The Most Powerful Words

Unlike what you see on TV, people who deal with emergencies or the critically ill don’t stop to emote about what they just saw or did.  We can’t.  We wouldn't last if we stopped to think about it.  We have to take the incident, strip it of the lessons learned to store them, and then stick the rest of the memory in a box.  The box gets locked and shoved to the back of our minds.  Then we move on to the next patient, quickly, because they likely don’t have spare time for us to “get it together.”

I saw a picture online recently (it can be found here).  It was pretty moving and dredged up some old thoughts.  The picture is of an emergency physician who, after a particularly bad death, walked out of the ED, knelt down and cried.  The picture was snapped by a paramedic in his squad and, with permission, he posted it online.  The picture went viral, especially in the emergency community, because we’ve all been there.  We’ve all had experiences with the death of babies or children or little old ladies who remind us of our grandmother or whatever.  Something about that patient flips a switch, prevents our normal coping mechanisms from working and ruthlessly guts us.  We grieve, quietly, privately, then the memory gets stuck in the box, we recompose and get back to work.

These incidents are rare, but they do happen (and if they aren’t rare for a person, that person will be gone from their profession quickly).  But what happens more often than the “gutted-grieve-get back in the saddle” events are moments of sadness.

Most of my moments of sadness came from my time working for private ambulance services in Toledo and Cincinnati, where the bulk of our runs were to nursing homes.  I transported countless people to the hospital when it was apparent this would be their last trip.  Most were so sick that they weren’t aware of what was going on, but more than a few were just as aware of their situation as I was, probably more so.  I learned early on that for these people the most effective therapy in my drug box, airway kit, the cabinets of my one hundred thousand dollar squad and my personal bag of tricks was simply to hold their hand.  For many of them, mine was the last hand they would hold, their last touch of humanity before entering the fast-paced, overworked clinical realm of the emergency department.  It always made me sad.

But something always made me sadder.  The sadness was strong but brief.  It was the sadness of bearing witness to permanent loss.  The permanent loss was always heralded by a physician who would speak what I consider to be the most powerful words: “Stop CPR.  Time of death is…” 

In that instant, that patient, that person, was gone forever.  All their knowledge and their experiences, their loves and losses, memories good and bad, tragedies and triumphs, an older person’s accumulated wisdom, a young person’s future and potential…poof.  Gone.

I know that I did a bad job of concealing my sadness in that moment.  Frequently, a physician or a nurse would see me and try to console me.  “It was her time,” they’d say.  Or “You did everything you could.”  They mistook my sadness as being a result of being defeated by our common arch-nemesis, death. 

That wasn’t the case at all.  I rarely placed any hope in saving these nursing home residents.  They tended to be either chronologically advanced, from their mid-80s to mid-90s, or ravaged by time and disease, with 65-year olds looking like centenarians and being just as fragile.  We were crushing their chests with CPR, inserting artificial airways, plying them with a dozen medications and blasting their hearts with strong doses of electricity.  We worked by the book and everybody got our A-Game, but I harbored no illusion of the outcome. Resuscitation was started on these folks because of a perverse 1980s federal rule regarding the number of deaths allowed in a nursing home, and because the concept of Do Not Resuscitate orders and advanced directives was still taking hold (because of this I have probably done more field resuscitations than most EMS personnel today who weren’t around in the 80s).

Obviously futile effort or not, the sadness overtook me whenever the physician said the most powerful words.  Stop CPR. Time of death is…

One day we transported a little old lady, whose weight and age were approximately the same, to an ED while doing brutal and pointless CPR on her.  As we wheeled into the resuscitation room we began to give verbal report to the assembling ED staff: “87-year old female, down for unknown length of time before nursing home staff found her.  CPR in progress for approximately 20 minutes.”

As we transferred her from our stretcher to their bed the doc asked how far along we were in the resuscitation.  We told him we gave the fourth dose of epinephrine as we pulled in.  That told him everything he needed to know.

“Stop CPR. Time of death is…”

As I pulled my gloves off and headed to the sink to wash my hands, I glanced over my shoulder at the body.  The sadness of permanent loss set in.  As usual, I didn’t hide it well and a nurse noticed.

“There wasn’t anything you could do for her,” she said gently.

“I know. It’s just sad,” I said. I pointed at my head, “Everything she had up here…everything she was is gone.”

