Code Gray: Death, Life, and Uncertainty in the ER

by Farzon A. Nahvi

And so, while the country was celebrating healthcare workers as heroes, we knew that the truth of our circumstance was much more complex.

Our lack of information did not preclude our mandate to act.

Reality is subtle, grayscale, and nuanced. It is playing the role of both savior and oppressor at the same time. It is taking action while recognizing that action to be imperfect, and moving forward despite being unable to see clearly what lies ahead. Life, in short, is complicated.

The mundane act of removing one’s mask was imbued with the potential of a slow-motion suicide.

I had always wondered whether my father had developed his cheerful outlook toward life despite the hardships he experienced, or, perhaps, precisely because of them.

Would the current tragedy make me more like my father, or less?

I haven’t been scared of the virus as a pathogen. I’ve been scared because it seems like no hospital administrator knows what’s going on.

By the end of the first twelve months of the coronavirus pandemic, more than 3,600 American healthcare workers would die of Covid-19.

“This is America. I have traveled around the world and can say that the hospitals I have seen in poor, developing countries were better organized than what I went through today,” he told me.

In a place designed to prioritize urgent matters among a vast pool of urgent matters, there is only a single matter over which nothing can be prioritized.

And so, where insiders can claim expertise, I learned, outsiders benefit from a fresh analysis.

But the truth is, the pandemic did not change the nature of our work. While the pandemic may have made things more difficult, it did not necessarily make them different.

Where, precisely, was the line between informing and empowering him, and simply being cruel?

Of course, the entire circumstance he found himself in—including his death and subsequent resurrection—would have never been necessary had he simply been able to obtain the procedure he needed when his problem had first been identified months earlier.

What actually made my job so difficult, then, was knowing that I was faced with a situation for which there existed no correct course of action, and then having to pursue one anyway.

And so, in this way, Covid-19 might have been new, but the complex web of social, emotional, bureaucratic, and philosophical situations that we had to work through in order to treat it was not.

Covid-19 was not a wrecking ball, then, but a magnifying glass. It did not break American medicine but reveal it for what it has always been.

The way we experienced the pandemic was a direct consequence of how we were living before it.

The indignity of medicine can be profound.

A common misconception of medical professionals is that our natural emotions become replaced by a cool, calculating demeanor. Where someone else might feel sadness or panic, for example, a paramedic, nurse, or emergency room doctor is thought to block out his or her feelings and take action. The truth, however, is that those powerful visceral emotions are not replaced by an indifferent calm. They are simply papered over by it.

Ultimately, there is one treatment protocol for death: CPR, oxygen, and a small handful of medications. Unlikely as it seems, whether the cause was a heart attack or malaria, the treatment of death is always the same.

Simultaneously, modern medicine is incredibly advanced and stubbornly Stone Age: we may be able to give you a literal new heart, but we have little to offer for your debilitating chronic back pain.

“Fine, I’ll give you one shot to get the IV but if you miss that’s it,” they may say, negotiating the terms by which we are permitted to provide the medications that will save their lives.

The truth is that we do not liberate these patients from their disease, but reduce their sentences down to life on parole. Our most incredible medical miracles prolong life at the cost of living.

I began playing a game I call “Medical Degree versus Puppy Dog.” After each patient I saw, I would ask myself: Would this patient’s problem be better handled by myself, with a decade of rigorous medical training and board certification in emergency medicine, or by a yellow Labrador with a wagging tail?

Many of the minorly ill already know deep in their hearts that we cannot cure them.

Even today, in the era of computerized medicine and protocolized decision making, there exists no definitive algorithm for the process of stopping a resuscitation attempt. It may come as a surprise, but the technical point at which we should cease our efforts and call a time of death is not clearly defined in the medical literature.

What this means is that, ultimately, there is no clear answer to the question, When is this dead person truly dead with absolutely no chance of recovery? Or, more practically, At what point do I stop trying to save them?

A person who dies in a hospital is not acknowledged as dead upon their last breath, as nature may dictate, but is dead when their physician declares agreement with nature’s assessment.

Despite having plenty of opportunity to work more agreeable schedules, they nevertheless stuck with the graveyard shift. I suspected that they simply wanted to do their job without the invasive oversight of hospital administration judging their every move.

Our actions have to be quick—but in order to work effectively, our thought processes need to remain slow and deliberate.

My lies and my deflections are not an effort to hide some other, hidden truth. There is no secret that I prefer to keep to myself. Nor am I protecting my audience from stories that I assume they would prefer not to hear. The reality is that I demur simply because I do not know what else to say.

Before medical school, I spent years working in restaurants as a waiter and bartender. I worked those jobs simply to support myself, yet the skills I picked up along the way proved to be surprisingly useful in the emergency room.

The truth is, I often go weeks in the emergency room without calling upon a single lesson taught in my embryology or genetics classes, but an hour never passes where I do not employ the skills I have honed as a waiter.

It is not that we see unique problems in the emergency room, but rather, that we see common problems uniquely presented.

We may find that, at their extremes, the fundamental principles upon which we build our entire lives are not so straightforward.

It is often our most well-informed patients who want the least done on their behalf.

In such a case, I wondered, would it be better to respect the wishes she herself had previously expressed when she was in a sound state of mind—indeed, the wishes she had specifically expressed upon anticipating this exact scenario—or would it be better to respect the wishes that she expressed now, despite, perhaps, not fully understanding them? How coherent does one have to be, after all, to determine that they want to continue to live?

To preserve life would necessarily come at the cost of creating more suffering. And in order to minimize suffering we would have to give up on the idea of preserving life.

Too often we scroll through our smartphones for the duration of a forty-five-second elevator ride, preferring the dopamine of our mindlessness over the discomforts of our unresolved thoughts.

She asked me if she was going to die. I was caught off guard. “We all do,” was the best reply I could come up with.

Depending on a variety of factors, strokes can be treated only within the first four and a half to twenty-four hours after the onset of symptoms. After that, we can offer physical therapy and rehabilitation to help patients adjust to their deficits and cross our fingers for some improvement, but we have nothing to reverse the damage that has already been done.

It’s never easy to know whether some little pain is going to turn out to be a big deal or turn out to be nothing at all. It’s difficult to know when to make that call.

Death causes us discomfort by reminding us of the humanity we share. Our healthcare system’s handling of death, on the other hand, causes us discomfort by reminding us of the shared humanity we choose to ignore.

Technically, every death is ultimately “due” to cardiac arrest. After all, “cardiac arrest” is nothing more than medical jargon for “the heart has stopped.” Cardiac arrest is, in a way, both a cause of death and the definition of it.

These laboratory specimens are sent off, then, not to help guide our immediate resuscitation in the emergency room, but with the hope that their results could help to guide their care later, should our patient survive the initial critical moments.

KNOWLEDGE IS POWER. IGNORANCE IS BLISS.

Does the status of one’s existence matter when considering one’s obligations to them? Does one have a greater obligation to the living than to the dead?

Many emergency room doctors and nurses develop superstitious beliefs. “It’s going to be a rough night tonight,” the nurses I work with sometimes tell me whenever a full moon is out. And it is not uncommon for someone to get chastised if they note aloud, while at work, that a shift is particularly quiet. It is a common belief in the emergency room that invoking the “q word” can cause the remainder of a shift to become especially busy.

“It’s better to be lucky than to be good,” she would say with sincerity. “Only the good people die young. It’s the assholes who live forever.”