She’s in her forties, married with kids and a house in the suburbs—the whole dream, presumably. But now there’s cancer, metastasized to her kidneys, liver, and along her spine. The doc has offered to keep her in the hospital, but she wants to go home, so we’re discharging her from the emergency department.
As I wheel her outside, I start to say how beautiful the weather is—early February, but already it feels like spring. Then I catch myself: This will be her last spring. If she even makes it to spring. Suddenly I don’t know what to say. I usually leave people with Good luck! but that’s about propelling someone forward, toward tomorrow, the next thing, the next stage. This is it for her.
I help her into the passenger seat of their Subaru. Closing the door, all I can think to say is “Take care.”
The only thing nurses like more than time off is overtime, and for a while the hospital let us pick up extra hours administering COVID shots in the vaccine clinic. Sometimes, if it was slow in the ER, I’d maneuver my way up there during my regular shifts too. It was always a nice break—just giving shots, no stress.
Once, an Indian man poked his head into the room where the clinic was set up, then sat down across from me, eyes wide, mouth hanging open. I asked if he was OK, because clearly he was not. India was in the news then, as another wave of the virus swept the subcontinent. Hospitals were running out of oxygen. People were dying. What variant was this? I’d lost track.
The man was an engineer, he said, and had been living and working near our hospital for a couple of years. He hadn’t been back to India to see his family since the start of the pandemic. When his dad had gotten sick, his local hospital had refused to admit him; they’d said there was nothing they could do. The man’s sister had bought a couple of oxygen tanks on the black market, but they weren’t enough.
“He died. We had the funeral over Zoom just now. I didn’t know what else to do,” the man said, pulling up his shirtsleeve, “so I came here to do this.”
I was chatting with an older woman about my two boys when she said, “I had two boys too.”
“How’d they turn out?”—my standard follow-up question.
She told me her oldest had died of a ruptured aneurysm in his forties.
“Well,” I said. “At least you still have the other one.” It’s like a reflex sometimes, this impulse to keep the mood light.
Thankfully she seemed not to have heard me. Or she was ignoring me. She just stared ahead. Then she said, “You never get over it.”
I’ll call him Hector. His wife had just left him, taking their three girls with her, and he had no idea where they were. So he’d swallowed a handful of ibuprofen.
In situations like this—and there are a lot of situations like this—once the patient has been medically cleared, they can either voluntarily go to a psychiatric hospital for inpatient treatment, or we have to call the police, who evaluate whether they’re still a threat to themselves. If they’re deemed a threat, they’re placed on a Chapter 51 hold, Wisconsin’s law regarding involuntary commitment, and forced to receive inpatient treatment.
When I asked Hector if he would harm himself again once he got home, he broke eye contact and didn’t respond. Our job is to keep people safe, right? So I convinced him to accept inpatient voluntarily. It seemed like the right thing to do. He would get help, but he also had to sign paperwork acknowledging that, because he didn’t have insurance, he would be billed roughly $1,200 a day, in addition to the bill from our hospital, and the bill from the physician group that staffs the emergency department. Conceivably, after it was all over, he’d owe more than $10,000. Hector owned a small construction business and would never be able to pay that out of pocket. The debt would presumably go to collections and eventually bankrupt him. Now I wonder if, by trying to help, I actually destroyed his life.
There’s a Hemingway short story, “The Snows of Kilimanjaro,” in which the protagonist and his wife are stuck high up on a mountainside, and he is dying of gangrene. He’s a writer, and, believing he’ll die before help arrives, he drinks to pass the time and daydreams about all the stories he’ll never have a chance to write—the stories he had “saved to write until he knew enough to write them well.” All those stories are included there, within the frame story, in italics.
I wonder, is that what I’m doing here?
But no, there’s more to it. This isn’t about telling stories. Honestly, I think I’m just trying to break your heart.
