall grass that might not have seen a game of football in decades. The town is awash in violent crime and drugs.

The town of Brockton is served by a community hospital that mirrors many of the characteristics of the town it is located in. Medicine residents from my program would go to the intensive-care unit (ICU) in that hospital for an away rotation, and it was an experience of legendary proportions. Unlike the large academic referral center we were used to, with an abundance of nurses and doctors, the Brockton ICU was run predominantly by the residents even though the patients there were sicker in many ways. In the primary hospital where I was training, there was a surgical ICU, a neurological ICU, a cardiac ICU, a trauma surgical ICU, and a bevy of medical ICUs, but there was only one ICU at Brockton, leaving the care of patients with a host of acute conditions in the hands of the medical residents and the supervising physician.

It was a Sunday, Super Bowl Sunday no less, and it was my last day in Brockton. The Patriots had lost the week before, so my interest was somewhat muted, but still, it was Super Bowl Sunday. I was scheduled to be there until seven in the evening and it would take me an hour to get back to Boston with the traffic, which would mean I would miss a large chunk of the game. But this Sunday was an almost miraculously quiet day. My team was done with rounds by noon, and we got no new patients afterward. It was so relaxed that I did the unthinkable: I asked my team who was going to be there overnight, whether I could call the shuttle early if we continued to have a quiet day. We had a deal. When the clock struck three, the ED was not buzzing, all our patients were well behaved, and there was no one headed up from the wards, so after checking again with the team, I called the shuttle service to come pick me up at five. I called my wife, ecstatic that I would be done early, and asked her to call our friends so that we could actually have the Super Bowl party she had so wanted to host.

It wasn't long after I hung up that my pager buzzed. There was a medical emergency on one of the wards. I picked up my stethoscope and shuffled toward where the emergency was. When I got there, the whole ward stank of human excrement. One of the nurses directed me toward a room outside which a large crowd had gathered. I made my way through the throng and found that there were three nurses in the bathroom struggling with a patient who didn't seem to be fully conscious. He was slouched over on the toilet seat, totally naked, and the entire bathroom floor was covered in black and bloody feces. The bathroom was very small, and the patient was at least six and a half feet tall and must have weighed at least three hundred pounds. The nurses were trying in vain to lift him up, while a few others were attempting unsuccessfully to get his bed into the bathroom. There was complete chaos, and no one had any idea what was going on.

The man was barely breathing, but he had a pulse. I quickly realized two things: There was no way the bed was getting into the bathroom, and there was no way we could get the patient into the bed. I asked one of the nurse assistants to grab a wheelchair. He brought the wheelchair right up to the bathroom door, and I carried the patient with the nurses from the toilet seat to the wheelchair. Given how sick he was, I knew I didn't even have the time to fully examine him. I had the room emptied so that we could get the wheelchair out of the bathroom and roll the patient to the ICU. One of the nurses threw a bedsheet over his naked body, and we wheeled him up, his head slumped on his chest, to the ICU. He was drooling all over his chest, he was barely breathing, and in his wake he left a long trail of blood and stool that smeared the entire hallway behind him. The resident who was with me took a picture of the hallway with his smartphone. Neither of us had ever seen anything like it.

Once he was up in the ICU, it took about six people to transfer him from the wheelchair to the bed. One of the nurses who had been taking care of him on the ward and had accompanied him upstairs to the ICU told us that he was forty-something and had presented with some bleeding from his rectum last night, but it was only a small amount and he had never experienced similar symptoms before. The team on the ward had actually been thinking of sending him home later that day. The nurse had already called his wife, who was now on her way thinking she was taking him home.

The man, who had been very somnolent until now, started to wake up. But this was not a good thing. He was in shock and was completely delirious. He started thrashing around and pulling the IV lines from his arm. He was immensely powerful, and it took one person per limb to keep him from falling over. It became clear to us very quickly that his risk of choking was high and there was no way we could guarantee patency of his airways without intubating him and having him breathe with the ventilator.

I made my way to stand at the top of the bed and used one hand to keep his head planted down. He was looking me straight in the eye, grunting, with a towel in his mouth preventing him from biting down on his tongue. His blood pressure was in the tank and he had lost almost half his total volume of blood. He was in dire, dire straits. My eyes darted away from the patient's as I looked for the equipment I needed to be able to intubate him. A nurse on the other end of the room had a large green container, so robust it would fit right in at a bomb shelter, with all the tools I needed. With the supervising physician by my side, I picked out the appropriate-size laryngeal blade, which was basically a large tongue depressor made out of metal. I took the blade out and opened it up to be in its usual L-shaped configuration. All the while I was running through my head what I was going to do. I had intubated patients in the past, but never in such a boisterous environment. My attending, an anesthesiologist with Jedi-master skills, stood by me and didn't even hesitate in handing the blade over. Most attendings would get nervous and take over the intubation rather than wait for the trainee to mess around, but not him.