She stared at me for a second, looked to the body and back at me.  I could see in her eyes she felt it, too.

By the time I finished washing my hands the sadness had passed. I had pushed it into the box and headed out to clean and restock the squad, making it ready for our next adventure.

For decades I thought that other than that one nurse, I was the only one who was so deeply affected by the most powerful words.  It turns out I was wrong.  It turns out that most, if not all of us, have that feeling.

In February 2014, a nurse from Charlottesville, VA, named Jonathan Bartels published an article in the journal Critical Care Nurse.  In it he describes “The Pause,” a sort of brief and quiet ceremony that begins right after the most powerful words are said.  In Bartels’ words:

After a death in the emergency department, I would stand, ask that no one leave, and invite my peers to bear witness with me, to be together and present in a singular moment of grief and loss. I would ask each to, in their own way, offer silent recognition of the lost human life—someone’s mother, father, sibling, or child—to remember that the person who had died loved and was loved, to understand that the person’s passing deserved recognition, and to acknowledge that our own efforts, too, were worthy of honor.

Even though it started out that way, The Pause isn’t just a little local ritual.  It caught on at his hospital and is now part of the curriculum of the nursing program at the University of Virginia and others.  Word of The Pause is spreading: I heard about it through a story on NPR.

While I may have practiced my own personal mini-version of The Pause, I’m glad that Bartels had the courage to speak up and do the first one openly.  I’m sure that for many people it will help blunt the power of the most powerful words.

Tamed

The Missus and I were grocery shopping today and one of the items we were looking for, Kleenex, sparked a memory.

In the late 1980s, I was a 20-something action-adventure paramedic living in Cincinnati.  I was working a lot of jobs, mostly related to EMS, but still didn’t have much money, mainly because I worked in EMS.  But I was happy.  I had my own apartment, a small circle of intensely close friends, did an exciting and important job, and had no serious cares.  I am also the type who doesn’t equate being alone with being lonely and was comfortable with spells of solitude.  Most people who knew me at the time (except those intensely close friends) assumed that I was going to be a lifelong bachelor.  It may well have turned out that way because there wasn’t a need to change anything.

And then I met Shelagh.

The particularly pretty one and I met while running here.
This squad is where we first kissed...
BEST. VEHICLE. INVENTORY. EVER.

I was introduced to a group of new recruits who had just joined the squad, noting one particularly pretty one with a British accent to die for.  To make a long story short, I found myself one day asking the particularly pretty one if she’d marry me.  {SPOILER ALERT: She said yes.}

As a result, in early 1992 I moved out of my apartment and into suburbia.  The house I was moving into was instant and unadulterated “American Dream”…it came complete with a wife, two kids and two dogs.

It was a bit of an adjustment for me.  As in, the Titanic took on a bit of water.  While Shelagh and the boys had been living as a family unit since Alan was born, I had been flying solo for the better part of a decade, including the formative years of my early and mid-20s.  There were any number of bachelor ways that failed to conform to the standards of the landed gentry and, more importantly, family man.

Gradually, I caught on.  Besides becoming fluent in British English, I became a better team player, thinking in terms of ‘we’ and ‘us’ instead of ‘me’ and ‘I’.  I became used to and adopted the various folkways and traditions of the family I had married into.  I was introduced to the concept of laundry hampers, a truly radical idea for a guy whose apartment had been right across the hall from the laundry room.  We decorated the house together, including a brief bit of madness where the particularly pretty one and I tried hanging wallpaper together.  Throughout the process of catching on, however, I never had to give up the core of my identity: action-adventure paramedic.

So I continued my paramedic ways, doing the things paramedics do, and thinking in the twisted-but-self-preservational way that paramedics have to think to survive the horrible things we encounter.  I thought that little had changed in me, except my behaviors at home.  Then it happened.

I was given a shopping list.  It included Kleenex.  As I hit the tissues aisle I started examining my choices.  The type with lotion was out since they are the exact opposite of helpful when trying to clean your glasses.  I found the type I wanted and started to figure out which box colors would be appropriate for the rooms where we keep Kleenex.

“Wait,” I thought to myself. “Colors?  Where the hell did that come from?”

