The Secret Language of Doctors

by Brian Goldman

  “Approximately 30-year-old man collapsed while on duty at work,” the paramedic told us in a rat-a-tat staccato. “Found in full cardiac arrest. CPR started at scene. V-fib on the monitor, shocked times four, given Epi times three, plus Vasopressin. Went into asystole and has been that way for twenty minutes.”

  Asystole meant the heart was showing no electrical activity. A flat line for twenty minutes—added to the time that he was in ventricular fibrillation—meant the man was essentially unsalvageable. Those were the cold, hard facts. But he looked far too young for this to be happening to him. You never want to stop trying to save a patient like that.

  “I don’t think there’s any point in continuing,” said my colleague. “I’m calling it.”

  Calling it is slang for stopping resuscitation efforts and pronouncing the patient dead.

  Just like that, it was over.

  I went back to the ambulatory care area of the ER where a growing horde of minor problems awaited me. But I kept thinking about the man who had just died, and how his family would react to hearing the news.

  About an hour later, I glanced up from the desk to see a short Asian woman in her mid-fifties walk past. She was accompanied by two police officers. I knew right away that she was the dead man’s mother.

  I decided to follow them as they made a sharp right turn and headed down a long hallway, past the main nursing station, until they reached the fourth bay in the resus—the only bay with its own sliding door. Built to prevent infected patients from spreading germs, it also allows a private space for family members to see their dead loved one and to grieve.

  As the woman and the two police officers approached the entranceway to resus 4, I spotted my colleague who had called the death. Breaking bad news is the most difficult thing we do in the ER. I asked my colleague if he wanted me there when he talked to the mother. As I expected, he brushed me off. There’s a code among doctors in the ER: if it’s your patient, it’s your duty to tell the next of kin.

  I backed away as my colleague introduced himself to the woman and escorted her into a room at the far end of the resuscitation stretchers. I lingered for a second as the woman disappeared into the room. The instant the door to the room slid shut, the screams began.

  Loud, grief-stricken, hysterical screams filled the ER.

  By the time the nurse asked me to look in on the woman, an hour had passed since my colleague had broken the news that her son was dead.

  I approached the door to the resuscitation room, where the nurse was waiting for me. “We were hoping you could talk to her,” she said. “We’ve tried comforting her. She won’t leave the bedside. It’s like we can’t reach her. We don’t know what to do.”

  The room was dark as I walked in. The dead man was lying face up on the gurney, his eyes wide open. To the left of him stood his mother, flanked by two nurses who were holding her and trying in vain to soothe her. The woman was shaking her son’s lifeless body and shouting at him to wake up, as if he were asleep.

  That the woman could not get past this moment and face the future was totally understandable. I kept what I hoped was a stoic yet kind look on my face as I made my way slowly towards her.

  Truth is, I was stalling. I had no idea what—if anything—I could do to help her.

  * * *

  This was almost certainly the woman’s first time seeing death up close. As a thirty-year veteran of the ER, I have seen it many times. Some patients—like the Asian man—arrive in full cardiac arrest the first time I set eyes upon them. Others die on my watch.

  Despite my long experience, I always feel as if I’m rather inept at helping families deal with all things death. I’m not alone. As a profession, we find it difficult to talk to patients near the end of life about taking a pass on heroic measures. Telling next of kin about an unexpected death is the most difficult experience because you have to stay there and absorb that raw moment when they’re processing the reality of what has happened. There is no training in med school or residency that prepares you for that.

  If that’s how I feel after thirty years on the job, imagine how residents and medical students feel. We’d never allow senior medical students or first-year residents to give it their best shot taking out your gall bladder without an experienced colleague there to provide support, if not take over. But when it comes to pronouncing someone dead in hospital, it’s often the youngest and most inexperienced person on the team that gets the job.

  Dr. Peter Kussin—the expert in medical slang at Duke University Hospital—also happens to be an authority on how to talk to patients who hover between life and death in the ICU, as well as to their families. He is trying to teach residents to follow in his footsteps—sometimes in vain.

  “Have you listened to young physicians talk about end-of-life issues?” Kussin asks rhetorically. “I will sit there and let my residents sometimes lead the conversation. I want to bury my head in my hands, which I won’t do, because that would be disrespectful to my young colleagues.

  “They are devoid of the sort of communication skills that you need to do it. I tell them you’ve got to come and listen to old doctors with grey hair who’ve done this for twenty-five years like I did. And learn how they do it and model yourselves after them.”

  A young resident who could learn a thing or two from Dr. Kussin told me an illustrative story. He was once on call at a hospital when he was awakened at 4:30 a.m. to pronounce a patient dead. The 92-year-old man had been transferred to the hospital from a nursing home with symptoms of heart failure. It was his third hospital admission that year, and doctors suspected that he’d had a heart attack prior to being admitted this time.

  The resident had never treated the man or met his family. As the resident on call, it was his job to pronounce the man dead. The hitch is that the young resident had never done it before.

  “I called the senior resident and she said to listen to the heart and lungs for a minute,” says the resident. “Look in their eyes to make sure their pupils are fixed and dilated. Test the pain reflex to make sure there is no response. And then fill out the death certificate.”

