Dead. With perfect makeup. Thick died black hair, almost invisible white roots. She was wearing a frilly chemise under her hospital gown stained with vomit. Proper in fashion and grooming in the way that only the elderly can be. Her skin was yellow from the cancer that has torn through her liver. The same cancer that ate away her fat and muscle, so that she nothing but hollowed temples and scaphoid belly.
The goblin green line of the cardiac monitor scribbled electrical chaos. Ventricular fibrillation. Our patient, limp and grey, lay bonelessly on the CT scanner table. Her heart fluttered like a bag of worms. That sort of chaos can’t pump blood, can’t supply oxygen to the brain.
The CT suite had bland white and chrome features centered on an enormous metal donut. Surrounding my dead patient was a cadre of nurses, techs, her doctor, and me. The smell of death was cheap air freshener and cold sweat.
I do not suffer death in my presence.
Randy, sweaty and bald in scrubs that hung in all the wrong ways, held a finger over the orange SHOCK button.
“Everyone clear? All clear?,” I said, my voice certain and monotonous from thousand resuscitations. “Shock.”
The LifePak buzzed as it unleashed an electrical storm. My dead patient’s body arced upwards. All eyes went to the monitor. Still a scribble.
“Still in V-fib. Charge again,” I said.
“Charging,” Randy replied. The LifePak 12 whined.
“Shock,” I said. The LifePak buzzed, and the dead woman’s body arced upwards, as if trying to reach for heaven. Then she flopped down again.
Her doctor was talking on the phone to a nurse on one of the many floors of one of his many patients. Abdul Malek was a skinny dark guy with a belt of pagers and phones that seemed to weigh more than he did, all going off constantly. I looked up at him.
“It’s your Code, Big Guy,” he said, with a thick Eastern European accent and Gallic shrug. He knew it was my thing.
Code Blue was the euphemism for cardiac arrest. When they announced Code Blue over the loudspeakers, it didn’t upset the patients as much. Sick people didn’t like to hear that other people were dying around them. Other doctors ran away from codes. As an Emergency Physician, I ran toward them. On any given day I was a generalist, treating anything from runny noses to gunshot wounds, psychotic breakdowns to pneumonias. Resuscitations were the one thing I did best. So, when we heard “Code Blue: CT scanner,” on the loudspeaker overhead, Randy and I came running.
“Check the pulse,” I said. Randy, my nurse, had a sheen of sweat over his bald head. Shocking, childlike blue eyes under craggy brows, turned to me and nodded. The racing green line of the monitor showed fast regular complexes, like the same calligraphy letter written over and over again. Her pulse thundered in her wrist.
“She’s back,” I said. Her eyes were closed, and the oxygen mask steamed with each breath.
“Pressure is 180/120, doctor,” Randy says, swinging his stethoscope around his neck dog-collar style.
“She’s riding the ‘Epi’ train. It won't last long,” I said. Epinephrine is pure adrenaline. Shoot into someone’s blood like I just did, even a dead hearts will beat for a few minutes. “Hang dopamine at 10 mics, and let’s get ready to intubate.”
I look up at Malek. He puts the phone back on the wall and shakes his head. He claps his hand on my shoulder in a brotherly way.
“Listen, big guy, you did a great job. I just talked with her family. She’s a DNR.”
DNR. Do Not Resuscitate. The wisdom to realize when medicine has reached the end, and when the disease is our best friend because it will take the pain away. Malek looked sad, sad for me. He knew that I lived for the resuscitation. I got wrapped up in it, the battle between medicine and death, and I lost perspective.
I looked down at her. Her mascara wasn’t even smudged. She had recently done her nails with burgundy polish. This was a woman that wanted to live. She wanted to live.
“Elaine! Elaine, can you hear me?!” I shouted.
No response. She coughed.
“Elaine, we just restarted your heart. I want to put you on life support. Do you want us to do that?”
She coughed. Her mouth seemed to be moving, but I couldn't hear what she was saying. I leaned in closer.