I stopped thinking about Kleenex and started thinking about my own thought processes.  At no point did Shelagh ever tell me I picked the wrong color of tissue box, nor would she.  If brought home a red box for placement in a room that was predominantly green in its décor, there would have been no problem.  No scoffing or sighing.  No rolled eyes or frowns.  It would simply be put where it was needed.  It was just a box of Kleenex.  I was the one with the aesthetic tissue issue.  It came from me.

My arms dropped to my side, my jaw went slack, and I lost focus on what was in front of me when I realized what had happened.

“Dear God,” I thought.  “I’ve been domesticated.”

Erskine’s Home for Wayward Pets

At my Mom’s funeral last week, there were many lengthy descriptions of what a nice, sweet person she was, of her love of family, of her love of parties (she would celebrate pretty much anything as long as it got the family together) and of her strength.  Mentioned only once or twice was her love of animals.

It wasn’t until everything was over that I realized this was a bit of an oversight and a lost opportunity.  I’m taking this opportunity to correct that lost one.

Yes, Mom loved animals.  All of them.  She fed squirrels on her porch and that food also attracted birds.  And there was also ‘Mama Dove’ - a mourning dove who decided to nest in a hanging plant on the back porch.  It would have taken no effort to shoo her away and save the plant.  After all, the bird could find someplace else to lay her eggs.  But that was simply not the way things were done at the home of an animal lover.  Mama Dove laid her eggs undisturbed, hatched her clutch, they fledged and Mama and Papa Dove moved on, leaving the dead plant behind.  But they came back for the next couple of years, taking advantage of the safety of the hanging basket and enjoying the Erskine hospitality.  This hospitality extended to Mom buying a plant in a hanging basket each year, for the sole purpose of giving Mama Dove a safe and comfortable nesting place.  And this wasn't just any cheap hanging plant.  It was carefully and thoughtfully acquired, including criteria such as Mama's comfort.  She was that kind of animal lover.

In my 21 years there, our house was without a pet only for a couple of years when I was a boy, between the time our German Shepherd Fritz died and when we took in Daisy because Diane’s apartment complex changed its rules and wouldn’t allow dogs anymore.  It wasn’t long after that before it became a long-term, multi-critter abode with the arrival of Jane’s cat, Christy (which is its own long story involving the sickly little runt-of-the-litter kitten who melted the heart of the crusty old, cat-hating firefighter to win a new forever home).

Fritz, in need of a good brushing.

Christy

Mom imparted that love in her kids and that was clearly manifested at its strongest in Diane and Jane.  There’s never been a lack of a menagerie in Jane’s residences, nor was there ever at Diane’s.  I guess I also got a big dose of it.  I mean, my first word was not "Mama" or "Dada," it was "Fritz," the aforementioned German Shepherd.  Shelagh and I have always had two dogs, and for a while we also had two cats (Shelagh’s allergies meant that when Phydeaux and Spike died, we wouldn’t have cats again).  I don't have a bird feeder, I have a bird feeding station, dubbed ‘Tim’s Diner’, that serves up four different types of feed to ensure no birdie in our neighborhood goes hungry.  This includes the hawks that dine on the slower patrons of Tim’s Diner (hey, when you get close to nature, you’re going to see it uncensored).  I also put corn on the ground for our non-avian customers, including, but not limited to, squirrels, white-tail deer, raccoons, possums, bunnies, and skunks, who in turn, are fodder for the coyotes that live in farm field behind our house (see previous parenthetical comment).

But Mom was different.  She loved animals as much as anyone.  But what was different was that animals were attracted to her.  Not just ‘they all wagged their tails when they met her’ kind of attracted.  We’re talking iron-to-metal, moth-to-flame, swallows-to-San Juan Capistrano kind of attracted.  Reincarnation of St. Francis of Assisi kind of attracted.  Seriously, there wasn’t a stray animal in the south end of Toledo unable to find its way, somehow, to 568 Colima Drive.

All the cats except Christy were strays who found their own way to Mom.  KC, Boomer, Kitty…each of them was a tiny little kitten that just showed up on the front porch and wouldn’t leave.

Boomer (L) and KC (R)
It should be noted that as long as these two wanted 
to use this basket, nothing was put in the basket by any humans. 
This went on for months.