Sticking a tube down a person's throat is actually way harder than it may seem. The last thing you would want to do (although it happens frequently enough) is go down the esophagus and into the patient's stomach rather than down the trachea, which leads to the lungs. Blocking the way is the tongue, which extends much farther down than most people imagine. And then there is the small issue of the epiglottis, a trapdoor-like flap, which covers the trachea to prevent food from going down the windpipe when we speak or breathe. And then once you make your way past the epiglottis, you need to go past the vocal cords, which hang like fluttering curtains right at the top of the trachea.

Standing at the head of the bed, looking at his upside-down face, I signaled to the nurse holding a syringe full of milky propofol to inject the anesthetic. Even in the maelstrom, she was careful, flushing the IV with some saline, injecting the anesthetic, and then flushing again. After the propofol had been injected, we continued to hold the patient down, awaiting the relaxation of his muscular tone. Two minutes passed and we realized we needed something stronger, so we injected a paralytic. His head, which had been thrusting against my forearm, relaxed down; his eyes, which had been staring at me with unspeakable grit, now just stared at the ceiling. Everyone let go and the patient became limp. He stopped breathing, and the respiratory therapist continued giving him oxygen through a bag mask. As soon as the patient's oxygen levels hit 100 percent, the race was on: I had only seconds to be able to intubate him before his oxygen level dropped.

I passed the laryngeal blade past his tongue and then used it to push the tongue down, lifting his chin up, in the hope that I would glimpse my goalpost — the vocal cords. But his tongue was beefy, and even when I flexed my wrist to the maximum, I could barely see them. I didn't want to just blindly thrust the tube down, which I was anxiously holding in my other hand. My supervisor, on the other hand, was now starting to get impatient. He told me that I wasn't flexing my wrist enough. I looked over my shoulder and saw that the patient's oxygen level was already down to 80 percent. I snaked my blade farther down his throat, almost lifting his head off the bed, and there it was — the thick rim of the vocal cords, pale like chapped lips, surrounded by membranes laden with small capillaries. I grabbed the J-shaped breathing tube, curved it down his throat, and jabbed it through the cords into the black beyond. I pulled out the metal wire that was maintaining the tube's form, and the respiratory therapist connected the bag mask and inflated the cuff in the tube that prevents air from leaking. Next, all of us looked for the telltale signs of the tube going down to the stomach instead of the lungs. The respiratory therapist squeezed the bag, and thankfully it was the lungs, not the belly, that inflated. A nurse put her stethoscope on the belly and heard no breath sounds there from the mask. This man was not out of the woods yet, not by a mile, but I looked up, my visor fogging up, my scrub cap sweaty; I was relieved that at least his airway was secure. I took my gloves off and saw the aides outside the room waiting to take over, with bags upon bags of blood, platelets, and clotting factor.

I didn't even make it out of the room before my pager rang, and before I could even look at it, the overhead speaker blared: "Code blue. Hospital lobby."

Torn, I looked at the other resident, who told me to run down and that he would hold the fort in the ICU.

There is an etiquette to running in the hospital; I avoid running under almost all circumstances, because it can make other people panic and can ruin one's composure. The rule I have for myself is that it's okay to run in stairwells where there are no patients or family members, but not in corridors. Which is why I went for the first stairwell I could find so I could just flat-out run.

I emerged from the stairwell on one end of the lobby and walked toward the entrance, where there was a large crowd of people gathered. Most appeared to be people who were visiting family members in the hospital and now were captivated by some kind of commotion. As I got closer I could hear a woman wailing and crying. A wall concealed the scene itself, and as I approached the entrance I became increasingly full of dread as to what I would find. Just before I caught a glimpse, a child cried out, "Is Mommy gonna die?"

Right in front of the double doors that led into the hospital, a young woman lay on the ground, seemingly unconscious. Next to her, a paramedic was kneeling, and as soon as he saw me, he told me that she still had a pulse but that she had just had a seizure. The woman, curled on her side, was very obviously pregnant. It had to be a seizure from eclampsia, I thought. I laid her flat on the ground to make sure she was breathing fine, which she was. But the commotion was still ongoing. Her mother was going completely berserk, pulling her own hair, screaming, and clearly scaring everyone around her. The crowd, now growing as more doctors and aides converged, was reacting more to the mom than they were to the woman, who was miraculously quite stable at present. The mom was even distracting the emergency-room physicians who had come to help the young woman, but then one of the aides told the mother more sternly than I would have, "Hey lady — keep it together."

