by Tilda Shalof
On a cold winter’s night that was so deep.
Noel, Noel, Noel.
Born is the King of Israel.
I was back at my Christmas gig for the lunchtime crowd.
God rest ye merry, gentleman,
Let nothing you dismay…
O tidings of comfort and joy.
I was building up to my personal musical Everest: “Jingle Bells.” To do it properly, it’s gotta fly! I could barely keep up the tempo. The tune kept getting ahead of my fingers.
“That’s funny,” said Dr. Huizinga, stopping by for a sip of apple cider. “You, Tilda, of all people, playing Christmas carols. You, being, er, you know, celebrating Chanukah, and all. It’s very ecumenical of you.”
“I’m nothing if not ecumenical,” I said. (Usually I could play the piano and keep up a more intelligent conversation, but “Jingle Bells” required my full concentration.)
“Merry – er – Happy Holidays to you,” he said and placed his paper cup full of cider on the piano top. “They should spike this stuff. It’s vile.” He rushed off.
Next, the stirring “O Holy Night.”
Who could not be moved by the supplication: “Fall on your knees”? I thought about the devotion of Christians or true believers of any religion. I admired how they lived by their principles, especially the moral ones. The rules about food and clothing seemed much less important to me. But sometimes I did feel a longing to belong to a church, temple, mosque, or synagogue in order to experience prayer and faith within a community.
The synagogue services I had attended as a child with my father had been cerebral, intellectual exercises. The prayers were about ancient, archaic laws and the pursuit of justice. They didn’t speak to my soul like the exhortation “Fall on your knees!”
I recalled that when the Sikh family had prayed in Manjit’s room, I’d become aware of a certain phrase they kept repeating. I asked the father what it meant.
He broke off his chanting to tell me: “God is one. God is one.”
That was exactly the same as the central prayer of the Jewish faith, the Shema, I had thought at the time. The Shema says, “Hear oh Israel, the Lord is our God, the Lord is One.” What, really, was the difference? Weren’t there more similarities than differences and weren’t the differences primarily cosmetic, or involving costume, custom, and cuisine?
O bring us figgy pudding
a cup of good cheer.
From which I slid smoothly into
Go, tell it on the mountain
Over the hills and everywhere
There was a tap on my shoulder. It was Rosemary. “We need you to come back to the ICU, Tilda. You’re getting a new admission.”
A stretcher was being wheeled down the hall as I arrived back in the ICU. Since I could see that it was the body of a young man, I assumed that the two people who were trailing close behind him were the mother and father, still in their snowy boots and coats, their scarves flapping open. They looked like any frantic parents facing life’s worst nightmare.
“No spontaneous movement, no eye opening, no gag or cough reflex, no response to deep pain.” The doctor who had accompanied the patient on the flight from North Bay was reporting to Dr. Bristol, standing at the foot of the patient’s bed. I joined them there and listened in. “An eighteen-year-old boy, sudden collapse … likely cerebral aneurysm. Normal medical history. Blood pressure and heart rate stable, but no spontaneous breaths. Unresponsive.”
Even the paramedics, who prided themselves on their cool demeanour and emotional control under all circumstances, seemed shaken.
Early that morning, when I was sipping cider and playing carols in the lobby, far away in North Bay this young boy was busy being the team’s star forward, playing in a regional hockey tournament. He scored a first-period goal, then had a breakaway with another shot on goal, and then a blood vessel burst in his brain and he collapsed on the ice, face down. A CT scan showed a massive intracerebral bleed and global oxygen deprivation. His brain was swelling up rapidly inside the vault of his skull.
“Can’t something be done?” the mother asked Dr. Bristol in the hallway.
“The neurosurgeons have examined him. They had hoped to be able to insert a drain to release the pressure in his brain, but have decided it would be of no benefit. The damage is too extensive.”
“Is he in a coma?” the father asked, clearly hoping for a coma, rather than what he must have begun to suspect.
“After we examine him thoroughly, we will have more to tell you.” Dr. Bristol pulled the curtains around the patient’s bed and directed the parents to the door. I accompanied them to the waiting room and returned to the patient, who was being examined by the doctors.
This was not the first patient like this that I had taken care of, so I was familiar with the methods used to sustain a body until a final determination of the situation could take place. I knew there would be a period of limbo, a time of ambiguity between this hovering life and the slamming down of one of the two most likely pronouncements: persistent vegetative state or irreversible brain death. These seemed to be the only two possible outcomes for this young hockey player.
As I went about my work, I thought about the parents in the waiting room. They were probably imagining the worst – which in this case would be accurate – and I hoped for their sake that the testing period would not be too prolonged. Waiting was torture for families. However, I also knew how thorough and exhaustive the testing had to be in order to avoid a pre-emptory or mistaken declaration of death.
Perhaps this waiting period was a good thing. Perhaps it gave the family the time they needed to register the shock, say their goodbyes, and consider some important decisions. There was no doubt in my mind that if this young boy was declared brain dead, the family would be approached regarding organ donation.
