CHAPTER SIX

THE DESCENT

Jay had been in the hospital since Saturday, when he’d spiked his first post-chemo fever. All through the weekend his fever raged, despite antibiotics. Over the course of Sunday, Tara grew increasingly worried about his difficulty breathing, although a chest X-ray didn’t show a pneumonia or fluid in his lungs. He’d been continually complaining that his stomach felt full. In Tara’s opinion, his abdomen seemed swollen, as did his feet. But the blood cultures had finally provided a definitive answer on Monday morning—MRSA. Methicillin-resistant staph aureus isn’t a calming diagnosis by any stretch, but once you have a diagnosis, you can at least construct a plan of action. For Jay, the plan consisted of two things—an antibiotic specifically for MRSA and removal of his indwelling catheter, since catheters top the suspect list when bloodborne staph infections are diagnosed.

Because the recent chemotherapy had devastated all his cell lines, he didn’t possess sufficient platelets to protect him from internal hemorrhage upon removal of the catheter, so Jay had to wait for hours as unit after unit of platelets were transfused into his veins. By 5 p.m., the platelet count was finally high enough, and the catheter was removed in the operating room. Afterward, Jay added another post to his blog: “Just got back from having my line out. Since this was the source of the infection, I should begin to fight it out and begin to recover. They may put another line in—by the end of the week is a possibility. Thanks for everyone’s support. It has meant the world to me. Everyone’s been so very helpful. Jay.”

But even those few lines were a struggle to write. Every effort, it seemed, tired him out. Even speaking was exhausting, and Jay was reduced to whispers for the entire day. Using the urinal was a Herculean task that consumed every ounce of breath. At 8 p.m., Dr. Amir came by. Jay mustered his strength to force out three agitated words: “I . . . can’t . . . breathe.”

“Jay seems really anxious,” Dr. Amir said to Tara. “We can give him something to help him relax.” He ordered some Ativan for sedation and Ambien for sleep.

“What about all the Tylenol he’s getting round the clock for his fevers?” Tara asked. “That could be affecting his liver, and that’s where he’s complaining of pain.”

Dr. Amir didn’t think the Tylenol was causing the pain. “His liver enzymes are only a little bit elevated, not enough to be toxicity from Tylenol. Besides, he needs the Tylenol because of his fevers.”

Jay continued to have chills throughout the evening and required additional Demerol to control them. He kept pointing to his abdomen and saying it hurt. Tara finally hunted down the nurse to get him something stronger for the pain. Tara had to work in the ER the following morning, so she tried to get some rest that night. But it was nearly impossible. The spasms of worry, along with the rasps of Jay’s breathing, rattled her sleep.

The predawn hours in a hospital offer up a spectral stillness, a foreboding semidarkness that is a breeding ground for apprehension and doubt. Tara tried in vain to still her agitated thoughts. Was she overreacting to insignificant things? It was hard for her to tell. Or was the staff blithely ignoring concerning clinical signs? In the bewildering limbo that she and Jay now inhabited, it was impossible to know which way was up.

Tara considered herself a reasonably experienced nurse, having worked in critical-care units in addition to her years in the ER. But she wasn’t an oncology nurse. She hadn’t spent extensive time with cancer patients and wasn’t versed in the highly specialized care of bone marrow transplant units. She didn’t presume to know the intricacies of chemotherapy agents or bone marrow transplantation. That was legitimately beyond her expertise.

But still . . .

It was 5 a.m. when Tara was roused by Jay’s struggling to breathe. His heart was racing and his temperature was 103. “There’s a puppy on top of the TV,” Jay whispered hoarsely. “People are laundering money here.”

Tara called the night nurse. “Jay is hallucinating,” she reported.

“It’s probably from the sleeping pills that he received,” the nurse replied.

Sedatives can definitely cause hallucinations, as can the very act of being hospitalized. Disorientation, fevers, dehydration, and interrupted sleep/wake cycles can all cause hallucinations in hospitalized patients.

But still . . .

When Tara emptied his urinal, she saw that his urine—what little there was—shone a dark amber, the color of heavy oak. She noticed that his toenails were pale blue and his hands were puffy. His breathing was ragged.

It was early Tuesday morning already, though still technically the night shift by the hospital clock. Tara convinced the nurse to wake up Dr. Amir—the overnight doctor—because of Jay’s labored breathing. Dr. Amir drew a blood gas from one of Jay’s arteries to measure the level of oxygen. (Standard blood tests are drawn from veins, but venous blood does not reflect the true level of oxygen that the body’s organs are receiving; arterial blood is needed for this.) The results showed that Jay was hypoxic, that his oxygen level was critically low. “He probably has ARDS,” Dr. Amir said, before he left the hospital that morning. “He’ll probably get moved to the ICU later today.”