“Are you a religious man?” she whispered from frothy, cracked lips.
I leaned closer. I was pretty sure I imagined her voice. Most people are unconscious that close to death. It makes tearing them open, shocking them, violating their deaths that much easier. She couldn’t be talking to me.
“Are you a religious man, doctor?” she asked again, and either from her lungs or my conscience I heard her.
I have heard this question a hundred times from my patients. As someone who stands with one foot on the border between life or death, these questions are of importance. It’s a question I frequently ask myself.
I can hear the clanging of bells in the distance. Ten arms falling as one, ten iron bells clanging. Chanting.
To Ho Ka Mi Eh Mi Ta Me.
I am no longer wearing scrubs and a stethoscope. I am twenty years younger, with wisps of beard clinging to my face. I am wearing a simple t-shirt with a logo of a mountain, and gi pants. Sennin Kai. I am chanting.
This is my first Misogi.
To Ho Ka Mi Eh Mi Ta Me. To Ho Ka Mi Eh Mi Ta Me.
Misogi is an ancient ritual of purification. We gather in the dawn light, when the dew still clings to the grass, on New Years Day. We are teachers, computer programmers, lawyers and accountants by day. By night we learn the rituals and meditations of monks long dead. Sennin Do means we live like the Sennin, the immortal ones who ate air and flew with the dragons. We are men and women of science and modernity, and we understand these rituals are only to focus our minds and clean our bodies, but that makes them no less magical.
The chant itself has no translation. It means what you want it to mean. There is no magic except the sweat of ten arms falling and the overwhelming clamor of ten bells and ten throats. I am benevolently obsessed. Absorbed.
The chant becomes faster.
Toho Kami Ehmi Tame! Toho Kami Ehmi! Tame!
She had gotten off the Epi train. Her heart was slowing, and the aggressive pink sheen of her skin was starting to fade to grey.
“Sinus brady,” I said. The calligraphy letters on the cardiac monitor were getting farther and farther apart. “We’re going to pace her. We can do that with a DNR, right?”
“Right. Randy, give me a half-mig of Atropine and grab the pads.”
He pulled off her gown to show folds of excess skin over rotten ribs. Plastic pacer pads were stuck over her chest and back. Unlike an internal pacemaker under the skin, this was a cruder kind. Her own heart couldn’t give the electrical kick, so we would provide our own.
“100 milliamps, rate of 60.”
Another line of green.
Malek looked sad. Not sad for the patient. Sad for me.
“Big guy, she’s got cancer. She’s only got a few months anyway.”
He stepped back, already divorcing himself from the drama. We were in sketchy territory here, legally and ethically. On the edge between life and death, it was each doctor’s decision. At least we thought so. Usually the choice was out of our hands whether we believed it or not.
Toho! Kami! Ehmi! Tame! Toho! Kami! Ehmi! Tame!
This is my second Misogi, that we do every year. I have become an instructor, the youngest instructor in his dojo. Twenty years old.
I sit on the right hand side of my Sensei. His eyes are closed. My eyes should also be closed, but I can’t help watch him. He has a handsome, childlike face with thinning brown hair and horrible brown teeth, likely stained from tetracycline when he was a child. Soon, it will be my turn to take his place.
Even through the chant, my mind would wander. I thought of running the dojo, how I would attract more students. How I would motivate them, inspire them. I would help people understand the peace and power that I had found.
Toho Kami Ehmi Tame!
I felt my hands shake. I was wasting my time. Let her die. Let her die. My mind, my training, my collegues are telling me to let her die. I’m not supposed to be here. I’m supposed to be in the ER.
“No capture, doctor,” Randy said.
Patients came to me and they died. That’s what it meant to be an Emergency Room doctor. They fell asleep while driving and roll their SUVs and they died. They drank for forty years and vomited blood and then they died. They smoked until their lungs were great useless bags of black paper and they die. They live in the wrong neighborhood and catch a bullet aimed at someone else and they die. They die and they keep dying.
