sometimes friends.

Seizures in young men are common. A few nights of hard drinking and little sleep. Poorly treated epilepsy. Traumatic brain injuries. Withdrawal syndromes. Thirty seconds and I could tell that this guy didn't look like an honest citizen. He was probably off his seizure medications. Or drinking. Or drinking and off his seizure meds. Or maybe they weren't really seizures at all. I had to leave the room to take a call and check on Room 3. I came back and tried to catch him in his words. Was this really a seizure? Loss of bowel or bladder function? Were you awake? Do you remember the seizure? You forgot your meds didn't you?

"I don't know. I don't remember... I just passed out and woke up on the floor with a headache. I had to crawl to the phone and call my neighbors. I live alone." I went to auscultate his chest. I opened his gown, I saw a massive, deep scar on his back. I smiled weakly at his neighbors. It was as if the very hand of god had reached down from the heavens to claim a pound of flesh from his back. It was a deep, eye-shaped crater characteristic of wide-margin excisions performed typically for skin cancers. "Melanoma he said" They found it two years ago and cut it out of my back... As I stood there awe-struck, Room 15, next door began a sort-of howling that could only come from gastroparesis...

When I came back into the room, the neighbors had stepped out. I remember he talked with a nervous joviality around them. That too, was now gone. He already knew what the return of his seizures meant. In fact, I think he had known for some time...

35 year old... History of melanoma excision 2 years prior with negative margins and negative sentinel nodes. 2 months ago he had some R hand twitching. A CT scan had revealed three small masses in his brain. 15 cycles of outpatient radiation to shrink the tumors. An outpatient MRI had been done 2 days ago and he was sent home to wait on the results. He lives alone. And today, he is carried in by neighbors, after having focal motor seizure. Joking. I opened up the MRI which reveals a brain riddled with disease. He has cerebral edema. I discussed with his oncologist. They advise a referral to hospice. 35 years old...

He told me he already knew. He also suspected that little could be done. He tried to remain composed. Imagine trying to spread cheer as your own life is being extinguished. Lying in an ER stretcher surrounded by people that you can't genuinely call friends... neighbors. He smiled indifferently..."what are you gonna do, right?"... I could see him trying to lighten the atmosphere..for their sakes. Maybe lighten is not the right word but numb... suffusing it with a novocaine to make this easier for us all to accept. After all, the realization of mortality had visited him long ago. The rotting teeth from focused radiation treatments, the patches of alopecia that dotted his scalp, the sallow cast that can only come from the ravages of cancer... He had known for weeks that things were rapidly deteriorating...that he was dying. Struggling to deal with his own plodding death while trying not to become a mire of pity. After all, no one wants to be around someone as they're dying...

Pity, sorrow, and a general melancholy seems to flow from people unconsciously around those marked for death. It stifles the human spirit when you're no longer a person with hopes and dreams. I wanted to call him several days later...What would I say? Maybe share a game of cards or a few minutes of idle chatter. Maybe have lunch. Over the years, doctors have become wary of crossing lines. Of HIPPA. Of impropriety. Of presuming and asking too much. Of human decency and emotion. Too often, we are the "sometimes friends"... willing to share a smile but never call on a rainy day.

certifying death.

i picked up the phone and sleepily punched in the numbers from the "Contact Info" tab on her electronic medical record. I paused for a moment and gulped. Heartburn. I felt the acid burn as it slid down my throat. Finally, the phone rang with an eery crackling in the background. A crackling that you can't help but notice at 3:30 in the morning. No matter how many times i do this, it never gets easier. "Hello..." A sleep-infused voice answered the line on the other end. It's always best to be direct and straight to the point. "Is this Mr. Peterson?" No matter how you broach it, an unfamiliar voice in the darkness that appears to know you, is always unsettling. "Yes... Who is this? What time is it?!?".

At this point I always, always, always apologize. It's the start of an apology that stretches beyond this chance telephone call and into the night. It stretches into the days following this tragedy, and sometimes longer than that. "I'm sorry to disturb you... this is Dr. Patel from the Hope Valley Emergency Department. Again, I'm sorry to wake you, but I'm calling about your mother, Mrs. Peterson". I usually offer a long pause and wait for a response. I hear "Oh my God! Is she okay? What happened?" Here the is always an instinctive pause. I steady myself and launch into a set narrative. "She was brought into the ER by paramedics. She had called 911 after complaining of indigestion that wouldn't go away. By the time they arrived with her, we were already set up to try and stabilize her. She had already lost consciousness." A cry or a wail usually interrupts me, but I typically press on. "When she arrived, we immediately began CPR and tried to get her heart to beat again. A breathing tube was placed to take the stress of breathing off her body and to get 100% oxygen to her. We used every medication we could to stimulate her heart. But..."