ARDS—acute respiratory distress syndrome—isn’t a disease, per se. It’s an acute inflammation of the air sacs of the lungs that can be precipitated by a host of conditions including severe pneumonia, sepsis, burns, drug reactions, and pancreatitis. The air sacs—the alveoli—are physiologic tollbooths that allow the oxygen breathed into the lungs to be transferred into the blood, which then fans out to supply the organs of the entire body. When the alveoli are inflamed, you can pump in all the oxygen you want, but the blood can’t effectively receive it.

ARDS—if that was what Jay had—is an ICU-level emergency. There is no specific treatment, but patients need aggressive medical care while whatever caused the ARDS is treated. Most patients require intubation so that a ventilator can take over the work of breathing. However, this is not a panacea because pushing air in from a machine doesn’t solve the issue of inflamed and recalcitrant alveoli.

Dr. Amir had said that Jay would likely go to the ICU, but as a fellow—and a covering, overnight fellow, at that—he didn’t have any say in the overall direction of Jay’s care. Besides, he was already gone. Tara called her boss in the ER and said she wouldn’t be able to do her shift that day.

Jay received a stronger oxygen mask that helped increase his oxygen levels somewhat. It was hard to take an oral temperature because of the jagged breathing, but in his underarm, the thermometer read 104. When the day nurse did her morning rounds, Tara pointed out that Jay’s lips and toes seemed bluish. The nurse pressed some buttons on the IV pump, jotted a few things on the paper she was holding, but didn’t make eye contact with Tara. “It was as if the staff were pulling away from us,” Tara told me.

Tara accompanied Jay for an early-morning CT scan of his chest, since yesterday’s X-ray hadn’t provided any answers. A CT could help determine whether there was a pneumonia, or an abscess, or maybe a blood clot, any of which could cause ARDS. After they arrived in the CT suite, Jay’s bed was wheeled into the scanner and Tara was left in the deserted waiting area. She suddenly felt so alone, so utterly lost. Jay was spiraling down in front of her eyes and nothing she could do or say could stem this. It felt as though she were speaking a foreign language and no one on the staff could understand her. Was she going crazy? Had reality abandoned her?

The sweltering grimness of the waiting room hung heavy, siphoning off any traces of hope. For the first time since Jay was diagnosed, Tara felt her nursing fortitude begin to falter. Her skills and knowledge were failing her, and she could not seem to help him. It was all so insurmountable. She wilted into the armrest of the worn leatherette seat, sobbing uncontrollably for the duration of the CT scan.

Dr. Mueller, the hematology attending, came to Jay’s room around 10 a.m. with the results of the CT scan. It showed a pneumonia at the base of Jay’s right lung, plus fluid around the lungs (pleural effusions) on both sides. Also, his liver was enlarged. She would consult the pulmonary service about the pneumonia and pleural effusions. Tara had regrouped somewhat since breaking down in the CT suite. “Will you also be consulting GI about the enlarged liver and ongoing abdominal pain?” she asked.

Dr. Mueller demurred, saying that it would be up to the pulmonologist. “What about the ARDS?” Tara pressed. “Is Jay going to the ICU?”

“That will be the pulmonologist’s decision,” Dr. Mueller replied. There was a flat tone to her voice, almost curt. For Tara it felt like a blunt message: stop asking so many questions, stop making our work more difficult, stay out of Jay’s care.

It was two agonizing hours until the pulmonologist arrived, but it may as well have been two hundred. Everything seemed to be riding on this doctor. Tara was on edge, ready to erupt, but at the same time utterly depleted, hardly able to maintain a cogent thought in her sleep-deprived state. The pulmonologist, Dr. Peterson, arrived shortly after Jay had received a dose of morphine. Tall, thin, and balding, Dr. Peterson parked himself at the foot of the bed. “So, what’s going on?” he said.

Jay was unable to speak loudly enough or clearly enough to make himself understood. He looked to Tara with exhausted eyes. Tara turned to the pulmonologist. “Jay has been dyspneic and tachypneic since yesterday morning,” she said.

“Those are fancy words,” Dr. Peterson said. The snide tone was unmistakable. He rocked back on his heels, hands jammed into the front pockets of his white coat, mostly making eye contact with the linoleum floor. “Where’d you learn those?”