Audrey had spent the past year taking care of Carl, her husband of sixty years, who’d finally died a few months back. She’d come in because her right arm had been swollen for months. “I think something stung me,” she said. “I think I’m allergic.”
Predictably, the CT scan showed a mass that had metastasized throughout her shoulder and was pushing into her sternum.
She had a daughter she hadn’t seen in years, and a granddaughter out of state. No other family. When she left, she refused a wheelchair, so I walked with her to her car, helped stow her walker in the back seat. I gave her a hug. “Good luck!” I said.
Audrey was back in the ER a week later because her arm had gone numb and she could no longer steer a car or hold a coffee cup—her neighbor had brought her in. A week after that, I called to see how she was doing, and she said she was fine, starting chemo soon: “I know it won’t cure it, but maybe it will shrink the tumor a little.”
She told me about getting a ride to an Aldi grocery store, and how a woman had given her a cart with a quarter already in it. Aldi’s carts are chained together and only come apart when you insert a quarter. “So, when I left,” Audrey said, “I did the same thing. I gave my cart to a woman with a little girl, and I told her to keep her quarter. And she was so happy. It was like no one had ever done anything nice for her before. That’s what I want to do. I just want to keep doing nice things for people, like they do for me.”
Karen arrived in an ambulance. Seventy-something, abdominal pain, weakness, failure to thrive. After the paramedics left, I asked her how she felt.
“Terrible,” she said. “I think I’m at the end of the line,” which made me laugh.
“Not yet, you’re not,” I said. I guaranteed she’d at least survive the night.
“If I have to,” she said.
Over the next few hours we had a great time chatting. She lived alone. At first she said she had no one, but then she told me about a son in Chicago.
“Were you married?” I asked.
“Oh, he left me for a younger woman twenty-five years ago,” she said. “It’s OK. He had to live his life the way he wanted in order to be happy. And I’ve had a good life too.” She seemed inexplicably content.
When I finally said goodbye, as she was being wheeled upstairs, I asked if she wanted me to call her son.
“Absolutely not,” she said.
It was a Friday night; maybe she didn’t want to bother him? Worried about her going home alone, I asked the case manager to follow up with her after she was discharged.
Monday morning, the case manager emailed to say Karen had died over the weekend.
The boss called me into her office because a chart audit had shown me discharging a woman with a documented pulse oximeter reading of 62 percent—brutally low. Dying low. The boss wanted to know why I hadn’t escalated this abnormal reading to the doc, but of course I had—the patient had simply refused treatment. She wanted to go home. People sign themselves out against medical advice all the time.
But then why, my boss wanted to know, had I documented that 62 percent? It didn’t look good in the chart. It looked like we hadn’t done anything, like we hadn’t tried hard enough to do something.
In truth I’d left that 62 percent in the chart because it would flag. That number was meant to be a bright-red fuck you, a middle finger to the whole crappy situation, to this patient’s disease and the fact that she was dying, that she would die, probably soon. It was a fuck you to the fact that so many of the wounds we tend never close, and the ulcers never heal, and sometimes a disease is incurable and dying at home is the only choice that’s still yours to make. It was a fuck you to the obvious fact that we all die, and the fact that having to play this role in her dying made me feel like shit.
This reminds me of a young kid, nineteen or so, who checked in with chest pain. “Everyone in my family just talks and talks,” he said while I hooked him up to the cardiac monitor, “but no one ever actually says anything.” His EKG was fine. “I’m just so lonely,” he said. When I clicked on the box to enter his official chief complaint in the electronic chart, I wrote loneliness—which, of course, is not a valid chief complaint. The system is built to only accommodate codable diagnoses. And numbers. Like 62 percent.
My boys were in Scouts one year. At the winter campout, the scoutmaster gathered the adults after dinner and said, “I say we let the boys run around, and we enjoy some beers around the fire!” He’d brought a twenty-four-pack and a bottle of whiskey.
We were strangers, so the conversation was mostly about hobbies and work. Of course someone eventually asked me to spill about the craziest thing I’d seen on the job.