One day I came home from school and headed into the kitchen where Mom was talking with somebody (Cindy, perhaps).  On my way to the kitchen I noticed a small brown dog crashed out behind one of the chairs in the living room.  I verbally noted the presence of the little dog and inquired if Mom was aware she had attracted yet another one (she was).  Turns out that earlier in the day, this dog was running around the grounds of Burroughs School, the neighborhood elementary school.  A boy took him home - likely using the old 'It followed me home' gambit - but wasn’t allowed to keep him.  He had to find a home for the mutt or it was going to the pound.  The kid was going door-to-door through the neighborhood desperately trying to find a home for the little guy.  When he got to our house, the boy was in tears and Mom, of course, couldn’t tell him no.  That’s how we got Hershey, a really good little boy and my bestest little buddy.

Hershey, who never, ever failed to put on his whipped puppy look 
whenever a camera was pointed his way.

Another time, Mom came home from grocery shopping.  She asked me to help unload the car since there were a lot of groceries.  I went out and leaned in through the open back door to grab a grocery bag, only to find myself face-to-face with a HUGE dog.  It looked like a Doberman, but one on steroids.  Lots of them.  It was the late 70’s and I had never heard of, let alone seen, a Rottweiler.  The dog didn’t seem agitated at me, but I didn’t see a wagging tail either (again, I didn’t know of the breed and docking), so I slowly backed out, hoping not to die a gruesome death in or just outside Mom's car (everybody had the same aspirations as a teenager, right?) and headed to the porch.  My conversation with Mom went something like this:

Me: Mom, what’s with the big dog in the car?

Mom: What dog?

Me: The great big dog in the back seat.

Mom: There’s no dog in the car.

Me: Um, yes. Yes, there is.

It turned out to be a friendly, well-behaved pooch.  It went willingly with us to the backyard, where we put it up until the owners were found, just down the street.

And then there was the dog that invited itself to the party.  Mom was having some type of Tupperware / Mary Kay party and a dog showed up on the front porch.  It wanted in.  It tried to get in.  It was insistent that it get in.  When conventional means of entrance were rebuffed, it chewed its way through the screen door, entered the living room and sat down as if it had an invitation, had made a reservation and was damned if it was going to be denied participation.  This encounter made the newspaper.

There were many more strays that found their way to Mom.  They were less remarkable, with the dog showing up, getting put in the backyard, fed and watered, and the owner located or the dog taken to the shelter (a true last resort).  But it happened enough to not be unusual.

Many years ago, a couple of decades ago, in fact, one of my siblings, thinking about all of these animals finding their way to Mom, declared that 568 Colima Drive should be known henceforth as Erskine’s Home for Wayward Pets.

And so it was.

-----

Post Script

While rummaging through my old photos for the pictures above, I found two that, in my opinion, capture the spirit of Mom better than any others possibly could:

Here we have five animals, all former strays, celebrating the birthday of one of them.  All the pets and all the humans had a great time doing this.  And that, more than anything, was Joe Ann Kathryn Erskine.

A bit late...

So I finally finished posting my Haiti diary.  The trip was in the spring of 2011, so it's only 4 1/2 years late.  School got in the way (I took a quarter off to make the trip).  I guess I could make other excuses:

• The sun was in my eyes;
• There were locusts;
• I had a doctor's appointment;
• I was washing my hair;
• I was dry cleaning my dogs;
• I was washing the squirrels in the backyard;
• I overslept;
• I was trying to find a word that rhymes with 'orange';
• The dogs ate my homework;
• I got stuck on Level 10 of Angry Birds;
• I wasn't allowed to leave the table until I finished eating the broccoli; 
• I've been having flare-ups of my Cotard's Syndrome and think I'm dead.

So choose the one you like, it doesn't matter.

Haiti Reflections: Epilogue

“Is this worth it?”

I can’t tell you the number of times I heard this question.  THE question.  I heard it in the Barracks and over meals, and an awful lot on the porch during our moonlit debriefing sessions over our Prestige beer.  My answer was always yes, but I rarely said it out loud.  This was because, at the time, I couldn’t clearly articulate why I felt it was, but also because most of the time it was asked by somebody who was clearly leaning towards an answer of no, and I wanted to hear why.  Overall, these negative perceptions were born from a sense of frustration and futility.