  It sounds as if the senior resident was schooling the newbie on how to put on a sling or an ankle wrap. From his account, she said nothing to him about how to inform the family, much less how to provide them with emotional support.

  “I was kind of half asleep and I walked into the room,” recalls the resident. “Two family members were crying. In my exhausted state, I asked them to leave the room, and I was left there with this man who had just died.”

  The resident says the patient was obviously dead. As he went through the motions of listening to the man’s heart, another thought formed in his tired head. “The longer I listened, the longer I didn’t have to go face the family behind the curtains,” he confesses.

  There are several aspects to this sorry situation that left the recent medical school graduate feeling embarrassed. One is that even though the patient was obviously near death when he was admitted, the hospital had stringent visiting hour procedures in effect. Only one visitor at a time was permitted in the patient’s room. “It was so awful because the family wanted to be there when he died and they were kind of in an argument with the nursing staff,” says the resident. “It was not a good way to die.”

  The other thing that bothered him was a near total disconnect between the mood of the family and that of the nurses. The resident discovered that when he looked for a quiet place to fill out the death certificate.

  “I go to the nursing station and everyone’s laughing,” he says. The nurses weren’t laughing about the death but they were having a good time. What’s so bizarre about medicine is how you walk from the worst part in people’s lives and then you enter the nursing station and I was laughing and joking with the nurses. I was cognizant of the fact that maybe the family can see me smiling now.”

  What the resident witn
essed was the absence of any emotional identification between those at the nursing station who were laughing and the bereaved family. As I have argued, in the modern, post-Oslerian world of medicine, emotional detachment by health-care workers should be balanced by displays of genuine empathy. But to accomplish that, you have to care about your patients and their families in the first place.

  I have no doubt that first experience pronouncing a patient dead will stick with the resident for the rest of his career.

  “I’ll probably never forget the looks on their faces and how I felt in that moment,” he says. “I don’t think I was afraid of the death or seeing the body. I was disappointed in myself that I wasn’t present enough to give to the family at that time.”

  * * *

  Sooner or later, doctors have to get comfortable—or at least appear comfortable—with patients who die. That is an almost impossible task when the death is unexpected, as was the case with the Asian man. These are the deaths that generate shock from loved ones—a shock from which it is almost impossible to maintain an emotional distance.

  In all such instances, medical slang helps doctors, nurses, paramedics and others who witness death up close maintain an emotional buffer. What’s striking is just how often the slang is intended to be droll and ironic. Discharged to God and discharged to heaven—two commonly used bits of argot—come to mind. In hospital culture, there are only two possible outcomes for living patients: discharge to their own homes or transfer to another hospital or a nursing home. In fact, these are the only two outcomes anticipated for all patients admitted. Call doctors superstitious, but to talk about an anticipated death is to almost wish it. Thus, the phrase discharged to heaven suggests in an ironic way that the death was somehow planned and accomplished in much the same way that an appendix is removed.

  A similar bit of slang refers to the death of a patient as following up with pathology as an outpatient. Once again, follow-up is a standard hospital transaction for all patients discharged—except of course for dead ones.

  We prefer death to be expected and—more important—accepted by the family. That means family members cry a bit but are otherwise stoical about the loved one’s demise. We hate screaming because bystanders may hear it and think we were negligent in the patient’s care or, at the very least, negligent in our handling of the patient’s family. When families accept death stoically, it means they move quickly from grief to taking care of operational details such as calling a funeral home. That enables us to move quickly to the next patient. Sounds cold, but it’s true.

  When a patient dies with no grieving relatives to deal with, so much the better. That’s how it was with the first death I witnessed. It was 1979 and I was on my first rotation in internal medicine as a fourth-year medical student. I was assigned to a ward reserved for patients with gastrointestinal (GI) diseases such as peptic ulcer, hepatitis and the inflammatory bowel diseases Crohn’s and ulcerative colitis.

  Like many GI wards, this one was filled with patients in the final stages of alcoholic liver disease. One patient was a man in his early fifties whom I’ll call Gustavo. After decades of drinking, he looked at least 70 and his liver tissue had been replaced with scar tissue. He had cirrhosis and now his liver was failing.

  Gustavo had been admitted to the ward a day or two before I arrived for my first day on my internal medicine rotation. A textbook case, he had physical findings of cirrhosis galore. Gustavo was jaundiced to the point that his skin was bronzed. His huge belly was round and full of a watery liquid called ascites. If Dr. Peter Kussin had been looking after Gustavo, he’d have called him a Yellow Submarine.

  Gustavo had a late-stage complication of cirrhosis called hepatic encephalopathy. Toxins that his liver was no longer able to eliminate were building up in his bloodstream. The toxins made Gustavo sleepy and often comatose.

  Cirrhosis is irreversible. Even today the only remedy is a liver transplant. The first liver transplant had been performed in Denver, Colorado, back in 1963, but this option wasn’t possible for Gustavo. They wouldn’t become commonplace until the 1980s, when the surgical technique was perfected and the use of anti-rejection drugs such as cyclosporine became routine.