Most days, I could handle it. Let it go, bitch to my friends, drink, laugh and forget.
“Not today,” I whispered to her. “I can’t let you go, my dear. I’m sorry, I can’t let you go. I couldn’t lose another one.
“Randy, push two amps of bicarb. I’m going transvenous.”
Randy beamed me a relieved smile. We were in the meat of it, we had Code fever, and he was as invested as I was. Randy was of strong Irish stock. He understood fighting but not giving up.
A transvenous pacer is a long, sterile wire that feeds directly into the ventricle. I’m running an electrical cable directly to heart, through her peripheral circulation.
My Sensei looked hurt when I told him the news. I was leaving the dojo. I was a young man, and my blood was too hot to sit and meditate while the world was being formed. I wanted to roam, to rage, to live a life outside of the dojo.
He told me that there would always be a place for me, but I knew that my place wasn’t at his side. It was out there. I still believed in the principles I had learned, but the dojo wasn’t my place to practice.
When you finish Misogi, you start to make your arm swing in a arc half as large. Then half as large again. Then again. Then again, until your hand is completely still.
I went to Israel, the land of the living bible, to learn my religion. I studied medicine. Then I went to the worst warzones of South Central and north Philadelphia to learn trauma and critical care.
It sucked. I hated it. I hated the hours, the abuse by patients and nurses, the constant complaints and lack of sleep. It made me tough and hard. I learned everything I read in books, practiced it a hundred times, lost ninety-nine, tried another hundred.
I could feel my own heart beat in time with hers. Fighter pilots get it when they’re pulling three Gs. Boxers get it when they’re punch-drunk. The sort of horrible focus that blocks out everything. I've got Code fever. Just me and her dead heart and my technology versus the cancer and the entropy that all things die. My hands were sweaty in the gloves. It seemed like the air was a hundred degrees. I slipped past the sweet spot again. My hands trembled.
I stopped, and stood straight. Closed my eyes, calmed my breath.
I could hear Randy’s voice quaver. “Doctor?”
I relaxed my hand, and swung it to the side. In great arcs that became smaller and smaller. Smaller, smaller. Soon, my hand was still moving, but to any eye it was completely still.
I slid the electrode through. Slowly. With infinite calm.
“Capture!” Randy said.
“Give me sixty at sixty, Randy. Sixty at sixty.”
A powerful pulse thundered through her body. It hammered against my finger on her wrist. Her color returned. She sucked on the oxygen mask.
Her eyes fluttered open. She was confused, sweaty and alive. She'd live for a few weeks, a few months. She looked at me and I thought she smiled.
“We’ve lost it. No capture,” Randy said.
“Okay, I’m tubing her,” I replied automatically. It was a lifesaving procedure, I was good at it, I could save her.
Malek sighed. I looked up at him, and the fever broke.
“It’s not what we want, Big Guy,” he said. “It’s what she wants, remember that. It’s what she wants.”
I looked up at the clock. 11:55 pm. The code was over. It had been over for a long time, but I hadn't known it. I had fallen from the perfect crystalline rush of CPR and emergency surgery, mechanical ventillation and cardiogenic pressor drips, back to the world again.
“Do you a religious man?” Elaine asked me, in a voice that could not have been hers.
“Yes, Elaine. Yes, I am.” I said.
Randy looked up at me, waiting for my response. They all look at me. All movement stops. Each doctor, it’s our decision, but really, it’s her decision. I hang my head, and say those words I’ve said so many times.
“Time of death, 11:55 pm.”
A collective breath was let out. The drama was over.
The crowd started to disperse. Monitor cables were folded. Gossip exchanged. I flicked off a bloody glove into the garbage, let out a long ragged breath and took in a new one.
“Do you answer to God?” her corpse asked, with motionless lips and empty lungs.
Back in the ER, the patients were piling up. Headaches and runny noses and broken bones and heart attacks, waves of humanity that would never stop crashing on my shores.