I TURNED TO my patient. He had a beautiful, young man’s body – veiny arms, defined muscles in his legs and arms, a taut flat stomach. The other nurses came to admire him and to give me moral support.
“Gosh, what a hunk. Look at that six-pack,” Morty said.
Frances shook her head sadly as she came closer to look at the young man’s handsome face and his athletic physique. “I had a brain-dead patient like this last week. She ended up being a donor. Can you imagine – she’d just been to the hairdresser. Her hair was perfect.” She sighed.
“I know,” I said. “It seems unreal, as if he’s playing a trick on us and will pop up any minute. C’mon, the joke’s over, I feel like saying to him. Enough is enough, I keep thinking.”
Tracy shook her head. “It looks like he’s just sleeping. He looks a lot better than all the other patients here. He looks just like a real person. I can’t believe it.” She walked away.
“How’re you doing, Tillie?” Frances stayed back to check on me. She peered at me and saw at once that I was fine. “I have to run off. There was a big car crash on the Don Valley Parkway. Another possible donor is on the way in from the Trauma Centre at Sunnybrook. Can you believe it? This always seems to happens during the holiday season.”
DR. BRISTOL AND the senior fellow, Jessica Leung, came back to perform the tests that were done only under these dire circumstances.
“Keith, Keith!” we all called out. “Open your eyes!”
“Keith!” Dr. Bristol shouted in his ear.
Jessica made a fist and pressed her knuckles deeply into the boy’s sternum, which was already rubbed raw from other, previous attempts to elicit some response. There was no flinching, grimacing, or withdrawing to that sternal rub, nor to a ballpoint pen rolled along his nail beds, nor to sharp squeezes to his nipples or presses on his eyebrows. There was no reaction to anything at all.
The reflexes were tested with a slender hammer. There was nothing.
Jessica rubbed the end of the hammer along the soles of his bare feet. We all noted the abnormal upward curl of the toes, and we glanced at one another with a grim understanding of where this all was likely headed.
/>
Dr. Bristol observed the patient closely. He set his teeth hard after each test and then nodded to the resident and me to proceed to the next test.
I held open the eyelids and shone a flashlight in them. There was no constriction of the pupils.
The corneas did not flinch and there was no protective blink, even when Jessica flicked the eyeball with the rolled-up tip of a cotton tissue.
We moved his head from side to side to check for eye movement, but like a porcelain doll with immobile glass eyes, the patient’s eyeballs stayed motionless in his head. In fact, that was the name of the test.
“Positive doll’s eyes,” Jessica said.
With each test, a shift was taking place within me. I was moving from thinking of him as a young man, a star hockey player, a son and a brother (I began to try to put all that out of my mind) to a patient in the bed, to a body, to a potential organ donor, to what he really was – a corpse.
For the next test, I brought over two basins, one filled with ice water, the other with warm water, and a large syringe that the doctor would use to inject water into the outer ear canal.
“COWS,” I reminded myself. “Cold, Opposite. Warm, Same.”
In a normal person, the cold water in the ear should make the eyes move in the opposite direction, toward the other ear. With instillation of warm water, the eyes should move in the same direction, toward the ear. This was the normal response, but this patient’s eyes deviated neither to the opposite, nor to the same side, with either test. His eyes did not move at all.
Finally, we removed him from the ventilator and waited for an independent breath – even a single one of his own breaths would rule out the diagnosis of brain death.
We had a strong instinct about this case, and all our tests and knowledge were leading us in the direction of one clear-cut, definitive diagnosis. Yet, at the same time, the search was conducted in order to prove ourselves wrong.
We waited and waited. The patient remained disconnected from the ventilator. His chest was still. His oxygen saturations began to fall and his heart rate began to block down, slower and slower. Dr. Bristol waited a little longer, and then looked at his watch. For a full ten minutes we waited for any sign of respiration from this boy’s body. Any rise or fall of the chest? There was nothing. The doctor looked again at his watch and said quietly, 1430 hours, December 24.
None of us could say for sure if that was truly the time of death. Was this the time of death or had that time occurred this morning, out there on the hockey rink when the hidden bubble burst in his brain? Was this the time of death, now, or would it occur when we finally turned off the ventilator and stopped the flow of powerful intravenous drugs, and allowed his body to die, as his brain already had?
As horrific as brain death is, as devastating as such a loss of a previously healthy person is, I had come to believe that in these circumstances, it was preferable to another, closely related diagnosis: persistent vegetative state. But some people preferred that latter diagnosis over death. I was never around to find out if any of those families ever regretted the decision they made on behalf of their loved one.
Until the declaration of brain death was made, during all those exhaustive neurological tests, we were on the alert for any sign of life: a slight twitch, a blink, or a minute constriction of the pupil in response to a source of light, a minuscule movement of a finger, an effort to make even one breath, or a primitive reflex. Any of those signs would mean there was still some brain activity. Families often interpreted these things in the most hopeful way possible and chose to believe that it was the start of a process – albeit a long and arduous one – toward a full and meaningful recovery. I had seen only a few of these cases diagnosed in the ICU. However, from what I had seen and learned, these patients were transferred out to the wards and soon became contracted into a fetal position and bedridden. Their days consisted of being turned from side to side, breathing shallow breaths through a hole in the neck (a tracheostomy) and being fed through a tube. Pneumonia and other infections were likely to develop, as well.