I took the young woman to the emergency room, ensuring that she would have someone responsible for her, fulfilling my role as the emergency backup. With that settled, it was time for me to head back to home base. I looked at my phone; it was overflowing with unanswered texts and phone calls. On my way back to the ICU, I called the shuttle driver who was waiting outside and apologized, telling him that there was a patient in critical condition and that it would be great if he could pick me up once the patient was stable enough for me to go home.

As soon as I got back to the ICU, I made a beeline for the room of the patient I had intubated about fifteen minutes ago. The nurse promptly handed me the kit for placing a central line: there weren't enough IV lines to get him all the blood products he needed. The other resident was busy with other patients, so I grabbed the package and dove back into the vortex. We started with a large IV line in the femoral vein in his groin, then placed another in his chest and an arterial line in his wrist. It was as if I needed to perform all the procedures I had learned during residency in one day and on one patient. By the time I got done, it was clear that it was unlikely that the man would ever wake up again. While he was breathing on a ventilator and his heart was beating, we weren't sure whether he was alive anymore or whether he was brain dead or whether he was somewhere in between.

When I first started residency, signing off was very difficult. It was hard to shift responsibility for a patient I had been taking care of to someone who was just covering overnight. Any amount of verbal communication or any number of e-mail signouts would still leave me feeling that I had somehow left my patients hanging. When you are taking care of a patient, you feel that no one else might be able to manage the patient as well as you can, based on the fact that you know the patient the best.

By this time, though, in the third year of my residency, I had become seasoned enough to know when to ease off. I could stay there as long as I wanted, but that was probably not going to change the outcome. Looking at the man in front of me gave me perspective, though: he had gone from having a completely normal life yesterday to having ten additional points of entry in his body and his ability to make it through the night under question. It made my own worries almost comical in comparison. I was going to miss much of the Super Bowl, but as I looked at the patient's wife in the waiting room on my way out, it was clear that there were many, many people in this world who had a lot more riding on this night.

I walked down to the lobby, which was much quieter than when I was last there, and saw the shuttle, a black Lincoln sedan, waiting outside.

"Did he make it?" the driver asked, once I had gotten in and started eating the salad I had picked up from the cafeteria.

I looked in the rearview mirror, and the driver was looking back at me. I was a bit surprised, but not in a bad way. "Did who make it?"

"The guy you told me over the phone about, who was dying."

I suddenly remembered telling the driver on the phone that I was going to be late.

"I am not sure," I told him.

His eyes moved away from mine through the mirror and back to the road.

"Death," he said, "is such a primitive concept."

Doctors experience death more than any other professionals do — more than firefighters, policemen, or soldiers — yet we always think about death as a very concrete construct. It's a box on a checklist, a red bar on a chart, or an outcome in a clinical trial. Death is secular, sterile, and singular — and, unlike many other things in medicine, incredibly binary. So it was interesting to think of death more as a concept and a process than as a fact and an endpoint.

Looking back now, I can say that the driver was right on many counts. Perhaps the most primitive aspect of death is how we respond to it, how we spend most of our lives imagining it away, how we fear it as some sort of unnatural schism in space-time. Every time we talk about death, the food seems terrible, the weather seems dour, the mood sullen. Every time we think about death, we get so depressed we can't hold a meaningful thought in our heads. Many families talk about death only after their loved one is in the ICU, hooked up to more gadgets than Iron Man.

When I first thought about writing a book about death, I went up to my wife, a civilian, and told her about it. She seemed bemused. Just hearing the "d" word made her feel ghastly. I was surprised by her reaction, but since then I have become a bit more used to getting a similar reaction from others.

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Excerpted from Modern Death by Haider Warraich. Copyright © 2017 Haider Warraich. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents

Acknowledgments ix

How Cells Die 1

How Life (and Death) Were Prolonged 24

Where Death Lives Now 41

How We Learned Not to Resuscitate 57

How Death Was Redefined 92

When the Heart Stops 117

When Death Transcends 135

When Guardians Are Burdened 171

How Death Is Negotiated 191

Why Families Fall 208

When Death Is Desired 227

When the Plug Is Pulled 249

#When Death Is Shared 267

Notes 279

Index 313