The Dark Mirror
Volume 57, No. 2, P. 146
Death can be viewed from many angles:
I die, you die, he-she-it dies.
We die, you die, they die.
Death is the ultimate disconnect, yet it tells us much about our living selves, serving as a dark mirror that reflects the truths obscured by our vitality.
Chance, risk, fate – what do they mean to you? What do they mean to me?
One of the patients I cared for during my fourth year of medical school needed open heart surgery for severe aortic stenosis and mitral insufficiency, a procedure that back in the 1970’s carried a mortality of almost fifty-percent. When an orderly came to wheel him off to what might be his doom, the patient wouldn’t budge, clung to the bedrails, resisting every plea for fifteen minutes so he could finish watching the latest episode of As the World Turns. The moment it was over, he thanked the orderly for waiting and climbed onto the gurney.
Should we flee from Death, or rush to embrace Him before He reaches our door? The annals of ophthalmology record a case of what one might call anticipatory suicide. An anthropologist in her early sixties, healthy except for a mastectomy five years before, attributed the visual loss in her right eye to a recurrence of her breast cancer. In a fit of despair, she and her husband killed themselves with overdoses of Phenobarbital. An autopsy showed that her blurred vision was due to optic neuropathy, a localized inflammation of the optic nerve. There was no sign of malignancy anywhere in her body.
Audie Murphy was seventeen years old when America entered World War II. He had the physique, the voice, the cherubic face of a choir boy, yet during numerous assaults through withering enemy fire he killed 240 German soldiers using only hand-held weapons, including on one occasion a Nazi machine gun seized behind enemy lines. By expert reckoning, the most dangerous of these assaults carried a risk of mortality greater than 90 percent.
I had to face down my own fear of death. At the height of my flying phobia, a table published by the Federal Aviation Administration informed me that each commercial flight presents a risk of one in 1.73 million, a fact so reassuring I needed only twenty-five milligrams of Librium to get on an airplane and one martini an hour to stay on it without keeling over in a faint. I always packed four or five Beefeater miniatures in my carry-on bag in case the pilot cancelled beverage service because of rough weather.
Audie Murphy survived World War II. In 1971, he died in plane crash.
If Death is the Eternal Footman, should we give Him a tip? During a PBS special on Vladimir Horowitz, the narrator interviewed Wanda Toscanini Horowitz, Vladimir’s widow and the great conductor’s daughter. She spoke fondly of the over-stuffed chair in which she sat during the interview. In that chair, at the age of 85, with all his faculties intact, Vladimir had suffered a quiet and painless death.
“My friends call me strange for keeping such a thing around,” she said. “They insist I should get rid of it, but this chair is my favorite object in all the world. I sit here often, especially in the evening.”
* * *
Maggie Mae Smith, a tiny, vigorous, rawboned woman in her late 80’s, came to the orthopedic ward at Santa Clara Valley Medical Center with a broken hip. I was her intern, and found her pleasant enough, but the nursing staff lost their hearts to the old lady. She was all smiles and compliments, grateful for every kindness. Never in her life had she allowed anyone to wait on her. A delightful but difficult patient – she never pushed her call button, wept with vexation when she had to request a bedpan from a passing aide, heaped thanks on the technician who drew her blood. The morning after her admission, I caught one of the aides tying ribbons in Maggie’s remaining wisps of snow-white hair, and the next day the charge nurse grilled the chief ortho resident with anxiety in her voice. “Doctor, Maggie’s surgery – how does it look?”
It didn’t look good. The broken hip was bad – a technical challenge, soft and chalky from osteoporosis – but her heart was the real problem. She had ventricular hypertrophy, congestive failure, atrial fibrillation with runs of ventricular tachycardia. The anesthesia resident raised her eyebrows, wrung her hands, finally called the chairman of anesthesia down to examine Maggie himself. He threw a fit. General anesthesia was out of the question.