"Is she okay? How is she??!@?"

"She's passed..."

I let the words sink into the space between us. I again offer my apologies and assure the family that she felt no pain. I ask them to carefully drive to the ED so that we can talk in person and they can spend time with their loved one. I offer to call her primary care provider. I again ask them to drive carefully. When they arrive, it begins anew. More family arrives. I tell my story to a series of faces that have already stopped listening. I begin the tale again. I offer condolences. I try to explain... But the reality is that we almost never know. In the morning I will scrawl my signature into a death certificate. Proclaiming the time that another life was extinguished...

Death is always unexpected. And never welcome. And in its wake, families are left with a gaping wound in their lives. The grief, the shock, the despair. A hopelessness sets in as all of the words left unsaid come to mind. It's exhaustive to witness. I seize the moment and ask families to be strong. To use each other. To cry as a family and to support each other. I've always considered it a deep privilege to be with families as they begin this grieving process. To be the one to deliver this news, to inflict this pain, and then to try and desperately begin to heal these wounds...

Sometimes, the way we dignify the passing of a life seems more human than all that we do to try and save it...

The Striker.

Looking back now, I had just come on shift and I think I was looking for...well, for someone sicker. I came to work psyching myself up on Eminem's Eight Mile soundtrack. I began scanning the electronic patient tracking screen looking for the sickest patients. When the ER is busy, you look at the board, make a plan, sign up for patients, map out the rooms in your head, and calculate the most efficient route. There are no pit stops. No water coolers. No chit chat. No deviations from course. You go all in, right from the beginning...

You acclimate to walking through chaos - through patients wailing, moaning, and retching. I must've walked past his room several times. At the start of my shifts, I am always looking for an adrenaline rush. A 31 YO male with "multiple complaints" was not only uninteresting, but would likely sap the little motivation I tried so hard to build at the start of my shift. It wasn't until the third time I passed the room that I noticed that he was a pallid, young Hispanic male. It was 11 o'clock at night. His brow was heavily creased and more than worried, he looked nervous. In retrospect, the whole scene looked wrong. Furthermore, there are some age and ethnic patient permutations that we almost never see in the ER... and when you do, they're always bad.

I opened up his triage notes. These summary notes often help encapsulate a patient's major concerns - "Pt complains of leg swelling. Pt pale. Interpreter assisted nurse with triage. Alert and Oriented x 4. Pt ambulated to ED with c/o sore throat and was told he had infection in mouth. Pt also c/o dizziness, vomiting when eats, R knee swelling x1 month. Pt states went to clinic approximately 2 weeks ago while in Florida. Pt was given prescriptions for Benzonatate, Loratadine, Amoxicillin, and Ibuprofen." Sometimes these notes are really helpful and help cater the workup. Unfortunately, not his...

As I walked into his room, I sat down and introduced myself. I had barely sat down, and he spit out two words: "spanish interpreter". It was already a busy tonight. I already had four patients to see. I looked at him with a kind of exasperation, and said, "Okay but you'll have to wait..." and marched out. My Spanish is good. I ran past the nurse and told her to get the interpreter so we could begin. An hour later, I was back in the room and learned that he had progressive leg swelling for 3 weeks. He had a large, smooth fleshy mass along his distal thigh. We also ran through his dental pain and his prior visit to a clinic in Florida where he was prescribed antibiotics for a throat infection. The dental pain. Leg pain. Dizziness. Vomiting. None of this made any sense... The more I asked, the more symptoms he reported. Finally, I shut up and asked to examine him. When in doubt, look at the patient right? When he opened his mouth, I had a 'Kobayashi moment' (Note: Usual Suspects reference). His gums were an angry, raw red and immensely swollen. They seemed to swell around his teeth. The crevices between his teeth were caked with dried blood. He lifted his chin and I could feel the chains of lymph nodes like marbles under the skin of his neck. The hollow of his right collarbone felt like the striker, the largest marble, was neatly tucked into it for safe-keeping.

There are times when you want to say so much. Often however, it's when nothing you say matters. When you want to explain how you're sorry for circumstance. When you want someone to forgive you your indiscretions...a long wait, a callous demeanor, a skeptical glance. Unfortunately, these empathetic epiphanies only come on the heels of great tragedy. This wasn't gingivitis. He had cancer. Likely Acute Myeloid Leukemia. He was severely anemic. His platelet count was dangerously suppressed, which was why his gums were gushing with blood. The swelling on his leg was a large hematoma.

As I opened my mouth to explain in my broken Spanish, I stopped, and went off to find the interpreter. This was gonna be a long night...