No One Left to Save

“Do you want to call time of death?”

I stared up at my resident Hassan, shocked by his question. My stethoscope was still pressed to the elderly patient’s emaciated chest. Her agonal breaths, those last shallow breaths the body takes before death, had ceased. Only silence filled my ears.

Hassan smiled at me. I knew that he was offering this to me as a reward for all my hard work, but still, I was stunned. My throat constricted as I looked around the hospital room: the dozen framed family photos at the bedside, the fluorescent lights, the mountains green and lush outside the window. I observed the woman’s white hair, pale face and eyes rigidly fixed on the ceiling. I felt my own lungs begin to heave.

I was a third-year medical student on my internal-medicine clerkship, trying to learn the rituals of hospital medicine, from succinctly presenting a patient case on rounds to interpreting the black-and-white shadows of an X-ray. Hassan was my senior resident. I spent my days close at his side as he taught me how to replete a low potassium level and to write a concise discharge note. He constantly tracked my work to ensure that I didn’t injure or kill someone with my inexperience.

It was a strange summer. I spent six days a week indoors in the hospital, shivering in the air conditioning. Outside, the summer was full and riotous, the air humid and hot. Every day I woke up panicked, in a cold sweat. I dreaded the long days, the peculiar smells of disinfectant and bodily fluids, and the possibility that I would fail in some unforgivable way.

Hassan, like most of the residents, was an international medical graduate who had come to this rural hospital to repeat his residency in order to qualify for a US medical license. Civil war was ripping apart Hassan’s homeland that summer.

From the first day of my rotation, I was struck by the way he greeted our team with a smile at rounds, by the kindness he bestowed on patients while slowly explaining their diagnosis and treatment and by the casual ease he exuded even when we found a patient unconscious, in respiratory failure. Although his black hair had thinned, his full, pink lips made him appear younger than his years. Every morning he arrived dressed in a pressed shirt and tie, tucked under an immaculate white coat. I never saw him eat, even though we often stayed at the hospital for twelve-hour stretches. He’d mentioned in passing that every morning he called his parents back home to make sure that they were alive.

One evening we went down to the emergency department to admit a patient. We found her sitting in the dark, wearing sunglasses. She begged us not to turn on the lights. Our careful exam was a cursory gesture, mostly for my educational benefit. Her labs and imaging had already come back showing viral meningitis: The membrane surrounding her brain was inflamed with infection.

Hassan beckoned me outside and lifted an eyebrow.

“Photophobia and nuchal rigidity [neck stiffness],” I said. “Classic findings.”

“Ah, very good. How do you want to treat it?”

“Acyclovir?” I said, naming a common antiviral medication.

“Valacyclovir: It’s better for the kidneys. I’ll see you upstairs.”

Since my answer was only partially correct, I was condemned to sit in the ER and write the admission note. That’s how it always was: success and failure intertwined, like invasive vines.

The next day, as we rounded on a new admission, a woman in her thirties who’d experienced a seizure and was found to have a mass in her brain, Hassan prompted me to review the differential diagnosis for a brain lesion. ”Neoplasm, abscess, stroke, hematoma, neurosyphilis…” I recited.

He beamed at me, pleased.

“She has metastatic melanoma. Please examine her to find the primary lesion.”

I balked at first—this exam would involve closely inspecting the woman’s body, skin and mucus membranes, from head to foot, potentially making her feel uncomfortable and even more vulnerable—then went back to her room, feeling ashamed about what I was going to ask her.

“We don’t know where your cancer came from, so I need to look at all of your skin to make sure we find the source,” I said, trying to sound composed.

To my relief, she was gracious, even helpful.

“Do you want me to turn over? Should I lift my gown here?”

I proceeded to scan every stretch of skin. Ear lobes, breasts, mouth, feet, scalp, even a gynecological exam. I found nothing.

Hassan later told me that he wasn’t surprised by this. Melanoma can be an elusive disease, and a PET scan would probably be needed to narrow the search. I wanted to scream at him, overwhelmed with the futility of my task, the humiliation of putting the patient through the exam with no answer, and the unbearable realization that she was dying. But we had too many patients to attend to, and too many notes to write. If we slowed down to consider the consequence of every diagnosis, we would collapse under the weight of it all. The next day she was transferred to the oncology team, and a week later I rotated off service. I never learned what happened to her.

Looking back all these years later, I realize that Hassan’s aim was to prepare me for the suffering I would witness, attempt to relieve and perhaps inadvertently inflict as a doctor. I believe that he had grown fond of me, and he wanted me to be successful. As my final days with him approached, he gave me every possible opportunity to get more hands-on experience.

Which is why, now, he had called me into this dying woman’s room: to give me a lesson about death.

I hadn’t known what I was walking into. The room was so quiet and empty. Where were her family members, all those smiling faces in the photos surrounding her bed? I knew her history from our team rounds earlier that morning. Her body had been steadily shutting down for days: She had stopped eating, her kidneys had failed, her mind was wild with delirium. She was very pale, her skin pulled taut across her thin face. Her body was still, except for the final slow, irregular breaths.

I had seen death before, but never up close like this. I was curious, but also terrified, my own pulse throbbing furiously in my neck. I couldn’t believe that I, who’d not met her until this moment, would behold the end of her life. I wanted to hold her hand or whisper some words of comfort, but she was passing quickly, and Hassan had made it clear that I was there to learn what death looks like.

“Time of death 4:32 pm,” I blurted out.

Hassan patted my shoulder and hurried out the door. The work of the doctors was done. There was no one left to save.