4 minute read
ONE DEATH IN JACKSON MEMORIAL HOSPITAL
By Frank Skilling, M.D.
“We had the experience, but we missed the meaning.” T.S.
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Eliot
“Life can only be understood backwards, but it must be lived forward.” Soren
Kierkegaard
In the early 1960s, there was a weekly TV melodrama called “Ben Casey.” The opening credits depicted the senior surgeon, Dr. David Zorba, writing five pictographs on a blackboard while he intoned, “Man, Woman, Birth, Death, Infinity.” It was an attempt to reduce the cycle of life to fit the contemporary theme of medicine as conceived by the writers.
I hadn’t thought about it for years, but now, over fifty years past my graduation from medical school, I recall it as a summary of an experience that has stuck with me since my early medical training.
I was an intern at Jackson Memorial Hospital (JMH) in Miami in 1973 when I was paged to the Emergency Department late one night to admit a patient who had been brought in by the ambulance service. I’ll call her Estelle Russell. She was a sixty-two-year-old white woman who’d been found unresponsive in her apartment in South Miami. I had no past medical history to go on. She was unaccompanied, and no relatives were listed. I immediately realized that she was severely dehydrated and in extremis with dangerously abnormal vital signs. After admitting her to one of the ancient non-air-conditioned wards at JMH, I did all the things that I had been taught to do: lab studies, urine cultures, blood cultures, chest x-ray, abdominal x-ray, IV fluids. An initial chest film showed an opacity in one lung, so I immediately started IV antibiotics because I thought that she might have pneumonia. Over the next several hours, her vital signs continued to deteriorate, and on early morning rounds, it became clear that she was going to die. I gave her IV steroids, a vasopressor, and more antibiotics. She died about 11:00 AM, less than ten hours after admission. I was at the bedside when she died. I obtained permission for an autopsy because no clear cause of death could be ascertained.
A few weeks later, I was ordered to present her story at the weekly M & M (morbidity and mortality) conference. After my presentation, I was given a scathing evaluation by the chief of internal medicine who berated me for not finding a cause of her systemic collapse and for not saving her. He was sure that she had an occult infection that I had missed. Even though I’d given her the prescribed treatments for a comatose patient at the time, he was sure that I’d missed something. I stood at the podium without responding. As was the custom, the autopsy results were then presented to the audience. The head of anatomical pathology delivered his findings: there was no infection in the lungs and the cause of death could not be determined. Her demise remained a mystery. With this conclusion, I felt justified in my care for Estelle Russell, but I was humiliated, nonetheless.
Now that I’ve passed the age when Estelle died, I more intently recognize that the cycle of life is one that carries its meaning primarily in how we live and die in the context of others. The lonely, the abandoned, the unrecognized are swirling around us, and it’s only in the presence of our spouses, families, and loved ones that the chalkboard chain of men, women, birth, and death holds us together. Infinity, the last symbol on the TV show’s introduction, is essentially a breath or a heartbeat away. Each person’s journey is solitary without the support of our family and loved ones.
Maybe this is why Estelle Russell’s death has stood out in my memory for over 50 years. I attended many deaths as a medical student and intern, but I remember hers more for the loneliness and abandonment that she experienced than for the medical aspects of her case. I can only speculate that perhaps she was aware that I was there when she died.
This is one of the most difficult aspects of medical education: we learn how to be doctors, to practice delivering medical care, but the implications and context of our practice isn’t realized personally until much later. During our training we’re so busy cramming facts into our heads that we can’t or don’t appreciate the great gift that we’ve been given to join a healing profession. Likewise, we put into the backs of our minds that what happens to our patients will inevitably happen to us eventually. We humans, who are eternally obsessed with determining who’s in charge or who’s ahead of us, eventually find that “all who have died are equal.”
We’re now living in the age of corporate healthcare (no longer called medical practice). Physicians have become replaceable cogs in the great wheel that doles out industrial style medicine. Everyone is a member of the “healthcare team,” but no one physician appears to be in charge. Since few patients have a designated full time primary care physician anymore, it’s a lottery who will care for them when problems arise. I certainly don’t think that “the good old days of medicine” were all that good, but at least there could be some semblance of acknowledgement or recognition in the encounters that patients had with their physicians. Ironically, hospitals are returning to their roots in medieval times when they were constructed to provide a place for people to die if they could not afford to be cared for at home. Most Americans say that they want to die at home surrounded by loved ones, but many of us will die in a hospital anyway. Estelle Russell was a harbinger of the fate that still awaits many today.
R.I.P. Estelle. I was your last human contact before infinity. I haven’t forgotten you.
