From the Wards
Leave a comment

The Silver Lining

“Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.”
–Dylan Thomas, “Do Not Go Gentle into that Good Night”

We stood in the shadows, a staggered line of nurses, students and surgeons in matching blue scrubs and masks. It was the middle of the night. Our tired bodies sagged against the walls, our bloodshot eyes dancing between the clock above and the gasping life below. A young man was dying in the operating room. He lay on the cutting table with his arms splayed wide, like a martyred saint stretched upon the cross. A single beam of honey-colored light bathed him from on high. That golden aura — thick and tangible and serene — gave him a false sense of vitality, maybe even peace. But it was a bitter trick. He was alive only in semantics. A catastrophic brain injury had left him shattered on Death’s doorstep, the doorbell ringing loudly. His journey was more than halfway finished: his brain bereft of conscious thought; his lungs stretched like accordions by machines; his limbs nourished through tubes and slurry fluids. He was never coming back from this. For a long week, his family had held their faithful bedside vigil. Then they decided that he would become an organ donor. We would withdraw life support and allow his heart to surrender on its own, so that we could harvest precious bits of him to live on in others. In the medical world, we had a clean name for what we were doing. We called it a “donation after cardiac death.”

In my mind, I had always seen this unfolding differently. I had assumed his loved ones would make their final goodbyes upstairs, and that his fate would be carved in silence beneath the surgeon’s scalpel, free from teary eyes. I pictured an unmoving cadaver surrounded by polite professionals in a bright, buzzing operating room. The last thing I would have imagined was all of us gathered together — family and doctors and students — to watch him fight for his last breath. And yet, here we all were. Envision a dozen shadowy figures huddled in a dark and silent mausoleum, heads bowed reverently towards the fallen figure, as if assembled in an opera’s tragic climax. Somehow it was both dignified and absurd.

The young man’s family sat on the far side of the operating room. A single curtain separated them from the panoply of machines keeping him alive. From their side of the divide, they could not see what we could — the blinking vital screens behind the curtain. They could not know that our eyes were glued to the dark side of the curtain, to those neon numbers and fluorescent screens. They could not have imagined that their son would be reduced to a set of ticking figures — an algorithm to be fawned and fussed over by doctors. We were two worlds apart: we the detached, they the dispossessed. Two worlds apart, divided by a single sheet of cloth. And as my eyes swung from one side to the other, I felt myself being shorn firmly in two.

I had to find a way to cope. And so I put the tragedy in context. I hardly knew this young stranger. I had met him only hours before he died. Upstairs in the ICU, bedecked in anonymity, he was simply another intangible sadness — another flame snuffed out in a single eye-blink on a dark, slippery road. What I saw was not a man burning with hopes and dreams, but a limp-doll body propped up on tubes and machines. He looked wooden and gray and un-human, well beyond the ship of self and salvation. Only in the most absurd sense would I have described him as “resting comfortably,” as the nurses scribbled in their daily charts. When I leafed through his record, I discovered a Tolstoyian novel of progress notes, consultations, and recommendations. It seemed like a heroic (perhaps even comical) effort in futility — like rearranging the deck chairs on the Titanic. He was hopeless.Anyone could see that. His bloodstream was a slurry of drugs and toxins and tube feeds. He was intubated for air support. He was peeing through a clear tube. He had no control over his bowels. He was prone to millions of tiny, wriggling, invisible bugs — ludicrous bogeymen with Latin names — which existed only in dusty textbooks, then on doctors’ frightened faces, then in the corpses left behind. In short, he was a tragedy that had already passed. And we all knew it. Here was the Epilogue. What remained was merely tidying up matters before putting the book back on the shelf.

Of course, had I really known the man, it may have been different. Had I tended to him day in and day out, I would have understood the tragedy for what it was — the end of a human life. But I didn’t know him, and I couldn’t bring myself to understand it. Not in the middle of the night, in a cold and crowded operating room.

What I felt was numb, tired, and defeated. Leaning against the cool plaster of the wall, I watched them remove his breathing tube, glistening with mucous and blood. I watched his lungs awaken frantically from their hibernation. I watched his blood pressure spike up and then trickle back downwards. I watched his breathing progressively lengthen into long, tortuous intervals: five seconds … eight seconds … twelve seconds between gasps. Each breath unquestionably his last.  Each subsequent stillness bringing his family to their feet, their eyes begging for relief — until another startled heave sent them sobbing back into their chairs. It was emotional torture for all of us; most of all his loved ones. If the patient himself did not wear at my conscience, then the family’s torment quickly did.

When death finally came, it was quick and shy and subtle. The patient’s heart rate dropped anchor, from 25 to two. The EKG monitor showed a few childlike scratches, and his blood pressure leveled out at 40/20. He was nearing “asystole,” the state of no electrical cardiac activity that hallmarked coronary death.  He looked calm and placid on the surface, but I knew his heart was raging its last dance deep within — a lightning maelstrom without rhythm or thunder.  Then the EKG scribbles evened out into their telltale plateau … and the journey ended.  There were no alarms. No whistles. No bells tolling for the dead. He was deceased, “clinically,” at least. But his loved ones wanted something more. They wanted closure. They wanted a doctor to touch their boy and look up at them and tell them that he was gone. They needed that special rite of passage. Still, it seemed like a bizarre Vaudeville act when the resident placed her stethoscope on his chest to “listen” for a heartbeat.  That is, until I remembered the curtain — that insurmountable wall between them and our algorithm of death. They could not see what we could. They had only these hallowed words to cling to: “Time of death: 2:59 a.m.”