Tara didn’t want to start a turf battle or raise anyone’s hackles. Her goal was to help Jay, not prove any point. She replied calmly but cautiously, “I’m an ER nurse, and I have some critical-care experience. I’m concerned about Jay’s increased work of breathing, the swelling in his feet and hands, and especially his distended abdomen, which is making it hard for him to breathe. I am hoping that you’ll move him to the ICU and maybe intubate him.”

Dr. Peterson did not lift his eyes from the linoleum or offer any reaction. (“He acted as if I’d just read him a segment from the phone book,” Tara recalled.) He moved around to the side of the bed to listen to Jay’s lungs. He had Jay sit up, which Jay did lethargically, and listened at the back. “His lungs sound clear,” Dr. Peterson announced, straightening up. “This is not a primary respiratory problem. I looked at the CT scan—there’s no pneumonia.”

For Tara, this was bordering on surreal. Yes, she was surviving on hardly any sleep and hadn’t eaten more than a few bites in days, but earlier in the morning Dr. Mueller had said there were crackles in Jay’s lungs. And later in the morning she said the CT scan showed pneumonia. Had Tara misheard? Or misunderstood?

“With my twenty-plus years’ experience,” Dr. Peterson continued, mainly toward the floor, “I can tell you that Jay doesn’t have pneumonia or fluid inside his lungs. His lungs are being constricted by the pleural effusions—the fluid around the lungs. This is simply atelectasis.” Atelectasis is a small, usually benign collapse of the lower parts of the lung. Most patients after surgery, for example, experience some atelectasis because they haven’t been breathing as deeply as normal.

“But what about his work of breathing?” Tara persisted, gesturing toward Jay.

“Looks like morphine’s doing the trick,” Dr. Peterson said. It was hard for Tara to tell if this was pure sarcasm or straight-up condescension. The slight chuckle in his tone made her think the latter. Was it because she was a nurse that he was talking down to her? Was it because she was a woman? Was it because she barely reached five-foot-three even with her sturdiest nursing clogs on? Or was he like this to everyone?

Morphine has been used for eons to relieve shortness of breath. In palliative-care situations it can be a godsend. In acute situations, morphine can be extremely effective, but it treats only the symptom of breathlessness, not the underlying cause.

Tara knew she could not afford to be intimidated or to take offense. Even from a condescending cad. She forced herself to respond as evenly as possible. “What about BiPAP?” she asked. “Can we try him on some BiPAP?” BiPAP is a special breathing mask that uses pressure to forcefully push oxygen into the lungs. It’s less invasive than intubation, so it is often used as a temporizing measure for patients who need assistance with breathing.

Dr. Peterson shook his head dismissively. “If anything we need to decrease his oxygen so that we can accurately trend his oxygenation. Right now, his oxygen saturation reads 100%, so he’s probably getting too much oxygen.” Normal oxygen saturation is in the high 90s. Dr. Peterson leaned over the bed and turned down the nozzle on the oxygen a little bit.

“But what about his edema?” Tara asked. “His hands and legs are swollen.”

The doctor’s body language was as flat as his affect. “The edema is just cosmetic.”

“Don’t you think he’s in fluid overload?” Tara asked incredulously. “He’s net in by two liters, and his urinary output is down.”

“If anything, he needs more fluids,” Dr. Peterson said. Patients with fevers have a higher fluid requirement, and most patients post-chemotherapy require additional hydration. “I’d want the Lasix stopped, even though he has slight crackles.”

Wait, thought Tara. Wait! Didn’t he just say before that Jay’s lungs were clear? Now he says there are crackles? It was all so disorienting. To Tara, Jay looked sick, worsening by the moment. But the nurses on the unit didn’t seem to think so. The hematology attending didn’t seem to think so. The pulmonologist—a critical-care specialist—didn’t seem to think so. Was she misreading everything? It was like stumbling through a house of distorted mirrors.

As Tuesday afternoon wore on, Tara grew more and more distraught. Jay’s chest, back, and neck were mottled bluish-gray. His hands were now as swollen as his feet, and he complained of an uncomfortable tingling sensation in his limbs. Now his right knee was hurting. When the nurse came to hang a bag of saline, Tara asked her about the coloration of Jay’s skin. “It’s a side effect of the chemo,” she answered.