That news sent Aaron Mason, the attending physician on the Orthopedic Service, into a fit of his own, since he had never done a hip replacement under local anesthesia. A six-foot-six bench-warmer for UCLA during two NCAA finals, he was proud and stuffy and – according to the chief resident on the ortho service – almost as good a surgeon as he thought he was. He had curly blonde hair. Behind his back, while he scrubbed his huge hands at the OR sink, the nurses giggled and rolled their eyes. “Ohhh,” they said, “here comes Doctor Goldilocks.” He laughed often, raucously, but it was the laugh of a man whose heart is filled with dust. His arrogance almost got his ass kicked by Maggie Smith’s son, a sturdy fellow whose half-bald head hovered an inch or two below Mason’s red bowtie.
“Mr. Smith,” Mason said, “you need to understand that, if we operate, your mother might not survive the surgery.” His voice was loud, strained. I suspect he was afraid Maggie might blemish his record by dying under the knife, but he came across as impatient and patronizing. “I want to do the best for her, but, in this case, perhaps the best thing is to leave her alone.”
Smith said, “Jesus Christ,” then turned on his heel and strode out of the conference room. He paused in front of a row of vending machines across the hall. Through the doorway, Mason and the chief resident and I watched his back as he studied multicolored bags of Doritos, Cheez Whiz, Lay’s Potato Chips. He didn’t buy anything, but after what seemed a long time he strode back into the room and stood before Aaron, rocking a little on his heels, tilting his head back to look up into that handsome, startled face.
“Doctor Mason,” Smith said, “I’m not an idiot.” There was a quaver in his voice, a quaver that spoke not of tears but of an iron will. His eyes bulged with anger. Mason backed up a step. Smith followed him.
“Of course my mother may die,” he said. “She’s eight-nine years old. But if you don’t operate, she’ll for sure spend the rest of her life in a wheelchair, and for her that would be ten times worse than death. Why don’t you stick to the bones and let my mother and me worry about the rest?”
The next day we operated under spinal anesthesia. Maggie didn’t turn a hair. She lay on the OR table wide awake, a frail, copper-skinned doll wearing a gauze mask and a powder-blue surgical cap. We laid her on her side for the spinal injection, tucking knees to chin until her ribs and vertebrae curved like the markings on a conch shell. The only sound she made was a soft grunt when the needle popped through her dura matter. When she was numb as a stone from the waist down, I scrubbed her naked hip with Phisohex, stained it with Betadine, then helped a nurse lay on surgical drapes until all that showed of Maggie’s torso was a maroon-colored square of sterile flesh.
During these maneuvers, Maggie gazed around the OR like an awe-struck child. “This is such a wonderful place,” she said. “I’ve never seen anything like it in my life.”
Three hours later, Maggie lay in the recovery room with her femur pinned and the wound on her lean brown hip sewn tight. Her vital signs remained stable. By dinner time she was back in her room.
That evening the ward clerk interrupted rounds to give me a message:
“The Smith family wants to talk to you.”
I went over that sentence again and again in my mind, and of this I am certain: nothing the clerk said, neither her words nor the tone of her voice, carried a hint of urgency. Yes, I am certain – “The Smith family wants to talk to you.” That was all.
After rounds, I treated a wound infection, then changed three dressings. A morbidly obese patient fell on the floor and had to be hoisted back onto her double-wide bed. Finally I washed my hands and went to Maggie’s room. She lay alone, her thin arms resting by her side on top of the sheet. She was dead. When I put my hand on her forehead, it felt cool. Her eyes were half-closed. The exposed corneas had begun to cloud over with the ground-glass haze of dehydration.
I called the son to tell him his mother had died.
“Yes, I know,” he said. His voice was full of grief, a dry, unbroken grief, weighted with a sorrow beyond words. There was no quaver, no sobbing, just exhaustion and heartbreak.
“You . . . you already knew?” I said. A surge of guilt twisted my tongue. “I’m sorry . . . didn’t know . . . the clerk, she didn’t say . . . rounds went on . . . I got there quick as . . .”
