The old woman's body lies across the backseat of a banged-up red Chevy. The car sits under the canopied entrance to the ED. The keys hang in the ignition, and the radio is still on. I hear Miley crooning: “Baby, baby, are you listening? Wondering where you've been all my life? I just started living.”
The woman remains silent. Like a pale hallucination, she moves in and out of my awareness. The flickering lights of the canopy illuminate her body in fleeting fragments. I cannot see well in the dark, but I detect a bald head, skin draped over bone, atrophied muscles. The words of the family play in my head.
“Grandma is sick,” they told the intake clerk. “We can't get her out of the car.”
“She's got cancer,” the daughter added as I walked out of the triage room. “We want you to do everything.”
Immediately, I ran out to the car.
Grandma's head rests against the passenger window, and her right arm hangs limply in the footwell. Chipped pink polish on the fingernails, a brown stain on the yellow blouse, a pink blanket folded over the legs; unimportant human details that catch my attention. The tech at my side hands me gloves. We move quickly. I climb over the driver's seat and into the back of the car. The tech runs around to the other side of the car, opening the door. The woman looks around 70; lines crisscross her forehead, and skin sags around her chin. Youth left her decades ago.
I wrap my arms around her torso and support her head on my shoulder; her cheek rolls against mine, and I feel the roughness of her skin. For a moment I feel spooked, but I keep her close. She's barely breathing. The tech curls his strong, muscular arms under her withered legs. Together, we lift her up and out. She weighs no more than 90 lbs. As I scramble across the seat, my scrubs dampen at the knees and the smell of her urine catches at my throat.
We place her in the wheelchair that the family placed alongside the car. It seems inadequate in the circumstances, but neither of us wants to wait for a gurney. It's faster just to move the patient. I tip the chair back to prevent her from falling out; her small body crumples in the chair. We race the woman through the waiting area past patients lining up to sign in. I feel bad for them. I want to cover their eyes.
We resuscitate the woman in room 3. Clothes stripped off, IVs placed, chest compressions, intubation. No holding back now. Paper fragments flutter to the ground. A syringe cap rolls under my foot. Blood droplets soak into the sheet from an intraosseous line to her tibia.
The trauma bay lights illuminate the curves and contours of the woman's broken body. No secrets now. Cancer has ravaged her. She looks like death. Lifesaving hands pound her chest, an ET tube covered in bloodied spit hangs from her mouth, and her clothes sit in a pile on the floor. The sounds of her ribs breaking make me want to lift her up and take her to heaven. I want to stop the process. I want to bring back the pink folded blanket, the stained yellow blouse, and the rock-a-bye comfort of a car ride in the middle of the night. Grandma's body flails and fails. We breathe for her, think for her, fight for her with all we have got. We do everything. There's no signed DNR, no paperwork expressing the patient's wishes; just a family standing by with a futile hope.
I ask myself: who and what are we fighting for?
Miley's lyrics reverberate in my head. Miley. Did it have to be Miley?
“When you say you need me; know I need you more....”
I still feel the roughness of grandma's skin on my face.
We call the code. The nurses go to the family, offering them warmth, love, and comfort. A tech covers Grandma with a sheet. The social worker and the pastor stop by. The security guard moves the car. The radio finally shuts down. The family weeps and prays, and the daughter murmurs, “She's in a better place.”
I walk out of the ED that night feeling unsure and unhappy about things: best interests, nonmalfeasance, spirituality, compassion, humane medicine, and love. Love hurts, and love prevents us from letting go. I wish Grandma had said, “Don't wake me up.” Sometimes in medicine I feel reassured and righteous, but sometimes I am left with questions. Is this good medicine? Is this what we are about?