Clinical, Emergency Medicine, Featured, Housestaff Wellness
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Gentle Into That Good Night: Death in the Emergency Department

“Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.”
–Dylan Thomas

The message, like all earth-shattering pronouncements, came with the softest of dings. As I was walking out from my house into the cold December air for a morning shift in the emergency department, my parents messaged me about the passing of my grandfather.

I stood for a moment in shock, and then collecting myself, remembered that I needed to walk to the train to be on time. I walked through the crisp, cold, morning air where I was as alone as I suddenly felt. The man who’d taught me to be a man, taught me the concepts of honor, of duty, of giving your word and holding to it, was dead.

I walked into my shift, burying my feelings, telling as few people as I could. That day, I threw myself into work and pushed down my feelings until it was safe to air them out again — a task that a year and a half of a grueling residency have made me expert at.

As I walked home and thought of the man my grandfather was, and what he meant to me, I realized how incredibly different my life would now be. His scribbled handwriting, illegible to most of the world, would live on only in my signature. The cheeky glint in his eyes as he made a sardonic comment about my belly or my sisters shockingly colored hair would live on in my sister’s eye. Never again would a letter bearing his recollections of his days as a cadet in the Royal Indian Army arrive, to provide succor in response to my letter about the challenge of trying to become an upper-year resident.

Christmas Eve, I was back in the emergency department. The afternoon began with an empty waiting room, and before I knew it, we were being hammered by EMS with sick patients. My phone rang off the hook from the back triage nurse asking for stroke evaluations and to eyeball sick patients.

My second patient of the night had been herself the night before, had just arrived to visit her kids, and hadn’t been seen since lunch the night before — they all thought she was just tired. They entered the room and found her in a pool of her own vomit and feces. 911 brought her in, the lights on their ambulance looking anything but festive. As I spoke to the family and explained that I didn’t know what was wrong with her but the prognosis looked grim based on her clinical status alone, they wanted us to do everything. It was about to be Christmas, after all. And the grandkids… So, I intubated her and, after getting some CTs, discovered she had a subdural hematoma and a stroke. I admitted her to the ICU.

Between seeing a young pregnant woman with vaginal bleeding and reassuring her that she wasn’t miscarrying, and a young man who had rectal bleeding and wanted to make sure he didn’t die from colon cancer, I got a call again from back triage.

I walked over to see this possible stroke and found an elderly and rather unwell-looking man. He was wheeled into the resuscitation room, and we started doing our jobs. He was tachycardic, hypotensive and tachypneic. As we began giving him fluids, trying to resuscitate before he required intubation, his family came into the room. His daughters, crying at the state he was in, told me he was DNR/DNI. But, they wanted us to give him as good a shot as we could, short of intubating or coding him. So we began. IV fluids. Antibiotics. Pressors at the bedside. As the labs began returning, I walked into the room to update them. He was in septic shock. His IV had infiltrated. I crouched at the bedside and made eye contact with them. I explained how sick he was, and asked them how aggressively the patient would want to be treated. Crying, they looked at each other and said just one word. “No.” Over and over, they said that word, softly, like a prayer. My patient’s eldest daughter looked at me, tears streaming down her face, and said, “This isn’t how he would want to live. We’re going to let him go now.”

So, the second time in my very short career, I made someone comfort care in the emergency department. I walked back into the swirling vortex of the busy urban ED into a code that rolled in from the field. Twenty minutes later, I was called back into the room to confirm that he had died. As I spoke to his family, they looked at me and smiled through their tears, asking if they could tell me how he lived.

There were a dozen patients in the emergency department waiting to be seen. Some of them may have been sick and dying, but there were other doctors in the department, and my humanity demanded I wait. So, I sat there as they told me about their dad. About how he had raised them and worked hard to give them a better life than he had. How he’d been the tough one of the parents, but at heart he was a big softy. They told me about how when their mother had died he’d been heartbroken, but had thrown himself into helping out at the retirement home, and how the grandkids had always brought a smile to his face. They told me about how strong-willed he was, how he had often told them not to keep him alive on machines after his hip surgery.

I was reminded from their stories inexorably of my grandfather. His furious fight to stay independent and self-reliant after a large left MCA stroke, his nature, and his wish to not live on machines. After his stroke, he had told me more than once that he’d wished he’d passed then, in his 70s, hale and hearty, with his broad warrior’s chest, his booming laugh, and his deep voice honed by years of commanding an army regiment, instead of becoming the wizened, weakened old man he became.

I thanked them for showing me the “elderly, sick-appearing, stroke rule-out” in a new light, and I walked back into the cold fluorescent lights of the emergency department to see the next patient.

As I left that evening, I realized something. They had also shown my grandfather and his life in a new light. I choose now to remember him as the larger-than-life figure he was in my childhood. The man who told me bedtime stories of battles he fought in the army and his travels around the world. The man who on our long walks around the block taught and talked about a different topic each day, from economics to military strategy to religion and spirituality. The man with the twinkling eyes, the booming laugh and the broad chest, with wisdom to share and a love for coffee and a good book.

I realized one other thing, too. I had a lot of sick patients that day. I tried to help them all. I sent a few to the ICU. But the one I sent to a funeral home, unmolested by an ET tube and a central line, passing in peace surrounded by his family, there to witness his death and remember his life — perhaps I helped him the most. And in that, I will disagree with the poet. Sometimes it is better to go gentle into that good night.

Author’s note: Specific details and dates have been changed to protect patient privacy.

Image creditEmergency Room by KOMUnews licensed under CC BY 2.0.

Sarab Sodhi, MD Sarab Sodhi, MD (4 Posts)

Peer Reviewer Emeritus

Cooper University Hospital

I'm an Emergency Medicine Intern at Cooper University Hospital, having graduated with my MD and Masters in Urban Bioethics from Temple University School of Medicine in 2015. Medical school helped me realize that the only way for me to stay sane after seeing and doing what we do is to express it- and this is how I express the madness that is my life, and my life in medicine.