The following is from the first chapter of Sherwin Nuland's book How We Die: Reflections on Life's Final Chapter.
The first time in my professional career that I saw death's remorseless eyes, they were fixed on a fifty-two-year-old man, lying in seeming comfort between the crisp sheets of a freshly made-up bed, in a private room at a large university teaching hospital. I had just begun my third year of medical school, and it was my unsettling lot to encounter death and my very first patient at the same hour.
James McCarty was a powerfully built construction executive whose business success had seduced him into patterns of living that we now know are suicidal. But the events of his illness took place almost forty years ago, when we understood a great deal less about the dangers of the good life -- when smoking, red meat, and great slabs of bacon, butter, and belly were thought to be the risk-free rewards of achievement. He had let himself become flabby, and sedentary as well. Whereas he had once directed on-site the crews of his thriving construction company, he was now content to lead imperiously from behind a desk. McCarty delivered his pronouncements most of the day from a comfortable swivel chair that provided him an unobstructed view of the New Haven Green and the Quinnipiack Club, his favorite grillroom for midday executive gluttony.
The events of McCarty's hospitalization are easily recalled, because the startling staccato with which they burst forth instantly and permanently imprinted them in my mind. I have never forgotten what I saw, and did, that night.
McCarty arrived in the hospital's emergency room at about 8:00 p.m. on a hot and humid evening in early September, complaining of a constricting pressure behind his breastbone that seemed to radiate up into his throat and down his left arm. The pressure had begun an hour earlier, after his usual heavy dinner, a few Camels, and an upsetting phone call from the youngest of his three children, an indulged young woman who had just started her freshman year at a fashionable woman's college.
The intern who saw McCarty in the emergency room noted that he looked ashen and sweaty and had an irregular pulse. In the ten minutes it took to wheel the electrocardiogram machine down the hall and connect it to the patient, he had begun to look better and his unsteady cardiac rhythm had reverted to normal. The electrocardiographic tracing nonetheless revealed that an infarction had occurred, meaning that a small area of the wall of the heart had been damaged. His condition seemed stable, and preparations were made to transfer him to a bed upstairs -- there were no coronary intensive care units in the 1950s. His private physician came in to see McCarty and reassured himself that his patient was now comfortable and seemed to be out of danger.
McCarty reached the medical floor at 11:00 p.m., and I arrived with him. Not being on duty that evening, I had gone to the rush party that my student fraternity held to inveigle entering freshmen into joining. A glass of beer and a lot of conviviality had made me feel especially self-confident, and I decided to visit the care division to which I had been assigned only that morning, the first of my clinical rotations on the Internal Medicine service. Third-year medical students, who are just starting out in their initial experience with patients, tend to be eager to the point of zealousness, and I was no different than most. I came up to the division to trail after the intern, hoping to see an interesting emergency, and to make myself helpful in any way I could. If there was an imminent ward procedure, like a spinal tap or the placement of a chest tube, I wanted to be there to do it.
As I walked onto the division, the intern, Dave Bascom, took my arm as though he was relieved to see me. "Help me out, will you? Joe [the student on duty] and I are tied up down the hall with a bulbar polio that's going bad, and I need you to do the admission workup on this new coronary that's just going into 507 -- okay?"
Okay? Sure it was okay! It was more than okay; it was wonderful, exactly the reason I had returned to the division. Medical students of forty years ago were given much more autonomy than they are allowed today, and I knew that if I did the admission routines well, I would be granted plenty of work on the details of McCarty's recovery. I waited eagerly for a few minutes until one of the two nurses on duty had transferred my new patient comfortably from the gurney onto his bed. When she went scurrying down to the far end of the hall to help with the polio emergency, I slipped into McCarty's room and closed the door behind me. I didn't want to run the risk that Dave might come back and take over.
McCarty greeted me with a thin, forced smile, but he couldn't have found my presence reassuring. I have often wondered over the years what must have gone through the mind of that high-pressure boss of large, tough men when he saw my boyish (I was then twenty-two) face and heard me say that I had come to take his history and examine him. Whatever it was, he didn't get much chance to mull it over. As I sat down at his bedside, he suddenly threw his head back and bellowed out a wordless roar that seemed to rise up out of his throat from somewhere deep within his stricken heart. He hit his balled fists with startling force up against the front of his chest in a single synchronous thump, just as his face and neck, in the flash of an instant, turned swollen and purple. His eyes seemed to have pushed themselves forward in one bulging thrust, as though they were trying to leap out of his head. He took one immensely long, gurgling breath, and died.
