On Pulling The Plug Right The First Time

Did you ever see Dr. Tetrazzini perform? I say "perform" advisedly, because his operations were performances. He would start by throwing a scalpel across the room into the patient. Then he would make his entrance like a ballet dancer - his speed was incredible.

-William S. Burroughs, Naked Lunch

There's a general and romantic vision of dramatic medical situations which always preserves a starring role for the doctor. The role can be that of the hero (i.e. the deeply sensitive oncologist who shows a patient how through their terminal diagnosis, they can really live for the first time) or the villain (the brutal and insensitive surgeon whose callousness brings the young mother to tears) but it's usually central. However, more often I find myself a bit player in titanic interpersonal dramas. I first started making these supporting-cast appearances in medical student. Some may remember my brief cameo as "Sympathetic Guy in Scrubs #3" at St. Helier Hospital in 2002, where I stood by, having no real idea what to do, as a family watched their grandfather die suddenly of a dissecting aortic aneurysm. I have since made a number of other minor appearances in immense human tragedies, which have garnered little critical attention.

The thing about these roles is that it's important to play them well, because, actually, people do remember them. Just because you're a peripheral figure in, say, they precipitous and unexpected death of a young father doesn't mean that, like every other detail of the situation, your performance isn't irrevocably seared into the memories of his family. Even as a bit player, one owes it to the people one finds oneself in these situations with not to do anything stupid or insensitive that will mar their inevitably photographic and deeply emotional memories of the event.

This can be harder than one might think it would be.

I am currently working in the ICU. Inevitably there is a lot of death around, some of which I actually participate in. I had a patient a little while ago who came in completely comatose and immediately had to be intubated and attached to a ventilator. It turned out that he had had a devastating stroke which had destroyed most of the back half of his brain completely and irrevocably. He was seventy-seven, he had enjoyed a long and happy life, and his family all agreed that the best thing to do would be to "withdraw care" which is our anodyne way of saying "pull the plug."

Once the decision was made, he was moved out of the ICU to a private room on a low-acuity ward. There's something of the knell about these transfers. It's a sort of pragmatic, capitulatory ritual where we admit that death is inevitable and that the dying don't need intensive care. Once we authorize death, the imminent decedent ceases to be a patient and becomes a sort of guest of the hospital for the (brief) period during which his vital signs persist. We sent him up to the ward with the ventilator, however, because the family understandably wanted to be there when we turned it off.

I spoke with one of his daughters, and she told me that the family were planning to convene for the dread moment at six. Having never done this before, I was a little nervous. My superiors didn't seem worried about my doing this alone - I guess they took the view that, since the whole point was to kill the patient, there wasn't really any possibility of medical error. But, again, these are the kind of scenes that are engraved in peoples minds with ruthless fidelity for the rest of their lives; I didn't want his children's recollection of their father's death to include some bumbling technical snafu perpetrated a cackhanded intern, so I spent my few spare minutes in the afternoon familiarizing myself with the basic maneuvers involved in removing an endotracheal tube without, say, leaving a trail of bloody slime across the patient's face. I talked to our palliative care specialist, who gave me some advice on setting up a morphine drip to prevent any unnecessary discomfort (although I doubt highly if the patient was physically capable of experiencing any) and by the time I arrived on the ward at six I felt relatively well prepared.

I hadn't accounted for two things, however. One was the family. There were at least forty of them. They spilled out into the hall, and occupied every possible cranny of the small hospital room. They all looked grave, and when I squeezed into the room I saw they had put the patriarch's favorite hat on him and sat him up in bed in a crude approximation of dignity. I spoke quietly with the daughter, who told me they were still waiting for a few family members, so I waited in the nursing station, fidgeting with the computer and getting progressively more nervous as more and more family member joined the swelling throng. While they were waiting, they broke into an impromptu collective eulogy in a sort of call and response format: someone would list some of his virtues, or give thanks for one of his qualities or accomplishments, and the group would issue a warm, collective "amen", or "praise Jesus". After fifteen or twenty minutes of this, they broke into song. They were clearly all regular churchgoers, because it wasn't some warbling dirge; without any kind of cue they broke into "Amazing Grace" in what sounded like a 17-part harmony. The strong swell of voices emanated from the room and permeated every corner of the ward. Some of the nurses looked slightly aghast. It was awesome and beautiful, but it did nothing for my stage fright.

After a few more songs, everybody had arrived and I made my way to the bedside with his nurse, literally pushing between people and squeezing into a space which hadn't existed a few seconds earlier by the bed. I explained briefly what I was about to do. Some of them had already started crying. I leaned down, and snipped the plastic bands holding the endotracheal tube in place. I hit a button on the ventilator which silences all alarms for two minutes. A few of the family broke into a sort of free-form, harmonic moaning, which caught on until I was inundated in rich, layered song. I deflated the balloon that held the tube in place internally, and, covering his mouth with some gauze, smoothly drew it out. I suctioned all the gross stuff out of his mouth, and did my best to arrange his face in a manner compatible with dignity. He continued to breath, irregularly but, for the moment, sustainably, as I had hoped he would. I was planning to be a few floors away at the actual moment of death.

This was when I realized that there was something else I hadn't accounted for. My plan had been to turn off the ventilator and simply squeeze back out of the room, leaving the family to their grief. The problem with this excellent scheme was that, I realized, I didn't actually know how to turn the thing off. Modern ventilators are very safe and dependable machines. They have backup batteries so that if the plug is, literally, pulled, they continue functioning as normal. Moreover, they have a number of alarms which are triggered by any worrying interuption in any of the parameters they continuously monitor. Needless to say, if you just pull the tube out they go crazy and make a lot of loud noises which are, by design, impossible to ignore. You can press the button I've already mentioned to silence the alarms for two minutes, but it's time limited so that it's impossible to forget to turn them back on. The only way to actually shut it up is to turn the whole thing off, which (I was rapidly realizing as I scrolled futilely through it's many on-screen menus,) was a much more carefully concealed function than I had anticipated. I hit the two-minute button again, but I knew this could only be a temporary solution - I couldn't stand at the bedside pressing the button every two minutes until everybody left, and I couldn't let their moment of profound loss and grief be turned into awkward bathos by the cacophany of incessant electronic beeping noises which would begin to issue from the machine if I stopped pressing the button. This was exactly the sort of thing I had been afraid of. For their entire lives, these people were going to remember me, with a twinge of puzzled irritation, as that vulture-like doctor who lurked at the head of the bed pointlessly fiddling with the ventilator while their venerable patriarch slowly passed on.

Eventually I gave up. I unplugged the ventilator, unscrewed its hoses from the oxygen supply wrapped its various tubes and cords roughly around it, and slowly, painfully, with much bumping of elbows and scraping of shins, hauled it back through the crowd and out of the room. Then I called the respiratory therapist and, I imagine sounding pretty beleagured and desperate, said, "Hey, I just have a quick ventilator question for you."

My two minutes were up again, and every alarm the thing had came on at once.

"How the fuck do you turn these things off?" I snarled.

(That's it. I'm not telling you how you turn them off. You'll have to figure it out for yourself. Or just just think slightly harder than I did about all the things that could possibly go wrong in such an apparently simple situation.)