Smith waited until I stammered into silence.
“We were all there,” he said. “We were talking to mother and she just faded away. At first we panicked, my son Jamie ran out, said something to somebody about getting a doctor, then we looked at each other. We waited. Nobody came. It was a blessing.”
“You . . . you didn’t stay?” I said.
“Jamie said for sure you guys would be pounding on her chest. Jamie said you had to, it was part of the rules, no matter what. He said you might break her ribs. We didn’t want to watch somebody pounding on our mother. We waited ten or fifteen minutes. Everybody kissed her. Then we left. ”
“But . . .why?” I asked. “Didn’t you know . . . we might have revived her . . . ” Even as this nonsense dribbled out of my mouth, I choked on my stupidity. Or duplicity. What kind of a world do doctors live in?
Maggie’s son was on me in an instant.
“And tell me doctor, what happens when you stomp the life back into an eighty-nine-year-old woman?” Now his voice quavered, but with anger, not sorrow. “What’s left lying there in that bed after you get through breaking all her ribs?”
The son was a forgiving fellow. Of course he was right – our chances of bringing his mother back from the grave as anything other than a vegetable or a hopeless cripple were less than one in a thousand. Perhaps he sensed the remorse in my voice, or felt sorry for the fool I had made of myself. I don’t remember what I said, but somehow, with brazen persistence, I found myself asking permission for an autopsy. Our Chief of Staff reminded us every week at morbidity and mortality rounds: if we don’t know why the patient died, we’ll never get any smarter. Maggie’s son interrupted my wheedling, semi-coherent pleas.
“Yes, Doctor, you have my permission for an autopsy. If . . . if you think it will help. Mother would have wanted it that way.”
The son was wrong about one thing. By the time I arrived, Maggie’s body had grown cool enough for me to talk my colleagues out of pounding on her chest, but I didn’t tell him that. I did call him a week later with the autopsy results: brittle plaques filled Maggie’s coronary arteries and choked off her aorta, leaving her heart a sea of infarcts. Only a few tenuous collaterals fed the surviving myocardium. The woman had a dozen good reasons to die. For years, perhaps a decade, she had lived on borrowed time.
* * *
Then there was Elmer Smith. Yes, Smith – a small but striking irony, since, measured by the scale of human worth, this poor man lived on the opposite side of the universe from Maggie Smith. He almost won me the Q-Sign Trophy, an unofficial award given each month to the intern with the most dehydrated patient. Q-Sign refers to an open mouth with a tongue drooping out one corner, the classic presentation when a patient’s serum sodium rises so high from loss of fluids it puts him into a coma. Elmer’s value, 203 milli-equivalents per liter, would kill a camel, but that month a rival intern beat me out with a rich boozer who had fainted in his sauna and boiled his sodium up to 217 before someone found him.
When they rolled Elmer in from the ER at the Santa Clara Valley Medical Center, he was hanging by a thread. His chart told a dismal story: Wernicke-Korsakoff syndrome, the technical term for alcohol-induced brain rot, had left him in a vegetative stupor, and, after eight years in a nursing home, pneumonia plus a summer heat wave and a failure of the home’s air conditioning system had turned his body into a pillar of salt. He was born in Australia, emigrated to California in his thirties, served as Tiburon’s mayor and ran a Mercedes dealership until one fateful Sunday morning when he showed up for mass at the Holy Saints Church wearing only his underwear and a pair of sandals. He was disoriented, confabulating, and – a bad sign – stone cold sober. The neurology service at Pacific Medical Center gave Elmer their best, but by that time the booze had washed away too much gray matter.
With his wasted torso and age-darkened skin, Elmer resembled nothing so much as a rusty railroad spike. His head was a skull. His crusted lips formed a perfect O, while his tongue, dry as a cinder, was stuck to the corner of his mouth. His pulse and respirations were barely detectable.
My resident washed his hands of the case.
“Elmer’s all yours,” he said to me. “Just don’t do anything heroic. You’d better get hold of his family and hang some crepe.”
