Exit Strategy

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Something had just happened that I didn’t understand. A man had stared death in the face and winked. But more than that, the life he had exuded, even in the moment of dying, seemed to still  be present. His son was different. I was different. More alive. More human.

I felt a little awkward as  the gray-haired man, every bit as big as me, draped his arms around my neck, laid his head on my shoulder, and wept loudly outside the trauma room. I stood stiffly. I had no words of comfort for him. His only son, a strong, handsome boy of eighteen, had just been declared dead by me. He was the victim of youth, speed, alcohol, and his own sense of invulnerability. The father’s pain pierced through my shield of professionalism only briefly to wet my eyes, but I quickly put it aside, dealt with the issues at hand, and moved on to the next patient. I handled the reality of his loss the same as I always did. Don’t get me wrong: I felt compassion for his pain. But death in the ED is a commonplace event. So death competes with distraction, fatigue, hunger, and intellectual curiosity. Sometimes it is simply one powerful experience among many.


When I was a kid one of my favorite games was playing war with my brother. And the best part was when one of us died. My brother used to climb up on the dresser and let me “shoot” him. He would then have a spectacular dive onto the bed, bouncing to the floor, followed by a long period of thrashing about as he died. He would always freeze in some funny position of “rigor mobus” as we called it. Like most kids, I had seen thousands of people shot, stabbed, and strangled on TV. And it looked like great fun. I suppose it could have turned me into some sort of sociopath. Instead it just made death feel very unreal.

Med school just reinforced this feeling. After my initial discomfort with dissection of a cadaver, I became very familiar with it. Like most med students, we gave a funny name to our specimen, ignoring the fact that the body we were cutting and probing had previously been a living person. And as the dissection proceeded, the body, and the person it represented, faded into its separate parts. The ugliness of death became completely lost on us.

We became much like the young marines that I encountered later in life. More than just watching violence on TV, they had grown up with high definition video games that tried to approximate the feeling of real warfare. Many desperately wanted to get into combat to see how it felt in reality. If they survived unhurt from a firefight they would be pumped up like a winning football team at halftime. But it all changed when one of their buddies was cut in half by an RPG. There was no chest bumping as they stood by watching a friend bleed to death from a gunshot to the neck.


Teenagers in general are like that. They are notorious for thinking that they will live forever. They consume poisonous amounts of alcohol and shoot things into their veins that were cooked in filthy spoons. I’ve grown accustomed to their blank looks when I’ve explained to teenage girls that their promiscuity is exposing them to unwanted pregnancy, disease, chronic pain, or sterility. Middle-agers are no wiser. Tell them that an airliner has a one in five chance of crashing and they would never think of getting on the flight. But tell them that their smoking has increased their chances of dying fivefold and they ignore it saying, “Maybe it’s just my time.”

I once saw this sense of fatalism played out in all its grimness. After calling an end to a cardiac resuscitation effort on a man the same age as myself, I went to the grief room to tell his wife. Feeling a little closer to the situation, I braced myself for the wife’s emotion and its impact on me personally. Entering the room, I found a middle-aged woman, plainly dressed, sitting all alone with a blank expression. I knew that she suspected the worst, but her reaction still took me by surprise. I informed her that we were unable to resuscitate her husband, saving the more stark statement for last: “I’m sorry to say that your husband has passed away.”

I expected the dam of emotion to break. I reached out to comfort her. But there was no reaction. None. She sat quietly for a brief moment and then abruptly stood up saying, “I’ll call the funeral home to come pick him up.” The experience left me dull and lifeless.

It reminded me of an episode I had seen on Animal Planet. The narrator whispered to the viewers and the tension built as we watched a lion creep up ever so slowly on a herd of grazing zebras. Then, with an adrenaline explosion of violence, the lion made his move. The herd ran for their lives as the lion singled out the weakest one for the kill. The viewers recoiled at the thrashing of the young zebra locked in the jaws of the lion. But when the animal finally died, everything returned to a peaceful setting. The remaining zebras went back to grazing, virtually within sight of the lion devouring the kill.


I feel like I’ve done that sometimes. In the rush of a code blue there are shouts of orders. The orderly sweats as he pounds on the chest. Blood gushes from central lines and chest tubes. But then, it all seems to come to a dull end. The person that existed before just becomes a thing—the body—to be viewed, prepped, and disposed of. People resume their conversations, jokes, and stories. Life goes on. We immediately switch gears to other issues. I found myself even hurrying to get to lunch one day before the cafeteria closed, almost forgetting to go to the grief room to tell the family of the death of their loved one. Another day, another death. If it didn’t involve any care I had rendered, the death of a person was of only a passing interest to me.

Is this how I’ll die? I stopped to ponder one day. Will some doctor who has a million other things to do pound on my chest for what seems an appropriate amount of time and then go back to doing what he was doing before? Will it just be another day, another procedure?

Then I met Albert. That wasn’t his real name, of course. It could have been Ralph or Ed. But he was anything but nameless to me.

