ANNOUNCEMENTS & PRONOUNCEMENTS
During my last six days as an inpatient, I have been a captive audience, listening to countless announcements through the overhead speaker system: Code Blue, Code Red, Code Stork. Though the tone of the disembodied voice is measured and calm, I know that the content of each message represents an urgent dispatch of emergency personnel to elsewhere in the hospital. The respective alerts for cardiac arrest, fire, and an endangered child remind me that there are people here in much greater need than me, each code a tiny inoculation against self-pity. This facility is much larger than my own room, and beyond my cloisters it contains many who are truly in extremis.
I also know that there are quieter summons happening here, again concerning patients with whom I should not conflate my own minor troubles. For these people, there will be no further alarms or surprises. When a patient dies having relinquished final efforts at resuscitation -- going gentle into that good night -- a different kind of call goes out, one not broadcast for all to hear.
An unsavory but formative task of medical training is being called to examine dead bodies, not the embalmed cadavers of gross anatomy but the fresh specimens of the recently expired. The process of their inspection is called pronouncement, as if you are enunciating as clearly as possible that a life is over. Legally a physician is required to declare someone dead, and in our medical hierarchy this is a distasteful duty that usually falls to the bottom of the totem pole. After all, how difficult could it be?
It’s actually harder than it looks, as more than one medical student has “pronounced” a slumbering patient. You don’t want to wake up squirming in a body bag because some trainee mistook deep and dreamless sleep for your final repose, so we follow a strict protocol looking for any vitality before we declare death. It starts with the eyes.
I’m a student of pupils. They can tell you so much about a patient, their physiology and pharmacology. Irreversibly constricted means an overdose on opioid painkillers. In the opposite direction, fixed dilation speaks of profound trouble in the brainstem, something rotten in the Denmark of our most primitive nerve center. If eyes are the window to the soul then a blown pupil indicates a defenestration: when you see it, the patient’s soul has fled through the opening. They will no longer react to light, having already gone towards it.
Next we assess response to tactile stimuli. These can be deliberately noxious, like knuckles rubbed against the sternum, such that the pain would awaken even Rip van Winkle. If there is no recoil, a stethoscope is applied to the chest, auscultating for a reassuring rush of air. The sound of breathing is an irritant to many laypeople -- a spouse’s rasping snore, for instance -- but a symphony to the ears of the internist hunting for signs of life. We are evolutionarily attuned to detect activity over stillness, and the body should be a machine in perpetual motion even when it appears outwardly to be at rest. Like the ocean amplified in a seashell, the tiniest breeze can speak to a larger movement, and so we listen carefully, the most meticulous beachcombers. Pulmonologists measure the rush of air in and out of the lungs as the tidal volume. But sometimes the tide goes out and never returns, marking the end of many moons.
Dead men tell no tales and they make no music. Adjacent to the left lung we find a drummer pushed past the point of exhaustion, the staccato beat of the heart replaced by eerie silence. In case our ears deceive us, we conclude our ritual of pronouncement where most people would think to start, by checking for a pulse. A failing ventricle might not transmit much force to the radial arteries so we don’t always trust palpation of the wrists, lest they prove too thready. Instead, we can feel for flow in the femorals, the trunk-like vessels that supply the legs, or the carotids, which climb the neck to perfuse the brain. If nothing is stirring, we call off the search and notate the official time of death.
It is a profoundly odd moment in the life and work of a doctor, to share this instant of absolute quiet with the deceased, whom in all likelihood you had just met and yet to whom you will be forever conjoined through the death certificate. As an intern manning the night shift, you know it will not be long before your pager erupts with another urgent peal, if it hasn’t already been beeping intrusively. So there is enormous temptation and ample reason to flee the bedside immediately. And yet, I would always stay for an extra beat. One of my senior residents referred to pronouncement as “watching the soul ascend,” and I could never quite tell if he was engaging in piety or its mordant mockery. But regardless of the observer’s creed, there is a sense of having witnessed some celestial occurrence, a quasar gone radio-silent.
For those of us who remain on earth, we can find some modicum of comfort in bringing out our dead and really looking at them. In doing so, we will enter the uncanny valley between person and mannequin, between performance art and still-life. We should be glad to find ourselves unduped by reproductions at the waxworks.
You may think it unspeakably morbid, but it’s the same reason I prefer open caskets at funerals. For all the garish makeup to conceal death-mottled skin, putting the body on full display reveals it for what it is: a shell. A corpse is but a vessel that has served its purpose and been emptied, a husk that once housed a cicada now in flight. Falstaff may have played the fool but even he recognized the corpse as the counterfeit of the man.
In the case of the oncologist -- no less a buffoon in some eyes -- paying last respects to his patient, I can see that an animated spark has vacated its battered container, and that I can't hurt them anymore. In our grief, let such works of mercy be our delight.