  From my vantage point as a senior medical student, it didn’t appear as if we were winning the battle to pull Gustavo back from the brink. Along with a junior resident, my senior and I would make rounds at eight in the morning. We would push a rolling chart rack along the hallway, stopping at each patient room long enough for a quick check. When we stopped at Gustavo’s room, the ritual went like this:

  “Good morning, Gustavo,” the senior resident would say with a trace of irony as the team walked in.

  “Mmmrrrrr,” Gustavo would growl back, half awake.

  “We’re going to have a good day, Gustavo, aren’t we?” my resident would reply in a tone of voice that sounded both ironic and condescending.

  And with that, we would leave Gustavo’s room and head off to see the next patient.

  That ritual went on day after day without change. One morning near the end of my one-month rotation, my senior resident and I arrived in the morning only to find that Gustavo had suffered a fatal heart attack. The cardiac arrest team was packing up to leave as we arrived.

  We stared at Gustavo’s lifeless body. Quietly, the senior resident scolded Gustavo’s lifeless form for drinking himself to death.

  And with that, my senior resident walked out of Gustavo’s room without a backward glance.

  That was my first death: seemingly cold, lonely and cruel.

  * * *

  Residents invent many slang terms to talk about the impending demise of patients. Entering the drain is slang for a hospitalized patient who is quite ill and could survive but is teetering on the brink of death. Circling the drain means the patient has entered the inevitable phase and can’t be saved. Crashing means he’s taken a sudden turn for the worse. Crumping is a synonym for crashing. Fixing to die is a term that implies that the patient has chosen his or her fate deliberately.

  You get the picture. There are many such terms. They serve several purposes. One of the most important is to give a heads-up to the resident on call to expect that a lot of time and attention will be needed to save the patient’s life and (if push comes to shove) to deal with grieving family.

  Dr. Clarissa Burke, who did a residency in family medicine at McMaster University in Hamilton, Ontario, told me that phrases such as circling the drain imply that death is inevitable: “I don’t know if that’s a way of trying to remove our own responsibility from the situation or maybe even make us feel better about what’s happening.”

  Such phrases usually get passed down from senior resident to junior and from junior to med student. Sometimes, they come from an attending physician. Dr. Rick Mann, who practises family medicine, told me a memorable example. “The one that has always stuck with me, unfortunately, is a staff physician who colloquially used to say about patients: ‘Tell them not to buy any green bananas’—in the sense that they weren’t going to be around to see them go ripe,” said Mann.

  As a resident in internal medicine in New York City back in the 1980s, respirologist Peter Kussin remembers sharing medical slang freely with his resident colleagues. Back then, two of Kussin’s favourite slang terms for patients who were dying were PBAB, for “pine box at bedside,” and the even more serious PBABLO, for “pine box at bedside, lid open.”

  “We would use those in our notes and our sign-outs,” Kussin recalls. “So we’d say, Mr. Smith, Room 8322, PBAB, NTD—for “pine box at bedside, nothing to do.” You have an intern who’s got forty patients to cover. He knows that Mr. Smith doesn’t need anything except end-of-life care.”

  But that was in New York City in the 1980s. Kussin wanted to find out whether the residents he teaches today at Duke use slang to talk about patients at the end of life.

  Kussin says he once told a resident in
the ICU “‘I need you to meet with this family today. I’ll meet with them tomorrow but I need you to hang crepe.’ None of [the residents] had heard it. And that’s a mild piece of medical slang.”

  Kussin was using the expression hang crepe to get the resident to prepare a patient’s family for their loved one’s impending death. He was also trying to make a connection with the resident—to let the resident know Kussin was there to share the emotional burden of telling the family.

  One young physician remembers being on duty in the ER and seeing a 20-year-old man with osteosarcoma, an aggressive form of bone cancer that usually strikes teenagers. Only two-thirds of patients survive long-term. He recalls that the young man was receiving powerful chemotherapy drugs that lowered his white blood cell count and rendered his immune system vulnerable to attack by bacterial infection. The patient had a fever, an ominous sign that an infection had invaded his bloodstream.

  “When I opened the door, it kind of hit [me] in the face,” says the resident. “This patient looked very sick to me.”

  He started antibiotics and fluids by intravenous drip and transfused the young man with blood because the chemotherapy had also caused his hemoglobin to fall drastically. He referred the patient to the internal medicine team to be admitted. Medically, he did everything right. But he knew the young man was likely to die.

  “You’re sitting there with family members of a 20-year-old,” says the resident. “They want you to tell them that everything is going be okay. And you want to tell them everything is going be okay. Instead, you have to find a middle ground and say things like you’re going to do everything you can to make him feel better while trying not to lie to them.”

  Sometimes, we do what the resident did to be kind to the family. And sometimes, we do it to be kind to ourselves.

  * * *

  Dealing with death and its aftermath is one of the great emotional burdens that doctors take on when they enter the profession. You might think we would do almost anything to stave off death. Instead, more and more doctors take a tangible step to try to hasten death’s arrival by securing from patients and loved ones permission to do nothing if and when death approaches and the heart stops. Doctors call that Do Not Resuscitate, or DNR.