When I picked up his chart I noticed that the chief complaint was “severe respiratory distress.” But I noticed that he wasn’t brought in by ambulance. Something didn’t compute on this one. My first impression of Albert was that he was thin to the point of emaciation; his hands looked like skin stretched over a boney frame. With each breath, his thin shoulder muscles lifted his rib cage as if it weighed hundreds of pounds. His mouth gaped open to draw in the tiniest breath. His sunken eyes seemed to beam, though, like headlights shining from a cave.

“Call respiratory therapy and get a vent,” I called out to a passing nurse. “We need to get ready for rapid sequence intubation.”

“He doesn’t want it,” the young man standing at his side said with a grimace. “He’s been expecting this for quite some time. And he has been clear that he doesn’t want to be on a ventilator.”

“I don’t think you understand,” I said impatiently. “He’s going to die, right here, right now, or within minutes, if I don’t intubate him.”

“He knows that,” said the young man whom I was beginning to realize was his son.

“I don’t want to seem uncaring,” I said, perplexed. “But why is he here then? Who brought him here?” I was anticipating a typical conflict. The dying patient doesn’t want resuscitation, but the family loses their nerve to carry out the patient’s wishes when the moment of truth arrives.

“He knows he’s dying. But he asked me to bring him here. He said he didn’t want to make my mom see him suffer like this. He said you guys are experienced at seeing someone die.” Albert shook his head in agreement between gasps.

“I want to help you live, not help you die,” I said to Albert with a tone of frustration. He simply reached out his boney hand and patted my hand paternally. I took a deep breath and sighed, almost as if my breathing was giving him air.

“He has end stage lung disease, as you can see,” said his son. “He worked for years in the mines. His doctor sent him to a variety of specialists. But they all say that they have nothing further to offer him.”

“Can I at least give you a little oxygen? It might help.” I wanted to do something, anything. He only responded by continuing to pat my hand as if to console me. Then he gave a very slight smile. I tried to return it, but the sight was truly ghastly.

My mind raced to find something else to do, inside or outside the room. I asked a whole list of irrelevant questions, which the son answered calmly without taking his eyes off his father. I performed a cursory physical exam confirming what was already obvious, he was dying. With nothing further to do, I wanted to leave the room and resume some busywork at the nurses’ station. But something held me at his side. I held his hand, or rather he held mine, as I stood on the other side of the bed.

“Are you sure you don’t want me to do anything more?” I almost pleaded with him. He looked at me, gave that twinkle of a smile, and winked. He took one more gasp like a diver about to make a deep plunge…and died.

I didn’t look to the clock to note the time of death. I didn’t break for the door to write my note or resume seeing patients. I just stood there holding his lifeless hand, contemplating the moment. Something had just happened that I didn’t understand. A man had stared death in the face and winked. But more than that, the life that he had exuded, even in the moment of dying, seemed to still be present. His son was different. I was different. More alive. More human.

I finally left the room to find any other family members to inform them of his death. But the grief room was empty. “Oh, there’s way too many people to fit in there,” the charge nurse had informed me. Opening the door to the waiting room I was confronted by a huge number of people, some pacing, some sitting quietly. The crowd silently parted to make a path to a little old woman seated in the corner. She had the same twinkle in her eye that I had seen just moments before. Having nowhere to sit beside her, I simply took one knee to be at her level. I took her hand and introduced myself. But when I started into my standard spiel of “We did all we could do, but…” my throat tightened and a tear leaped from my eye. She took my hand, patting it gently as her husband had done. I couldn’t say he had died. I just shook my head as if to say No. She smiled patiently and nodded her head Yes.

After a long moment I rose to answer questions from the family. But instead of the usual “Did he suffer?” questions, they each in turn told their story of this great man’s love, kindness, hard work, humor, gentleness, and on and on. One told of him taking his Saturdays to help them rebuild their worn-out kitchen. One teen told of being saved from an unjust punishment by his understanding intervention. After a long period that left me feeling refreshed, the charge nurse finally appeared at the door, signaling that I needed to get back to work. I knelt one more time to console Albert’s wife. But this time she pulled me to her face and kissed my cheek. “Thank you for helping him,” she said.

I returned to the rush of the ED, but never really left the spirit that was in that waiting room. When it was time to go home, I cleaned up the last charts and headed for the car. Is that what it’s supposed to be like? I asked myself.

My drive home led me through quiet stretches of highway with the Delaware wetlands reaching for miles on either side. As the fog rose to filter the morning sunlight I came to my answer. As gruesome as it might have seemed on the surface, I wanted to die like that man. I wanted to be able to look honestly at all the ugliness of death and still wink in defiance. Now I just needed to figure out how to live like him.

EPMonthly is excited to announce the upcoming publication of Mark Plaster’s…

“Night Shift:
Short Stories from the Life of an ER Doc”

Based on more than 30 years of experience in emergency medicine, the book features a collection of articles originally published in Emergency Physicians Monthly.
– Introduction by the author
– Foreword by Dr. Greg Henry

Available on Amazon soon

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