My examination of the old man had not revealed anything unexpected. Clearly, he was in great pain, and with good reason — the cancer had undoubtedly spread inside his abdomen. After trying vainly to reach his private physician by phone, I had simply started a new intravenous drip and ordered some Demerol to help him sleep. Nothing else had occurred to me.
The elevator delivered me to the ground floor at last. I quickly crossed the courtyard, entered the main hospital building, and used the back stairs to get to the patient's floor. As I stepped into his room, I saw the nurse standing helplessly in the soft glow of the bed lamp. The man was so thin that each individual rib poked out on the sides of his chest; his abdomen dropped into a pit below the rib cage. He lay perfectly still; his eyes were closed. I looked closely at his chest. I was so accustomed to seeing chests move in steady respiration that my eyes tricked me into thinking this one rose and fell a little, but it didn't. I tried for a pulse. Nothing. But some people have very faint pulses. I checked to make sure I was on the correct side of the wrist, the side with the thumb, and then I held the other wrist. Nothing.
"No cardiac arrest, Doctor. I was told by the attending that we shouldn't call a cardiac arrest." The nurse sounded defensive.
Shut up, I thought, irritated and relieved at the same instant. I wasn't worried about calling an arrest. I just wanted to be absolutely certain, because this was the first time I had been faced with the sole responsibility for pronouncing death. Sure, there had been deaths in medical school, plenty of them, but always back then — only last year, in fact, yet so long ago — always then the house staff had been there to help, an intern or a resident; it wasn't a student's job. Now I was the house staff, and I had to make the decision alone; a judgment call, I thought wryly, like baseball, safe or out and no appeal to the umpire. He was dead. Or… was he? Demerol, thin old man, deep anesthesia — the combination could produce suspended animation.
I took out my stethoscope slowly, postponing the decision, and finally settled the pieces into my ears while I held the diaphragm on the old man's heart. A series of brittle crackling sounds came up to me as his hairs moved under the stethoscope tip in response to my own trembling. I couldn't hear the heart — yet couldn't I, almost? Muffled and far away?… My overheated imagination kept giving me the vital, normal beat of life. And then I realized it was my own heart echoing in my ears. Pulling the stethoscope away, I tried again for pulses, at the wrists, groin, and neck. All was quiet, yet an eerie feeling said he was alive, that he was going to wake up and I was going to be a fool. How could he be dead when I had talked with him a few hours ago? I hated being where I was. Who was I to say whether he was alive or dead? Who was I?
The nurse and I looked at each other in the half-light. I had been so absorbed in my own thoughts that I was almost surprised to see her still there. Holding open the man's eyelids, I peered down into a pair of brown eyes, normal looking except that the enlarged pupils did not contract as my penlight beam passed over the aged cornea. I felt sure he was dead; I hoped he was dead, because I was about to pronounce him so. "He's dead, I guess," I said, looking at the nurse again, but she turned away. Probably thought I was an ass.
"He's the first patient directly under my care to die," she said, turning back to me suddenly. Her hands hung limply at her sides. It took me a moment to realize she was pleading for me to say something about the Demerol, that it hadn't been the Demerol she had given. But how was I to know what killed him? A scene from an old horror movie kept flashing in my head, the one in which the corpse rises slowly from a cement slab in the morgue. I was becoming angry with myself, but I simply had to listen again. The stethoscope went back in my ears. In the still night my own breathing crashed in my head. Dead, death, cold, silent, whispered the rational centers of my brain. I should say something nice to the nurse. "It must have been very smooth and effortless — he died with dignity. I'm sure he's grateful to you for the Demerol." Grateful? What a bizarre thing to say. There I was wrestling with my own uncertainties, barely keeping ahead, and still trying to persuade someone else to be calm. Fighting an urge to feel for the pulses again, I pulled the sheet up over his head. "We'd better call his doctor," I said as we left the room.
The private M.D. answered the phone so quickly his voice was like a cold washcloth on my face. I told him who I was and why I was calling.
"Fine, fine. Tell the family, and get an autopsy for sure. I want to see what happened to that connection I made between the stomach pouch and the small intestine. It was an anastomosis made with only a single layer of sutures. I really think the single-layer technique is the best; if s so much faster. Anyway, the old man has been a curious case, especially since he lived so much longer than we expected. So get an autopsy, okay, Peters?"
"Okay, I'll try."
Plunging back into the silence of my mind after this jovial one-sided conversation, I tried to organize my thoughts. The private doctor wanted an autopsy. Fine. Great. Where was the family's number? A female arm came over my shoulder, pointing to a line on the chart: "Next of kin — son." Really a lousy situation. Unknown stupid intern calling in the night. I tried to think of some neutral word, one to convey the fact without the meaning. "Dead," "demise"… no, "passed away." The ring of the phone was interrupted by a cheerful hello.
"My name is Dr. Peters, and… I'm sorry to inform you that your father has passed away."
At the other end there was a long silence; perhaps he hadn't understood me. Then the voice returned.
"It was expected."
"There's something else." The word "autopsy" was on the tip of my tongue.
"Yes?"
"Well… never mind. We'll discuss that later, but I must ask you to come to the hospital tonight." The nurse had been telling me that in frantic pantomime.
"All right, we'll be there. Thank you."
"I'm terribly sorry, and thank you."
An older nurse materialized from the darkness of the corridor and pushed a number of official papers under my nose, indicating where I was to sign my name and write the time of death. I wondered when he had died; I really didn't know.
"What time did he die?" I asked, looking at the new arrival, who was standing on my right.
"He died when you pronounced him dead, Doctor." This nurse, a night supervisor, was known for pithy rhetoric and a jaundiced view of interns. But not even her acid tone and her obvious scorn for my naivete could erase the scene of the dead man rising from the slab.
"Call me when the family arrives," I said.
"Yes, Doctor, and thank you."
"Well, thank you," I returned. Everybody thanking everybody. In my tiredness small things loomed huge and absurd. The urge to go in and feel again for a pulse was still with me, but with an effort I went rapidly by the dead man's room; the nurses might be watching. Why did I keep worrying about him waking up? What about the man as a person, didn't that matter? Yes, of course, but I didn't know him. I stopped on the landing of the stairway. True, I didn't know him, but he was a person. An old man, seventy-one, sure — but still a man, a father, a person.
I continued down the stairs. I couldn't fool myself. If he woke up now I'd be the joke of the hospital. Confidence in being a doctor was coming slowly enough; that would kill it.
Back in the elevator, I tried to remember when I had changed, but I could only recall scenes, possible small turning points, such as my first visit to the ward during medical school, and the eleven-year-old girl who lay on the bed looking hopefully up at us. She had cystic fibrosis, which is usually terminal. Listening to the house staff discuss the cases, I had melted, unable to look the youngster in the face. "Perhaps there's a chance we can keep her alive until her late teens," the attending physician had said as we walked away. At that instant I almost became a plumber.