Only one signature appeared on the sign-in sheet taped to the front of Elmer’s nursing-home chart, repeats of the same elegant script – Mrs. Eleanor Smith Huber. At first the visits came every week, then, for a while, every month. Five years had passed since the last visit.
Eleanor Huber wore a green silk dress, matching high-heeled shoes, three strings of pearls. Amidst the gray walls and coffee-colored linoleum of Valley Medical Center’s charity ward, she shone like an emerald. She was tall, statuesque, spoke with a cultured Australian accent, but in her subdued, down-gazing face I saw hints of ancient violence: a back-lit figure lurching through an open doorway, the shouts and slaps of nightly rages.
“Is he . . .” she said, but her voice broke off. She clutched a small black purse to her chest and stared at the floor. Silent tears flowed down her cheeks.
“It doesn’t look good,” I said. “He has pneumonia in both lungs, and his body is terribly dehydrated.”
“What are his chances?”
“His chances? Well . . . ” This was an intelligent woman, I thought – surely she could see that after eight years of vegetative coma her father’s time had come. “To be honest, we don’t expect him to live.”
Her head snapped back. For the first time her eyes met mine. She frowned, wiped a tear from her cheek with the back of her hand.
“If he’s that sick, why don’t you put him in the intensive care unit?”
“The intensive care unit? Well . . . he’s very sick, but . . . his mind . . . he’s been gone for years. We hadn’t planned to use aggressive therapy.”
“Doctor!” she gasped, glowering at me. Her face darkened. “Why that’s . . . that’s murder.”
When I reported this conversation to my resident, he covered our tracks by ordering the nurses to put a daily dose of Gantrisin down Elmer’s nasogastric tube. It didn’t cure his pneumonia.
We never saw the daughter again.
* * *
Elmer and Maggie Mae taught me the subtleties of death. When love runs deep, when the heart remains truly bound and unconflicted, death is not the enemy. But this was abstract knowledge, a philosophical insight that at the time seemed far removed from my own life, while Bryan Cubbage’s death gave me a personal torment unlike anything I have ever known. He was a harmless old veteran by the time I met him at the Palo Alto VA Hospital in 1971, but in his past, after emerging unscathed from Utah Beach and three assaults on the Siegfried Line, he had acquired a dozen tattoos, needle tracks down both arms, a knife scar from his umbilicus to his sternum.
“They cut me good,” he said. “I was a stupid shit, paid for a bag of horse with a phony hundred. They should’ve killed me.”
Now a loose-skinned man in his fifties, blowsy and disheveled, he attended AA meetings every week and lived a quiet life. Eczema had given his skin a frosty patina of scales. His stringy, uncombed hair was flaked with dandruff. Radiation therapy for squamous cell carcinoma of the tonsil had marked his left ear and neck and jaw with a red splotch. The radiation plus three courses of chemotherapy had dropped his white count to a dangerous level, but he felt well, ate well, passed his hours watching television and sharing war stories with his fellow veterans in the hospital lobby.
Amid the dilapidation of Bryan’s person, there lurked one precious item. This slothful man, a sartorial and hygienic calamity, was obsessed with time and with the jewel-bright instruments that measure its passing. On his wrist he wore a Bulova Accutron. I had read about it in Popular Mechanics. It costs hundreds of dollars. The New Yorker ads showed a gorgeous man, clean-flavored and imperially slim, his wrist aglitter with an Accutron. Bryan’s Accutron was solid gold, eighteen caret, its second hand turning not in jerks but smooth as butter, smooth as the turning of the earth itself.
“Come on, Doc,” he said one evening. “I’ve got something to show you.”
He led me to his room to hear a broadcast from the Greenwich Observatory. We leaned over the short-wave radio on his bedside table, our heads so close I could smell the musty odor of his unwashed hair. First we heard only the rhythmic ticks of a metronome marking one-second intervals, but then, after a few seconds, a mechanical voice droned, “At the tone, the time will be twenty-two fifty-two Greenwich Mean Time . . . tick . . . tick . . . tick . . . tick . . . beep!” I felt a thrill when the sweep-second hand of Bryan’s Accutron fell dead on the money.
