Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

From a distance, death looks absolute—a person is either dead or alive. But up close in the hospital, death isn't always that simple. Sometimes, the line between life and death can blur. I'm Emily Silverman and this is The Nocturnists: Stories from the World of Medicine.

We were really encouraged by the response to Season One of our podcast. So, after several months of hard work, we're so excited to finally be able to share a brand new set of stories with you. This season we'll be transported from the emergency room, to the inside of a prison, to the plains of Montana and beyond. Whether you're a fellow doctor, a student, another health provider, or just someone interested in the nuances of medicine, we hope you'll find these narratives as meaningful as we do. We're also thrilled to announce our first storytelling contest. So, if you're a student or a resident, consider submitting a story to us related to the theme of learning. If your story is selected, you'll receive a $500 cash prize and a slot on Season Three of The Nocturnists podcast. To learn more about the contest, visit our website at the nocturnists.com.

In our first episode, emergency medicine physician Joe Sills describes a startling moment with a patient he's already pronounced dead. Later on, Joe and I talk about what it means to die, the scripted art of delivering bad news and the challenge of being transparent with our patients. Here I give you Joe Sills.

Joe Sills

When I was an intern, sometimes I'd be asked to go to a room and pronounce the patient dead. Later on, I realized that this was one of the least important jobs, which is why it was assigned to me. These were always patients who had been expected to die and they didn't want to be resuscitated. And all that was really needed was a doctor signature for the paperwork. But at the time, I was terrified of getting it wrong—that later in the morgue, the patient would unzip herself out of the body bag and I would end up in the news. So, I once listened with my stethoscope on this 100 year old woman's chest for five entire minutes until the nurse finally came over and lifted up the diaphragm of my stethoscope and said into it, "Is this thing on?"

But since then, I've called the time of death for lots of patients that have died in my emergency department, or at least enough to be unable to remember most of them. And that's because there's just a predictability and a repetition about the work that I do. And the people that I meet—the kid with asthma gets an inhaler, the guy with heart failure gets a diuretic, the patient in cardiac arrest gets chest compressions and maybe she lives but usually not. And after enough iterations of that, the texture of a specific experience flattens into the broad and regular patterns of shiftwork. And on your drive home, it can be hard to say exactly what it was that happened to your patients or to you.

So, when something happens that defies my expectations, I know that I'm probably going to remember it, whether or not I want to, which brings me to Mark. On the day that I met Mark—the day that he was brought to my emergency department—he didn't look so good. His skin was gray and sweaty. And I could see that it was hard for him to breathe, but he made eye contact with me, which is enough for me to at least try and quickly introduce myself before going about the rapid work of keeping someone alive. "Hello," was about as far as I got when Mark's heart stopped. Mark's nurse started chest compressions and I intubated Mark to try and help him breathe and we went through the typical sequence of resuscitation, until Mark's pulse came back. And then it was lost again, and then it came back and was lost again. And after a few more episodes of that, I searched for Mark's pulse and found nothing, and used an ultrasound probe to view his heart up on a monitor where I could see its musculature had gone still.

No one plans to die in an emergency department. But I've become used to giving that news to the families of those who have. By now, I was comfortable with it. Sometimes it bothered me how comfortable I could be. I once had an attending compare giving that news to tossing a subpoena through a door that's about to slam shut on your hand. But now I tend to think of it more as a refrain with three beats that must be sung correctly: "I have terrible news"... pause... "your husband has died." And there's a lot more to it than just that. But that's the rhythmical core of it. It's the part that you must not stammer. And that's what I told Mark's wife, Samantha, when she arrived. I led Samantha down to Mark's room, where he lay, and I pulled up a chair for her and I stood beside her while she cried. And then I waited for a calm moment to excuse myself from the room. And while I was waiting, my attention wandered up to the clock. And I calculated the hours I had left in my shift and thought about what I might make for dinner at home when I got there. And that was around when Mark gently extended his neck, as if reaching for the surface of a lake. "What's that?" Samantha asked me. And I explained to her that this is what's called an agonal movement. And it's a brainstem reflex of the dying process, and it's normal. And then I asked her how she and Mark had met. Now, I never asked anything like that in a situation like this. And I wasn't really sure why I had. Maybe it was to help Samantha remember Mark differently from how he looked now. And maybe it was also to distract Samantha, while I quietly reached my fingers down to Mark's wrist, where I now felt a weak, and slow, but undeniable pulse.