The family was then led out of the room. The sterile lights came blindingly on. We blinked and rubbed our smarting eyes while the doctors disappeared to don their gowns. Moments later, the troupe of transplant surgeons came roving in, their sterile hands held high en-garde. Drapes were pulled off the patient’s body to expose a naked neck, a naked torso, a naked corpse. With a grand flourish, more drapes were removed from a tray of glistening instruments. This revealed humongous retractors, electric bone-saws, clamps and scalpels — a slaughterhouse arsenal that the surgeons meticulously surveyed.

We waited in breathless silence for five full minutes after “time of death” had been called. This was enough of a span to ensure that true brain death had occurred. All the while, the lead surgeon hovered over the body with his scalpel frozen above the thorax, ready for his command.  Until at last, he got his wish. From the back of the room, a bored and listless schoolteacher’s voice droned out: “You may begin now.”

Now we had a job to do. First, there was a feverish race to crack open the chest and reach the cargo before it spoiled. A whirring, grating bone-saw filled the room with the musty scent of a dentist’s drill. Enormous steel clamps cranked open the severed ribs like the gaping maw of a fish. It was breath-taking to watch six pairs of gloved hands dancing around bone-saws, scalpels, and sharp broken ribs. The surgeons worked in perfect concert. Bowels were yanked out of the way; clamps were snapped on blood vessels here and there. A suction hose gurgled out liters of blood, draining even that last bit of humanity, his human warmth. One after another, buckets of cold slush were dumped into the gaping chasm to preserve his organs. Then pumps were hooked up to his large blood vessels. Gurgling and chugging, the machines began flushing out the patient’s blood and cycling in preservatives. Now we could all relax. The surgeons had plenty of time to begin their careful slog through blood and ice to retrieve the gift of life.

As they proceeded, one of the surgeons began pimping his medical student about anatomy. The surgeon would point into the slurry of flesh and bloody stew and ask about vessel origins and organ blood supply. The conversation was strangely grating on my nerves.  The monotony of his voice, the tepidness of the student’s response, the very casual business-like feel of the conversion — all of it was jarring to me. Something so horrible had never seemed so banal. If I closed my eyes, I could have been listening to a simple appendectomy, rather than the evisceration of a young man. But my eyes stayed open, and the spectacle was entirely macabre and entirely mundane. I was warm and delirious with fatigue. I couldn’t look away. Soon I felt myself detaching from my body, my head floating towards the rafters. I gazed down at the mauled cadaver and the blood-splattered surgeons huddled around it — and it occurred to me, in that particular moment, that we had all lost our minds. This was crazy.

No, I told myself, it was medicine. It was beautiful and righteous, what we were doing. An awful, righteous thing.

When I finally grounded myself, there was nothing left of the young man’s body — just a husk of skin and bone, without kidneys, aorta, pancreas and soul. I was glad his family would see only his ashes. There was nothing left of their shredded boy to mourn. I hoped that they made their peace with his death. But of course they hadn’t. Of course they were still wracking their hearts with that age-old question: Why? Why? Why?  

To which a quiet voice within me replied, Why not?

Months have passed since the death of this young man. He was not the first person I had watched die, but he was the first person I had let die. In a dark room in the middle of the night, death had won unopposed — with strong hands waiting idly by, and all of us simply looking on. I trudged home that morning with a strange feeling in my heart. Only months later do I understand what I carried out of that room with me. It wasn’t inconsolable sadness, but quiet, smoldering rage. Why? I still don’t know. Perhaps it was my own sense of ineptitude — that sudden realization that medicine is ultimately a futile fight. Perhaps it was resentment for his family and their anguished cry of “Why?” — as if Death owed them a reason. Perhaps it was bitter self-reproach for my childlike dream that Life needs to be fair. Whatever the cause, anger was my mourning that day. It was Dylan Thomas’s words that burned in my heart.

Do not go gentle into the night.
Rage, rage against the dying of the light

I’ve learned that there’s a silver lining in every tragedy. In this case, it was anger. I’ve learned that anger can be its own catharsis. Anger can be controlled and channeled. It provides the kind of clarity and distance and detachment that doctors need to survive. It allows us to keep a steady hand at the helm in the storm, dry eyes to see the clock on the wall and a strong voice to call out time of death. Most importantly, it is the remedy for needing to feel, without wanting to feel too much. 

But there’s another reason I was angry that night. Deep down, I understood that this was only the beginning. I would see this same thing again and again and again. And it would always be senseless. It would always be unfair. And each time, I would hear that same pitiful question echoing unspoken through the room — why? 

My hope is simple. One day, when I have seen enough and suffered enough and lived enough, I will be at peace with no reply.

Matthew Trifan Matthew Trifan (6 Posts)

Contributing Writer Emeritus

University of Pennsylvania

Matt Trifan is a current resident of emergency medicine at Thomas Jefferson University Hospital in Philadelphia. He was a former medical student at the University of Pennsylvania. In his free time, he reads, writes, travels, and never misses a chance for brunch. He owes his life philosophy to Albert Camus and Adventure Time, equally.