A week later, I was down the hall helping my resident intubate a comatose cirrhotic when Bryan suffered his first cardiac arrest. Someone called a code over the intercom, and within seconds a crush of doctors and nurses exploded into the room. Scrub suits, white caps, IV poles waving about, a respiratory tech clattering down the hall with a crash cart trailing hoses and extension cords.
“Gimme that scope!”
“Where’s the endo tube?”
“Epi, where’s the epi?”
“I’ve got the paddles, gimme some paste . . . ok, stand back.”
It worked. A few seconds after the defibrillator sent a spine-arching jolt through Bryan’s body, the EKG monitor showed sinus rhythm. Minutes later he moved his arms, turned his head, stared wide-eyed at the circle of faces around his bed. He gestured for someone to take the endo tube out of his trachea. His blood pressure measured 90/60, pretty good for a man ten minutes away from cardiac arrest, so my resident pulled the tube, but he should have known better. Considering the IV fluids and the blast of epinephrine we had pumped into Bryan, the pressure should have been higher. Three days later, when the blood cultures grew out E. coli, we realized all had been lost from the first moment. Bryan was in florid Gram-negative sepsis.
An hour after the first arrest, he coded again. I was there. His eyes closed and he stopped breathing. The cardiac monitor showed ventricular fibrillation. The doctors and nurses rushed back. For half an hour, they prodded and cajoled his infected body, but this time he stayed dead. His sphincters loosened, the fecal smell of death filled the room.
The admitting clerk had marked the front of Bryan’s chart in bold red letters: CATHOLIC. With Catholics, we always left the respirator going until a priest had delivered Last Rites.
The priest showed up after midnight. His eyes were glazed with sleep behind gold-rimmed spectacles, but he wore immaculate vestments, and his iron-gray hair gleamed with pomade. His pomade or aftershave smelled like lemons. I hoped he would not suspect the truth, hoped the rhythmic hiss . . . clunk . . . hiss . . . clunk . . . hiss . . . clunk . . . of the respirator would give the illusion of life, but at the first anointment, the instant the priest’s hand touched Bryan’s face, he shot me a look out the corner of his eye. A conspiratorial glint. Or perhaps a resentful glint, since Last Rites are meant to be given in the waning moments of life, and Bryan was already cool. We had called the poor clergyman out of bed to bless a corpse.
“Hail, Mary, full of grace, the Lord is with thee; blessed art thou among women . . . ”
A reedy voice, weaving its way through the mechanical breaths of the respirator. As the priest chanted – touching Bryan’s eyes, ears, nose, lips, hands – he continued to shoot glances at me. Was that suspicion in his eyes, glaring through those gold-framed spectacles? Did he know what was in my heart?
The priest was gone. The bouquet of lemons faded from the room. It was one o’clock in the morning. Bryan and I were alone. I unplugged the respirator. The rhythmic hiss . . . clunk . . . hiss . . . clunk . . . of false life ceased, filling the room, the hallway, the entire hospital with a silence so deep I could hear a footstep a hundred feet away.
Bryan Cubbage – dilapidated and friendless. Bryan Cubbage – the faithless lover of many women, the named father of three children, the unnamed father of who knows how many more. Decades had passed since a relative of any sort last spoke to him. No one in the world to know or care that his body lay motionless, consumed by the final agony, descending into the chill that knows no end – with a treasure strapped to one icy wrist.
It was a terrible moment. I meant to walk out of the room, but I had to sit down. I sat on a chair next to Bryan’s bed and leaned my head against the mattress. I took long, slow breaths. My soul was beyond thievery – yes, well beyond, sick to the point of nausea. In the end I did the right thing, but Bryan’s death told me more about myself than I wanted to know.