Tara knew that her knowledge base did not extend to the intricacies of oncology. But still, was everything a side effect of chemo? How could that possibly be? Jay kept pointing to the right side of his abdomen, that it was still hurting. It was hard for him to speak, but he was able to signal a six with his fingers when Tara asked him to rate his pain on a scale of one to ten.

Later in the afternoon on Tuesday, Tara finally got a meeting with Dr. Mueller and Constance,* the nurse manager of the floor. In the conference room, Tara told them how unhappy she was with the care Jay was getting. “He’s been tachypneic since Monday morning and has had abdominal pain since Sunday night. No one can continue to breathe like that. I think he’s going to crash.”

When there was no response to her blunt assessment, Tara said, “I want Jay to be transferred to the ICU. Maybe he needs to be electively intubated.”

Intubation—getting a breathing tube inserted in order to allow a ventilator to take over—often takes place during an emergency, such as when a patient has a cardiac arrest or goes into shock. In emergencies like these, intubation can be life-saving, though it’s a very stressful, high-stakes situation (quite unlike the calm, controlled intubation that an anesthesiologist does before surgery).

Elective intubation is the decision to insert a breathing tube before a patient reaches an emergency situation. If you think the patient will ultimately need it, better to put it in before the chaos of blood pressure bottoming out or the heart or lungs ceasing to function. Of course you’d never want to electively intubate a patient who didn’t need it, since this is quite an invasive procedure with many potential harms to the patient. It’s a decision not to be taken lightly.

Dr. Mueller said, “We don’t electively intubate here at this hospital.” She glanced over at Constance, and Tara thought she caught a smile between the doctor and nurse. “We’ve dealt with this before,” Dr. Mueller added. Tara looked at her quizzically. Did she mean they’d dealt with this sort of clinical situation before or they’d dealt with pesky family members from the medical profession before?

“A little bit of medical knowledge,” Dr. Mueller went on, “can be a dangerous thing.”

So that’s it, Tara thought. They are just sick of me bothering them. I’m just that annoying family member. I’m that bothersome nurse getting in their way. They want me to just disappear so they won’t have to deal with me.

Tara took a deep breath to steady herself. It had been eight and a half weeks since Jay first picked up that Hula Hoop. Eight and a half weeks of what seemed like a descent into an alternate universe, an incomprehensible netherworld that refused to right itself. “I understand that you have gone to school a lot longer than me,” she said to Dr. Mueller, endeavoring to keep her emotions in check. “And I know that you know more than I do about oncology, but I still don’t see how Jay can keep up this increased work of breathing that he’s been doing for the past thirty hours.”

Dr. Mueller’s tone softened a bit. “Don’t get me wrong, your husband is definitely sick. But”—and here she sounded firmer—“he’s not sick enough. Maybe in a smaller hospital, he would be in the ICU, but not here.”

Is she being sarcastic? Tara wondered. Is it just the ego of a big-city hospital? She felt like she might vomit, right there in the conference room, as she realized that no one, not one single person, was going to help her get Jay to an ICU. She considered trying to transfer Jay to another hospital, but he was clearly too sick for that. Tara racked her brain to come up with something, anything, to get help for Jay. Anything to get their attention. “Knee pain,” she blurted out. “Jay’s been complaining about right-knee pain for the last few hours.” She knew that the knee pain was minor in the grand scheme of things, but she was desperate to get the medical team back to Jay’s bedside. Knee pain in a patient with a bloodborne infection could indicate infection of the joint, so it was a symptom that the doctors would be obligated to investigate.

Dr. Mueller seemed willing to placate her in order to end the meeting. “I’ll stop in and take a look at his knee before I leave for the day, okay?”

No, Tara thought, no it’s not okay! But she realized it was all she was going to get. Tara could barely lift her feet to walk as she left the room. She had never felt so helpless—as a nurse or as a human being—as she did right now. No matter what she said or did for Jay, she could not make the great machinations of the hospital grind forward.

The social worker happened to be standing right there when Tara stepped into the hallway. “These people deal with this every day,” she told Tara reassuringly. “Trust them.” Tara could hear snippets of laughter drifting out from behind the door of the conference room she’d just left. Constance and Dr. Mueller were probably laughing about something else altogether—she’d certainly been on the other side of that divide—but she imagined they were laughing at her and her pitiful efforts to play doctor.

Tara waited nervously for Dr. Mueller to arrive to evaluate Jay’s knee. Jay’s skin tone was slate-gray now, and his respiratory rate was in the forties. The dark-blue mottling seemed to creep out from under his gown up toward his face. He was restless, complaining again of the tingling in his hands and feet. When the nurse came to take vital signs, Tara asked about it.