I’m never sure what to say to requests like this. I have a sense of the drama people want to hear about, but most days our ER is filled with abdominal pain and vomiting—nothing like what you’re accustomed to seeing on TV.
I could have told them about the son who’d stabbed his father in the chest with a penknife, or the woman who’d shot her boyfriend in the leg while he strangled her against a wall, or the eighteen-year-old who’d run his motorcycle into a freeway median with his fifteen-year-old brother sitting behind him, and how they’d somehow escaped with bruises and scrapes and one broken ankle.
I could have talked about the twenty-year-old who was brought in tripping on shrooms, and who stripped naked and ran around the department and then head-butted a nurse in the face, or the woman who slapped my coworker—split open her lip—at the triage desk, or the woman who casually reached over the railing of her cot and grabbed a handful of my cock through my pants.
I could have talked about the sixty-year-old alcoholic who had a seizure in his parents’ basement, where he was living, and how his parents, both in their nineties, brought him in and said, “It’s fine. We’ve been through this before.”
I could have told those scouting dads about another drunk who came in every day for months wearing nothing but a T-shirt and the same soiled pair of snow pants, and how he once threw a phone at me from across the room, or the woman who called 911 every day and told the dispatcher she was suicidal, and how the paramedics would bring her to us, and we’d stash her in the hallway until we could discharge her. After a few months of this, one of the paramedics realized she didn’t have a TV, so he bought her one, and we hadn’t seen her since.
I could have told them about the time I started compressions on a thirty-something guy in the passenger seat of his family’s minivan. It took a minute for help to come, and another for us to extricate him, and we did eventually get a pulse back, but later his EEG showed no brain activity, so his family let him go. In the formal debrief I told everyone I was proud of our teamwork that day. We’d worked well together, we’d done well, “even though the guy ended up a vegetable.” No one blinked, but it was obviously a shitty thing to say. Later I apologized and acknowledged what we all knew: that everyone deals with stress and grief differently.
As we stood around the bonfire at that campout, kind of drunk, ignoring our kids who were running through the woods coatless and shouting and roaring with life, I could have told those dads about the three-year-old who climbed onto a shelf and fell and hit his head and died in our ER a few hours later. I could have told them what it felt like to be the last person to push on that boy’s tiny chest, and how a coworker who hadn’t been there later said to me, “It’s not fair. I miss all the good stuff!” and I snapped at her. I told her it was actually the worst thing I’d ever been part of and then walked away, and not long after that she quit, and now I can’t even remember her name. How’s that for a crazy story?
One of my kids is reading about the Salem witch trials and was just telling me about Giles Corey, an accused man who was “pressed” to death—killed by the weight of rocks placed on his chest. When someone asks to hear about the crazy shit I see at work, I want to pile these stories on them. I want them to feel the stories stack up, to know that the work we do is not about collecting anecdotes but about being present as others suffer and trying, and mostly failing, to assuage that suffering.
But actually, now that we’re here, I don’t think this is about those guys at all. I don’t think this is about you.
This is about a guy named Alex, and his really is a crazy story.
I happened to be there when a hospital volunteer rolled him in a wheelchair up to the triage desk. The Uber that had brought him to the hospital had dropped him off at the wrong entrance. His hand was inside a plastic bag, but he was talking and seemed fine, so I turned away to deal with some other emergency.
A minute later the triage nurse looked inside the bag and then rolled him directly back to a bed in the hallway, the only bed open at the time.
It was a partial amputation. There would have been more blood if not for the trauma tourniquet already twisted around his forearm. “Who put that on?” I asked.
“I did,” he said. “Before I did it.”
Confused looks all around.
“With a chainsaw.”
He’d been living with chronic pain from an old injury and had finally had enough. There was a steel rod in his wrist from a past surgery, and the chainsaw had nicked the end of it and bounced off. An eighth of an inch to the right, and he would have succeeded.
