Monday, February 14, 2005

Dead or alive?

The boundaries that divide Life from Death are at best shadowy and vague.
Edgar Allan Poe: Premature Burial (1844)

According to this article, a hundred billion people have been born. Out of those, about a hundred billion have died. We the living are here but for a fleeting moment, mere links in the great chain of human existence.

I'm still in a morbid mood. So this is going to be another one of my more-or-less existential posts.

One of my patients joined the Air Force last night. Good for her, given the circumstances. She was in her eighties, paralyzed and couldn't talk. She was barely conscious, with no hope of recovery. Another one is silently waiting for death. He won the Jackpot this year: metastasized pancreatic cancer plus a massive stroke. I've been giving him as much morphine as the nurses can carry. Finally this morning he seemed free of pain. I was happy about it. The morphine will expedite his vacating the runway, but he's had the clearance from Heavenly Air Traffic Control for some time now anyway.

Ever wondered how you can tell for sure whether someone is dead or alive? It's not always easy, you know. If the head is separated from the body, it's a pretty straightforward diagnosis. Sometimes it can be tricky though, and for laymen I imagine it might not always be obvious. Generally, the dead do not breathe, they do not have a pulse, and they don't react to anything at all. If you find someone who fulfills these criteria, chances are they've cashed in their chips. Should you start CPR, then? If you see a person collapsing and then find out that they don't breathe or have a pulse, go for it. But if you find your 90-year-old grandmother in said state, you'd be wasting your time. If you notice signs of rigor mortis, meaning the body is rigid, they've been dead for several hours and beyond the reach of any Earthly medicine.

Speaking of the Beyond, there is something called the "Lazarus phenomenon". That's when CPR (resuscitation) is deemed unsuccesful and therefore ceased, and after a while the patient gets spontaneous circulation and starts breathing. It's very rare, but it happens. When a patient is brain dead and moves spontaneously (due to spinal cord reflexes), that's called a Lazarus sign. We see that sometimes in the neuro ICU. Another tricky situation is hypothermia. There's a medical adage, "nobody is dead until they're warm and dead". Which is to say, severely hypothermic patients may recover after surprisingly long periods of apparent death, once warmed up. So maybe Mr. Poe was right.

I've seen many deaths. It doesn't bother me much anymore. We doctors builds a huge defensive psychological wall around ourselves, and the most terrible things can bounce off our psyche like rubber balls. It has its disadvantages, though. Sometimes we may appear "cynical" when we really are not, it's just a mechanism of preserving our own mental health. Someone's death or suffering still affects those caring for them, and sometimes the defensive bubble is filled from the inside, and when it overflows, I sit down and write a new morbid post in my blog.

Death can be a good thing, like for the patients that I mentioned above. Sometimes though, it's terrible. The death of a child is always hard to take, and accidental deaths involving several family members are the worst. The Tsunami, of course, was the ultimate random death-dealer. I treated some of the victims, and talked to their close ones. Was not fun at all.

Things happen so randomly. An orderly gets squeezed to death by a trash can in the elevator, a child drowns in knee-deep water, a youngster gets killed by snow falling from a roof. Never know what's gonna happen, and to whom it's gonna happen. I call it the Great Fly-Swatter of God.

Right now I'm acutely aware of my own mortality (writing this post sure didn't help). When will I kick the bucket, buy the farm, throw in the towel? These euphemisms bring to mind my personal favorite, translated from another language, "throw the spoon in the corner". It's absurd. Just like life and death.

So it goes.

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