What Working in the Emergency Department Taught Me About Death

In the five years I spent at medical school, I learned a lot about death. My classmates and I spent endless hours in a darkened lecture theatre, trying to understand the many and varied ways in which a body can malfunction. From flaws and failures on a microscopic, cellular level, to the signs and symptoms of thousands of diseases, which appear to lurk on the sidelines waiting to wage war against us. There were times it felt quite miraculous that human beings managed to survive at all.

In workshops, surrounded by real equipment and what were quaintly referred to as “fake patients” we acted out crash calls and emergency situations. We attempted to revive plastic dummies and sewed up oranges to hone our suturing skills. During those very long years, as we forced knowledge into our exhausted brains, we acquired information about every possible way the human body can expire, what we might do to prevent it, and how to break the news to a patient when we can’t.

Yet we didn’t really learn about death until after graduation.

In the ED, death feels so unlikely.

In August 2010 I walked onto a ward, with my shiny, new stethoscope and a combined sense of pride and sheer terror. Twenty minutes later my bleep shrieked at me from my lapel, and I was given my very first job as a junior doctor. “Could you come to Ward Seven and certify a death?” As first jobs go, it wasn’t a particularly inspiring one, but I knew what to do. I had been taught. I had completed a workshop where I successfully certified the death of a fake patient (who then got out of bed and ate a cheese and pickle sandwich) and I had answered several exam questions on the subject without a backward glance. It would be fine.

My patient was in a side room and the first thing I noticed when I walked in was how still the air was. Beyond the closed door the rest of the ward moved on, but where I was standing it felt as though the world had been paused. Around me was the detritus of a long admission. A pile of old magazines and newspapers, get well cards stuck to the wall behind the bed, crumpled tissues and long-forgotten cups of tea. I attempted to ignore all of these things and set about the task I had been trained to do. The patient was an elderly woman with tight grey curls and a face filled with aging and tiredness. Her death had been quiet and expected, but she gripped the bedclothes with both hands, as though she had tried to hold onto the world. As though she’d remembered something she’d forgotten to do and needed to stay.

I checked everything I was supposed to check. A shone my pen torch into her milky eyes. I pressed my shiny new stethoscope to her chest, and I listened for any sound of respiratory effort. I recorded everything meticulously in her notes and then I stood for a moment in that still, quiet room. It felt wrong to immediately turn and leave. Not to acknowledge her passing in some way. It was then I noticed the book at the side of her bed. It was a paperback, and deep within its pages was a bookmark.

“Now she’ll never know how the story ends,” I thought.

Long after I had left that room, my mind kept returning to the bookmark, and every shift from then onwards, I would gather more and more small memories like this one. I called them my Kodak Moments, and I collected so many, eventually I was dragging them around with me each day like a difficult suitcase.

Of all the places to learn about death, the Emergency Department offers you the richest opportunities. One stormy night, as the rain rattled on the roof, an elderly woman was brought in after suffering a cardiac arrest. Her name was Elsie, and the double doors crashed open as she was wheeled in on a trolley. Elsie and her husband had been watching the television, but when her husband returned to the room with their final cup of tea for the night, he’d found her unconscious in her chair. He waited in the corridor outside the resus room as they worked on his wife, but Elsie’s tired body had had enough of this world, and eventually they called time of death. Elsie was not my patient, and I left resus before the doctors had broken the news to her husband, but I passed him on my way to the next job. Another Kodak Moment. Because draped across his arm, creased and wet from the storm, and waiting to be worn, was Elsie’s navy blue raincoat.

In the ED, death feels so unlikely. All these people whose days started just like any other. The car crashes, the heart attacks, the collapses. No one expects to find themselves in a curtained cubicle, explaining themselves to a doctor, as they both try to work out how an ordinary day became so very un-ordinary.

I was writing up at my notes at the nurses station when Elizabeth was admitted, a thirty-five year-old woman with a racing pulse, tightness in her chest, and a feeling that something very bad was going to happen (a sense of impending doom as doctors describe it). Due to her young age and otherwise good health, Elizabeth’s symptoms were put down to just anxiety (because even now we like to put “just” in front of any mental health condition) and she was put into a cubicle in minors. Spying a potential “learning opportunity” two medical students followed her in there and closed the curtain. Within five minutes, the curtain was flung back again and one of the medical students bolted out of the department in a panic. The other medical student, in a surprisingly calm voice, asked if they could “have some help in here” because Elizabeth had stopped talking, slid from her chair onto the floor, and had gone into cardiac arrest.

Ten years later, long after I left those wards, I still carry these moments around with me.

It just so happened a consultant cardiologist was in the next cubicle and within seconds a resus team had gathered around the patient. If you want to see the definition of efficiency, a crash call is an excellent place to start. Under the supervision of the cardiologist, they pumped drugs and electricity into Elizabeth’s body, and within a few minutes they had brought her back. It was a miracle. Right in front of my eyes. I thought all crash calls would be like this (they are not). The patient even attempted to stand up (lie down Elizabeth! the consultant’s voice bellowed around the department). Elizabeth was eventually wheeled off to the Coronary Care Unit, and the cardiologist turned to his audience and said, “well she was right about the impending doom.” Because cardiologist have an impeccable sense of timing.

I watched him for the rest of my shift, glancing across the department as he continued with his day. I wanted to ask him how it felt to argue with God. What it was like to perform a miracle on the floor of an Emergency Department. However, I kept these questions to myself. I hadn’t been a junior doctor for very long, but I had already learned that a doctor’s job is to take histories and order X-rays and insert cannulas. A doctor’s job is not to talk about feelings (at least not until the sanctuary of the psych wards). And so I collected another Kodak Moment, another thing I had learned about death.

Ten years later, long after I left those wards, I still carry these moments around with me. They are small post-it notes I pull out whenever my own trivial problems start to overwhelm me. A legacy of patients long since gone who still bring me comfort and perspective. Because as a doctor the most important thing I learned about death, is you will never understand it until you walk in its presence. The true meaning of death lies in bookmarks and raincoats, not in textbooks and lecture theatres. You may be fluent in the language of anatomy, physiology and pharmacology, but you will only become a good doctor when you recognize that sometimes the very best thing you can do for a dying patient is to stop trying to fix everything, and just sit and listen.

There are some things which cannot be taught.

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An Unlikely Visitor by Joanna Cannon is available from Scribner.