I shouted out his name, and then I shouted for Dave, but I knew no one could hear me in the hectic polio room all the way down the corridor. I could have run down the hallway and tried to get help, but that would have meant the loss of precious seconds. My fingers felt for the carotid artery in McCarty's neck, but it was pulseless and still. For reasons I cannot explain to this day, I was strangely calm. I decided to act on my own. The possibility of getting into trouble for what I was about to attempt seemed a great deal less risky than letting a man die without at least trying to save him. There was no choice.
In those days, every room housing a coronary patient was supplied with a large muslin-wrapped package that contained a thoracotomy kit -- a set of instruments with which the chest could be opened in the event of cardiac arrest. Closed-chest cardiopulmonary resuscitation, or CPR, had not yet been invented, and the standard technique in this situation was to attempt to massage the heart directly, by holding it in the hand and applying a long series of rhythmic squeezes.
I tore open the kit's sterile wrapping and grabbed the scalpel placed for ready access in a separate envelope on top. What I did next seemed absolutely automatic, even though I had never done it, or seen it done, before. With one surprisingly smooth sweep of my hand, I made a long incision starting just below the left nipple, from McCarty's breastbone around as far back as I could without moving him from his half-upright position. Only a little dark ooze leaked out of the arteries and veins I cut through, but no real flow of blood. Had I needed confirmation of the fact of death by cardiac arrest, this was it. Another long cut through the bloodless muscle, and I was in the chest cavity. I reached over to grab the double-armed steel instrument called a self-retaining retractor, slipped it in between the ribs, and turned its ratchet just far enough to allow my hand to squeeze inside and grasp what I expected to be McCarty's silent heart.
As I touched the fibrous sack called the pericardium, I realized that the heart contained within was wriggling. Under my fingertips could be felt an uncoordinated, irregular squirming that I recognized from its textbook description as the terminal condition called ventricular fibrillation, the agonal act of a heart that is becoming reconciled to its eternal rest. With unsterile bare hands, I grabbed a pair of scissors and cut the pericardium wide open. I took up Mr. McCarty's poor twitching heart as gently as I could and began the series of firm, steady, syncopated compressions that is called cardiac massage, intended to maintain a flow of blood to the brain until an electrical apparatus can be brought in to shock the fibrillating heart muscle back into good behavior.
I had read that the sensation imparted by a fibrillating heart is like holding in one's palm a wet, jellylike bagful of hyperactive worms, and that is exactly the way it was. I could tell by its rapidly decreasing resistance to the pressure of my squeezes that the heart was not filling with blood, and so my efforts to force something out of it were useless, especially since the lungs were not being oxygenated. But still I kept at it. And suddenly, something stupefying in its horror took place -- the dead McCarty, whose soul was by that time totally departed, threw back his head once more and, staring upward at the ceiling with the glassy, unseeing gaze of open dead eyes, roared out to the distant heavens a dreadful rasping whoop that sounded like the hounds of hell were barking. Only later did I realize that what I had heard was McCarty's version of the death rattle, a sound made by spasm in the muscles of the voice box, caused by the increased acidity in the blood of a newly dead man. It was his way, it seemed, of telling me to desist -- my efforts to bring him back to life could only be in vain.
Alone in that room with a corpse, I looked into its glazed eyes and saw something I should have noticed earlier -- McCarty's pupils were fixed in the position of wide black dilatation that signifies brain death, and obviously would never respond to light again. I stepped back from the disordered carnage on that bed and only then realized that I was soaking wet. Sweat was pouring down my face, and my hands and my short white medical student's coat were drenched with the dark lifeless blood that had oozed out of McCarty's chest incision. I was crying, in great shaking sobs. I realized, too, that I had been shouting at McCarty, demanding that he live, screaming his name into his left ear as though he could hear me, and weeping all the time with the frustration and sorrow of my failure, and his.
The door swung open and Dave rushed into the room. With one glance he took in the entire scene, and understood it. My shoulders were heaving, and my weeping was by then out of control. He strode around to my side of the bed, and then, as if we were actors in an old World War II movie, he put his arm around my shoulders and said very quietly, "It's okay, buddy -- it's okay. You did everything you could." He sat me down in that death-strewn place and began patiently, tenderly, to tell me all the clinical and biological events that made James McCarty's death inevitably beyond my control. But all I can remember of what he said, with that gentle softness in his voice, was: "Shep, now you know what it's like to be a doctor."