We arranged to transfer him to the regional trauma center. While we waited for the ambulance, he asked me, “They can’t fix it without my permission, can they? They need to finish it! Don’t knock me out! I need to be awake so I can tell them I don’t want it fixed!”
He also asked me to call the friend he’d been staying with and let him know he was OK.
“Are you in a grocery store?” I asked when the friend answered. It sounded like a grocery store: Muzak and kids nearby asking for something.
“I am,” he said, hesitant. It’s never good news when the ER calls you in the grocery store.
I told him what had happened. I wanted him to know so he could clean up the mess before the kids saw it.
The friend just kept saying, “Oh my God. Oh my God. Oh my God.”
I found out later the trauma surgeons saved the man’s hand anyway, the fuckers. Though that’s just what I heard from the doc. I really have no idea how it played out.
How’s that for a crazy story?
Of course, even this story is mostly just sad.
Sometimes I feel like I’m made of sadness. I see myself walking my boys to school, taking the long way home, waving to neighbors on their way to work, stomping the snow off my feet in the hall, turning on NPR, moving dishes from counter to sink, doing the laundry, drinking coffee, watching TV. Looking at all this from outside, would anyone suspect such inner drama? Surely this is the story of our lives: so much hidden behind blank or smiling faces. No one ever really knows what anyone else is thinking.
What is it like to know you’re going to die? To feel your wonderful, soft, lovely body—your physical connection to this world—decaying, giving out? What is it like to finally feel you’ve had enough, to give up?
That woman I rolled out to the Subaru—in her forties, married with kids and a house in the suburbs—I was there when she told her husband she’d had enough. She was ready. “I think I’m done,” she said. When I insisted on wheeling her out to their car, her husband joked that I just wanted to be outside for a minute, and I told him he was absolutely right.
“Take care,” I told her after loading her in.
I am trying to break your heart because I want you, too, to take care.
My father-in-law, one of my favorite people, has not moved from his bed in more than a year. He is on hospice, his dementia so advanced that my wife and her sisters and their mother must spend hours every day helping him eat, rubbing his legs, and keeping him company. For a while music eased his agitation. I once sat with him and listened to John Luther Adams’s Become Ocean in its entirety: all forty-two minutes and fourteen seconds of it, just sitting with this man I love, whose incredibly rich and purposeful life had shrunk so drastically. I sat and listened to the music and thought about these stories that have been stacking up for years, and how I’d slotted them into a mental folder for some future writing project already titled I Am Trying to Break Your Heart. But why that title?
Maybe I want to break your heart so that this morning, after you drop the kids off at school and stomp your boots in the back hall, you’ll sit on the couch, with the winter sun warming your shoulders, and do whatever you want: read or listen to music or make more coffee or do absolutely nothing. Whatever it is, do it for a good hour before going back to the dishes and the laundry and the other business of living. Maybe I want to break your heart so you might live and love more fully.
Maybe I’m not trying to break your heart. Maybe I’m trying to mend it, to mend all our fraying hearts. To focus our spiraling attention. To find stillness. I want this for you. I want this for myself.
I want this for Karen.
Karen, who arrived in an ambulance, failure to thrive, who said, “I think I’m at the end of the line.” Who said, “I’ve had a good life.”
When I saw the case manager’s email that Karen had died, I tried to find her obituary online. Maybe there would be a funeral I could attend. Though what would I say to any family there? What would I do if no one was there? Anyway, there was nothing. She was gone, having disappeared from this life as thoroughly as anyone can these days.
I tell these stories as a reminder of how I want to live, but also to remember these people I’ve met, these strangers who allowed me to care for them during some of their most difficult moments.
What would I have said at Karen’s funeral if it had been just me with some empty chairs and a bouquet of dahlias—because it was summer and the dahlias were in bloom and that was what I would have brought? I would have spoken to the empty room, to the chairs, to the floor, to the flowers. I’d have said, “Her name was Karen, and she said she’d lived a good life. I believe she meant it.”
