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In Your Words  |   December 2012
Waste Land
Author Notes
  • Address correspondence to Jeanne Zukas, DO, Internal Medicine Resident, Lehigh Valley Health Network, Department of Medicine, 1255 South Cedar Crest Blvd, Suite 3200, Allentown, PA 18103-6256. E-mail: jeannezdo@gmail.com  
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Cardiovascular Disorders / Gastroenterology / Neuromusculoskeletal Disorders / Being a DO / In Your Words
In Your Words   |   December 2012
Waste Land
The Journal of the American Osteopathic Association, December 2012, Vol. 112, 809-810. doi:10.7556/jaoa.2012.112.12.809
The Journal of the American Osteopathic Association, December 2012, Vol. 112, 809-810. doi:10.7556/jaoa.2012.112.12.809
What is that smell? Where do I know that smell? 
I cannot help but grimace as I walk outside into a wet and warm summer evening. It has stopped raining and the air has a putrid, yet natural, smell to it. 
Oh. It was the same smell from earlier today. I think to myself, How could the smell of new growth after a warm rain smell the same as death? 
*** 
“Can I come watch? I mean, do you mind? I need to learn this part of medicine too,” said Ryan, our medical student, earlier that day on our intensive care unit rotation. 
“Sure,” I say. At that moment, I remember that I have pronounced the deaths of less than 5 patients and begin to have anxiety about my ability to teach the steps to someone else. This has been a familiar sentiment these past few weeks, ever since I started my second year of residency. 
As we walk down the hall toward the patient's room, I begin to collect my thoughts about the steps of pronouncing a patient's death. Feel the pulse and listen for breath sounds. Remember to collect a rhythm strip to give the time of death. We arrive at the patient's room and I start explaining the process to Ryan. “Feel for a pulse at the central vessels such as the carotid or femoral, and make sure you feel for more than just a few seconds.” As we both feel for a pulse, a noise escapes from the patient's mouth. Not a groan or a moan but the sound of a small burst of air. 
Ryan jumps and says, “What was that?” My pulse races, and I begin to imagine that the patient is about to turn and yell at us to stop touching her. Then, Ryan and I look at each other. He says it first. “I think I feel a pulse.” 
“Yes, I do too. This is regular. Weak, but regular.” My mind jumps to the cardiology section in medical school when we learned about the automaticity of the heart, and I realize I never thought of its specialized conduction system in this way: to allow a heart to beat in death. Suddenly, the lines between life and death are blurred. 
We turn the monitor back on because the patient's telemetry was off while she was on comfort care. Sure enough, the monitor shows a slow but regular heart rhythm. “We'll give her a few minutes and then come back. Sorry, Ryan, this has really never happened before.” 
I walk out of the room with 2 separate schools of thought running through my mind. Physiologically, her body cannot maintain this state much longer because agonal breaths such as these are not adequate respirations to sustain life. Emotionally, I feel guilty that the woman is in the dying process and that she is in it alone. Could she hear us say, “We'll give her a few minutes,” or “It won't be long now?” I wonder if the noise we heard from her mouth was actually her soul escaping, a thought I quickly push from my head. 
*** 
During my 6-week rotation in the intensive care unit, I pronounce the deaths of more patients than I have during the entire prior year. After days, weeks, like these that are both emotionally and physically taxing, I yearn for something completely nonmedical. Once home, I turn to my bookshelf. Seventy-five percent of the shelves are full of medical textbooks and journals. Another shelf is devoted to a haphazard collection of cookbooks, art books, and an instructional yoga book. I look to a lone shelf reserved for novels and scan the titles. How long has it been since I bought a new book? Have I read all of these? I decide to look closer, and I find my T.S. Elliot book. My heart jumps as my fingers race to my favorite pages:
 

Let us go then, you and I,

 

When the evening is spread out against the sky

 

Like a patient etherized upon a table;

 

Let us go, through certain half deserted streets,

 

The muttering retreats

 

Of restless nights in one-night cheap hotels

 

And sawdust restaurants with oyster-shells;

 

Streets that follow like a tedious argument

 

Of insidious intent

 

To lead you to an overwhelming question…

 

Oh, do not ask, ‘What is it?’

 

Let us go and make our visit.1

 
While standing among the volumes of medical textbooks and journals I worked to commit to memory, I realize the first lines of The Love Song of J. Alfred Prufrock are the only lines of poetry I ever memorized. I never fully understood the meaning of that poem, and I never want to know the author's intention. What I do know is that I love the way I feel every time I read that first stanza; every time, I pause to savor it. 
No longer do I know where the line between life and death lies. It's not in my textbooks or in my novels. I also don't know why death smells the same as new growth after a warm rain. So, I decide to stop trying to understand it all. Like my favorite poem, some things are best left just felt, enjoyed for what they are, and not analyzed. All I know is I am in the process of learning how to practice medicine, just as my patient was in the process of dying. And I feel relief in the fact that I can choose to practice in my own way. From now on, I decide to take one new step when I pronounce the death of a patient: I will take a moment to hold his or her hand and say, “Goodbye.” 
   Financial Disclosures: None reported.
 
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Reference
Reference
The Love Song of J. Alfred Prufrock. In: Elliot T.S. The Waste Land And Other Poems. New York, NY: Harcourt; 1962:3.