Not too long after coming back, Shelagh and I were in Tampa.  We got together with Rich and Ginny Salkowe for dinner one night.  We got along pretty well and I wanted Shelagh to meet them, and them to meet Shelagh (“See? I told you I married Mary Poppins!”).  One new thing about Chantal came up while we ate.  We were talking about the hypertension we encountered.  Why would so many people who are malnourished or starving have such spectacularly high blood pressures?  Rich, who has an interest in geology, has a friend who is a geologist at the University of South Florida, and he asked him if there were any geologic clues.  In looking at the hydrogeology of the region, it was clear that the source of the problem was probably the drinking water.  The aquifer around Chantal has extremely high levels of sodium that will leech into the water.  The aquifer around Canon also has high levels but somewhat less than Chantal.  This would explain a lot of the B/Ps we saw and the differences between the two areas.  It also follows Haitian luck: their sources of “safe” drinking water are poisoning them.  Slowly, but surely.

The Question came up here, too, over dinner.  Was it worth it?  The Salkowes didn’t feel that it was, at least, not for them.  But from my perspective, if they hadn’t gone, the aquifer might not have been identified as the problem.  Will it get fixed any time soon?  No.  But a problem can never be fixed until its cause is found.  Rich, with his geological affinity, likely completed Step 1.  The chances that anyone else with his combination of interests will happen by Chantal are so slim as to be unimaginable.  So if his discovery of the correlation between rocks and blood pressure is remembered, then in my estimation their trip was worth it.  At the very least, his was.

Many times during our stay, Father Yves told us, “We are not here to save Haiti.  We are here to do what we can to help.”  Clearly, he was trying to temper some expectations.  And I think expectations are the source of the sense of frustration, and the sense of futility.  These expectations have both individual and cultural origins.

In listening to all those who said no in answer to The Question, I found that some of the individuals clearly went to Haiti with an idea that they were going to effect some great change.  Some clearly had the idea that, even though it was 15 months later, we were going to be providing more earthquake-related relief.  But while there was a population surge because of the quake, it was made clear to us from the outset that we were there to provide primary care.  These individuals with great change or possibly even heroics on their minds were going to be disappointed from the get go, and as a result, got frustrated.

But the origin of the sense of futility comes, I believe, from our culture.  We are Americans, and when we get sick we have a reasonable expectation that when we go to our primary care physician, we will be cured.  In the subculture of American clinicians, we are used to being part of the team that provides cures for everyone we see, or at least a fighting chance at being cured.  And therein lies the source of the overwhelming sense of futility: the lack of a cure.

The vast majority of people we saw had maladies that we weren’t going to be able to cure.  There were profound numbers of people who had chronic musculoskeletal pain, mainly because they are subsistence farmers and for them “backbreaking work” is not a cliché, it is literal.  There were people with heart failure, cancer and a host of disorders caused by malnourishment.  We weren’t going to cure any of them.  This reality was emotionally insurmountable for a few of the team because the inability to cure is considered a failure here at home.  Those who had this mindset were of the opinion that if we don’t have even a remote chance of curing, what we were doing is futile.

Most people could see past this inability to cure, knowing it wasn’t going to happen.  But the culture of American clinicians tripped some of them up with the sense of futility when they realized what help we were providing was so very limited.  They had expectations of being able to provide care based on American standards, not the harsh reality of the third world.

For those who may go to Haiti or another third world country to provide help, but haven’t been to the third world before, I would like to engage you in an empathetic exercise.  It may help you understand.

You are a Haitian, living in a remote area outside Chantal.  You are a subsistence farmer, growing the only thing that is marginally viable: rice.  To produce enough rice for you and your family to live on through the year, you must plant several acres.  It requires you to work all day, every day, bent at the waist, whether you are planting or harvesting.  The very nature of rice farming means that you will, with 100% certainty, develop chronic lower back and hip pain, probably at a very early age.  As you get older, the pain will get worse.  There is no relief and you will live with this pain.  You will also work with this pain, which will make it worse still.  There are no drug stores and you can’t afford any medicine anyway.  And there is no welfare, so if you stop working, you will starve. 

I am willing to come to you and help you as best I can, even if it’s just to provide you with a few weeks of reduced pain.  If I cannot cure you, or treat you to normal American standards of care, I will still provide you with some relief, some respite.  It is the kind thing to do.  It is the compassionate thing to do.  It is merciful.

So my answer to The Question remains yes. 

Mercy is always worth it.