“It’s a side effect of the chemo,” the nurse answered. She jotted down the vitals and then left the room.

Jay’s feet were swollen and ice-cold. Tara reached down to warm them, massaging them gently to coax in some heat. “Does that help?” she asked. She couldn’t hear Jay’s answer, so she leaned in closer to him.

“I love you,” he whispered, and Tara began to shake with panic. From the corner of her eye she noticed blood oozing from Jay’s chest, from where the indwelling catheter used to be. She grabbed the call button and pressed it desperately, even though she knew the nurses were sick of her.

It was nearly 4 p.m. when Dr. Mueller finally arrived, almost an hour after their conversation in the conference room. She made a beeline for Jay’s right knee, bending it and palpating the joint. She shrugged, not seeming to find much there. Then she pulled back to look at the rest of him and it was almost as though she was seeing Jay for the first time. “How long has his skin been like that?” Dr. Mueller asked, slowly. Her voice was now hard-edged with concern.

“Since lunchtime,” Tara answered curtly. “The nurse said it was a side effect of the chemo.”

Dr. Mueller hardly waited for Tara to finish her sentence. The panic was visible in her eyes. “That is not normal,” the hematologist said, rushing out of the room to order a stat blood gas.

Ten minutes passed, and Tara was still alone. She checked Jay’s oxygen saturation on the monitor and it was 82%. She pressed the call button again. No one came. Tara dashed out to the hallway and saw Dr. Mueller on the phone in the nurses’ station. The time for niceties was over. “Jay’s saturation is down to 82%!” she bellowed at Dr. Mueller. “He’s crashing.”

“I’ve ordered a stat blood gas,” Dr. Mueller replied, but her voice sounded uncharacteristically nervous.

Tara rushed back to Jay’s room. “Where the hell is that stat blood gas,” Tara barked hoarsely at the two nurses who’d finally arrived, but they didn’t know. The nurses tried to get an oxygen saturation reading, but now the monitor wouldn’t pick up anything. They tried it on Jay’s fingers, on his toes, on his ears, on his forehead, but no reading. They tried another machine in case the first one wasn’t working, and then another.

Tara watched them in disbelief. It was crystal clear to her that the nurses couldn’t get a reading, not because the machines were faulty, but because Jay’s entire vascular system was clamping down. “He has to be intubated,” Tara shouted.

Jay pointed feebly to his bladder, indicating that he had to urinate. They brought the urinal to him and out came one hundred cc’s of blood. Tara became frantic. “His kidneys are going,” she screamed at the nurses. “He has to be moved to the ICU!”

Another fifteen minutes went by before the tech finally arrived to do the blood gas. Of course it was impossible to find Jay’s pulse at this point so the tech couldn’t get an arterial blood sample. It was 4:40 when Tara heard Dr. Mueller yell from the hallway, “Call a rapid response!”

“It’s about damn time,” Tara shouted back from Jay’s room, shaking with panic and relief at the same time.

Rapid response teams developed in hospitals after the recognition that once a cardiac or pulmonary arrest has occurred, it is rare to get a meaningful “save,” no matter how assiduous the code team is. The idea came about, then, to create an emergency team to intervene before the code occurs. You wouldn’t have to wait until the patient actually lost their pulse or respiration (i.e., coded) to get intensive help—you could activate the assistance of an ICU-level team to the bedside as soon as the patient’s clinical situation began to deteriorate. The goal was to prevent the code before it happened.

As soon as the rapid response was activated, a flood of people descended upon Jay’s room. As they were gowning up, though, Jay began to gasp for air, gurgling and grunting. “God damn it,” Tara exploded. “You people should have listened to me! Now he’s agonal-breathing! He should have been intubated this morning!” As Jay’s breathing withered away, the rapid response team switched into cardiac-arrest mode, sliding a board under Jay’s back so they could begin CPR.

As Jay was rolled to the side to get the board under him, his head was briefly turned toward Tara. For a second, Tara and Jay were eye to eye and she watched as his pupils suddenly widened to the maximum possible. In medical terminology, he’d blown his pupils—an ominous sign of the brain swelling and beginning to push out of the skull into the vertebral column.

“You fuckers!” Tara screamed at everyone and at no one. “He’s unresponsive now! I told all of you, but no one would listen! I told you he was getting worse all day!”