As for Keith, the tests confirmed what we had suspected: he was dead. We were keeping blood and oxygen flowing to his organs to give us time to explain all this to the family and then to give them time to make some important decisions. I went over it again in my mind as I prepared myself to bring in the parents. By now a sister and brother had joined them. First I stepped back and gave them privacy to grieve and to come to their own conclusions.
“Keith, Keith, wake up!” I heard them call out.
“Time for hockey practice!”
“Come on, the Leafs are going to make the playoffs this year!”
They sobbed.
Then we led the family back out to the quiet room, where Dr. Bristol explained the situation.
“We have performed exhaustive tests on your son’s brain functioning. Those findings, coupled with the CT scan that shows massive global infarction, led us to the conclusion that, unfortunately, your son is brain dead. I am very sorry.”
“Dead? What do you mean?” the father cried into his hands.
“Dead means a total and irreversible cessation of brain functioning, even in the presence of a beating heart,” the doctor said, reciting from the textbook of his mind.
“How can he be dead?” the father cried. “He was fine this morning. He’s perfectly healthy. He’s never been sick a day in his life.”
“Keith has no brain function. He is in an irreversible coma. I’m very sorry. There is nothing we can do.”
“Is he dead or just brain dead?” the father asked.
If it’s just a technicality, we’ll overlook it. If it’s just his brain that is dead, we’ll take the rest of him.
“He is not alive.” The doctor tried other words to help explain. “He is dead. He is not just brain dead. The machines and the drugs are keeping the blood flowing and the oxygen circulating. We are perfusing his organs and keeping the cells alive.”
“But what about the life-support machines? Aren’t they doing any good?”
“The ventilator is maintaining oxygenation, but it is not keeping him alive. It is purely biological life. It is life at the cellular level, only,” Dr. Bristol said.
“Have you ever seen a case like this get better?”
“No.”
“How long could he live like this?” the mother asked.
It was too much for anyone to grasp, much less a mother or a father. However, more time with their son, even if he was in this condition, must have seemed preferable to … that. The other. The alternative to life.
“Not very long,” said Dr. Bristol. “A few hours, a day, perhaps. His brain is not working and already complications are setting in. His brain cannot control his temperature and he is becoming hypothermic. His kidneys are not functioning properly and are producing large amounts of watery urine. His blood pressure is very erratic, high then low. These are commonly the things we see that happen to the body in these situations. He cannot continue like this much longer.”
“But his heart is beating. Surely given time, he’ll recover?” the mother reasoned. “Keith will wake up from this coma, I know it. We’ve all heard of cases where –”
“Recovery is impossible in the presence of brain stem damage,” said Dr. Bristol. “Your son suffered a massive subarachnoid hemorrhage. A blood vessel burst in his brain. Likely it was an anomaly present since birth, but undetectable, asymptomatic.”
“The family doctor never told us anything about it.”
“He couldn’t possibly have known, and it could not have been prevented.”
“What’s to be done? You’re going to pull the plug on him?”
“We won’t do anything until you are ready, but there is something very important for you to consider. You have the opportunity to donate Keith’s organs. His heart, lung, liver, and kidneys could all go to help other people who are terribly ill.”
The mother sobbed as she asked her next question. “What if you
took his organs and he was still partially alive?”
“There is no such thing as partially alive, and we do not harvest organs from living people,” Dr. Bristol stated. “Now, should you wish to donate Keith’s organs, you will have to decide soon, as we are under time constraints. In these situations, we have to preserve organ perfusion to maintain the viability …”
He droned on but they couldn’t bear to hear any more.
If only he could show a little emotion, I thought. In some situations, I had the feeling that families cared more that we cared than they cared about what we knew. When Dr. Bristol said he was sorry, he said it as if he meant it and I knew that he did. Of course he did. He was not heartless; he was not made of stone. After all, he had children of his own. He had shown me pictures of them and of his beloved horses that he kept at his country home. Perhaps he simply did not know how to show his caring to the family, other than by being the superb doctor that he was, without losing the image of who he was. Perhaps it would disturb him too much if he showed his emotions and it might render him unable to do this work, day in and day out. Perhaps it would exact too high a price. Perhaps it was too much to ask of anyone. But I believed that if he could show them his feelings, share even a tiny portion of their sorrow, it would help them and be remembered always.
I tried to make up for his detached manner with my sorrowful eyes and my arms across their shoulders, but my gestures also seemed inadequate. I decided instead to sit there and simply be still. I would bear witness to their grief in the hope that my presence alone might offer some comfort.
After a few minutes, to no one in particular, I said into the suffocating room, “Perhaps the family would like some time alone, to think about all this?”
They looked at me, stunned, but grateful.
They gave consent to donate Keith’s organs and then came to the bedside to spend some time with their son and say goodbye.