The code proceeded in the standard manner that codes do, the standard manner that was oh so familiar to Tara in her professional role but stutteringly otherworldly right now. At the head of the bed someone was intubating Jay and then squeezing an Ambu bag to press air through the tube into his lungs. Another team member was throwing his full bodyweight into CPR through his interlocked hands, lurching the bed with each compression. Someone else was jamming vials of epinephrine and atropine into the IVs to corral Jay’s heart and vasculature into action. Another person was furiously drawing labs. A nurse stood in the corner, methodically charting the proceedings.

Tara spotted Dr. Mueller at the back of the room. The hematologist was looking up to the ceiling with her hands clasped in front of her, almost in a prayer pose. “You did this!” Tara hissed at her. “You’re going to be sorry.”

CPR was briefly halted to check the heart rhythm. “PEA,” someone announced and Tara could feel the floor careering out from beneath her. Pulseless electrical activity is a perilous state in which the heart is firing electrical signals but these aren’t translating into meaningful cardiac contractions that could ultimately be detected as a pulse. It’s a sign of a desperately flailing heart. Tara ran out of the room screaming, not knowing which way to turn.

Constance confronted her in the hallway. “You can’t make a scene like this, Tara.” She pointed a finger at Tara’s face, scolding her, nurse to nurse. “If you keep on like this, we’ll have to have you removed.”

“That’s bullshit, Constance,” Tara spat back. “I told everyone this was going to happen and you all ignored me.” The two of them stood there, a foot apart. Through gritted teeth Tara said, “Go ahead and try to make me leave.” She spun away from the nurse manager and returned to Jay’s room.

The code was in full swing, simultaneously chaotic and controlled. Gowned, gloved, and masked bodies entombed the space around Jay’s bed. Sweaty desperation hung heavy in the air. Tara’s volcanic anger now began to leach away in the agitating churn of bodies, machines, protocols, hierarchy, and apprehension. Disbelief became numbness and she could feel herself almost slipping away.

In the middle of this, a nurse Tara had never seen before materialized in the room. She wordlessly guided Tara to a chair and coaxed her into it. The nurse kneeled in front of Tara and took her hand. “I’m an ER nurse also,” she said. “Like you.” She kept up a soft stream of words as Tara sat there, nearly catatonic.

“She had the presence of an angel,” Tara recalled. “To this day, I am not even sure if she was real or just a figment of my imagination.”

“We have a pulse,” someone shouted, and Tara felt the dubious arrow of hope stab into her. Jay’s heart was now beating! A surgical team had arrived to insert a central venous line, since Jay had only two small IVs after the indwelling catheter had been removed and they were insufficient for the massive resuscitation efforts. The surgeons and the code team debated whether to insert the line right there in the room or to move Jay to an OR where the environment was sterile. They decided that the OR would be better, now that Jay had a pulse, and began the preparations to transport him.

They hadn’t made it out of the room when Jay’s rhythm and pulse were lost again. Someone jumped on the bed to resume CPR. The code began again in earnest.

For Tara, the scene was both unfathomably intimate and piercingly brutal. It was as if a serrated grater was rasping away at her, flaying deeper through skin, muscle, and bone. At the same time, though, she was entirely numb. How was it possible to simultaneously be in so much pain but also feel nothing? Time was spooling both backward and forward. The code was going on forever—round after round of epinephrine, atropine, CPR—but was also unimaginably fleeting.

The ER nurse who’d been sitting with Tara looked her in the eye for what seemed like forever. “Tara,” she said quietly, “you might need to make a decision here.”

Tara knew what she meant. She had been on that nurse’s side of the conversation many times before. She’d been the one to ask the distraught family members when to stop the resuscitation efforts. She’d been the one to present what seemed like a life-or-death decision but really wasn’t. It was a death-or-death decision, the two options separated only by an arbitrary sliver of time.

Tara gathered the last remnants of her clinical reserve and asked two questions: “How long has he been down? What’s his rhythm been?”

The answers came: “Forty minutes.” “PEA.”

She didn’t have to look at Jay to know, but she did nevertheless. He was blue. His skin was mottled and leathery. He was dead.

“Call the code,” she whispered to them, hospital shorthand for ending resuscitation.

And like all nurses do, she instinctively noted the time. It was 5:20 p.m.

__________________

* I recognize that the practice of referring to nurses by their first names and doctors by their last names underscores an unfortunate legacy of hierarchy (and, frankly, sexism). I am using “Constance,” though, because that’s how Tara referred to her and also because it reflects the reality that nurses generally permit patients and families to call them by their first names.