So, I stood there with Mark's pulse flickering in my hand, while Samantha told me that she had met Mark 15 years ago, while at a park. And by that point in their lives, they were each in their 50s and had become used to the idea of being single, but three months later, they were at their own wedding. By now, Mark had been physically unwell for a long time. And Samantha said that she had begun to imagine the ways in which Mark might die—maybe she would find him in bed one morning, maybe they would be out on a walk together. And he would have to take a break and catch his breath and just be unable to get back up. She hoped that by imagining his death, it would somehow make his actual one more bearable, as if she could pay off some of that grief in advance rather than having to bear all of it in one lump sum. But now that it was here, it felt unreal, as if this were just another version of his death that she had thought up. And she looked up at me and asked, "Is that normal?" Normally, by now I would have left the room.

Now, I knew that there was nothing that I or anyone could do to save Mark's life, and I already felt his pulse becoming weaker in my hand. But I had never told the wife that her husband was not really dead. I had just never learned how to do something like that. And by now, I think Samantha must have noticed a dent in my composure, and she asked me, "Is something wrong?" And without knowing if what I was saying was the right thing, I told her that, "I feel a weak pulse. And it's getting weaker now, and I expect it to disappear soon." And she asked me, "What do you think we should do?" And I said, "I think we should let Mark die." And she seemed relieved by that. And I felt more grateful for that reaction than I'd like to admit. Afterwards, when I was able to excuse myself, I walked down the hallway into the bathroom and closed the door and locked it and stood there for a long time. Or at least as long as the department would allow—there were already other patients waiting in other rooms and more tests for me to order, and I could hear another ambulance backing up into the entryway, and I worried about what I'd say next to Samantha. But by the time I had gotten caught up, she had already left for home, and eventually Mark's body was collected for the morgue.

The thing about life is that one day you'll be dead. And that's as terrifying as it is forgettable. That contradiction is as much a part of working around death, as it is just simply living. So, on my better days, I'm mindful of the details and the people around me. And on that day, on my drive home, I reflected on none of that. And, instead worried over all the other mistakes that I've ever made in my life. I have a really long commute. And so I got as far back as preschool, tapped on the panels of the class ant farm and collapsed all of the diligently excavated tunnels. But by the time I'd gotten home and parked my car, my anxieties had mostly burned themselves out. And I thought about Samantha, and that Mark had been a pretty lucky guy. And walking back up to my apartment, where my wife waited, I felt lucky too. Thank you.

[MUSIC]

Emily Silverman

I'm sitting here with Joe Sills. Thank you, Joe, for coming to chat with me today.

Joe Sills

Yeah, thank you for having me.

Emily Silverman

I loved your story. I thought it was word for word, just beautiful.

Joe Sills

Thank you.

Emily Silverman

And you had the audience laughing. You had the audience crying. And so, I am excited to dive into the story a bit with you. I'd love to know, because you've been practicing emergency medicine now for how long?

Joe Sills

I've been out of residency for a year and change.

Emily Silverman

Okay

Joe Sills

I graduated in July of last year.

Emily Silverman

I see.

Joe Sills

So, not long.

Emily Silverman

So actually, not as long as I thought, but long enough that I'm sure you've accumulated a lot of stories. And I'm just curious to hear, why this story, in particular, you chose to tell out of, you know, everything that you've experienced as an emergency room doctor?

Joe Sills

Well, this is one of the few patients that I've had that have come in alive and died during my care. It's not infrequent that a patient dies in the emergency department, but you usually see it coming. But I can probably count on maybe two or three hands, like the amount of times that a patient has come in alive and ended up dying and maybe three times that a patient has actually died like mid-sentence, like while they were, they were speaking to me. So, I think that's why it has outshone those other memories of other patient encounters.

Emily Silverman

It sounds like that transition point can be sometimes very slow for people, but in the emergency room, sometimes it can be very fast, as you say. It can happen mid-sentence. Can you tell us a little bit about what that's like to witness?

Joe Sills

Yeah, well, I remember one gentleman came in with a pain in his armpit. "My armpit's been hurting for a couple weeks." And we did an EKG, which looks at a patient's heart rhythm, and it looked a little funny to me. So, we were repeating another EKG. And on the EKG machine, it's very sensitive to patients' movements. So, I could see that it was kind of like jostling around, so I looked up and said, "Sir, do you mind just staying still for a second while we finish this test?" And he had gone completely white and his eyes had rolled back in his head. And I checked his pulse and it wasn't there. He had gone into v-tach or ventricular tachycardia, which is a life threatening rhythm. And we shocked him—we put defibrillator pads on him and gave him, like, electricity to restart his heart. And I remember, he looked at me and said, "Hey, what happened?"

Emily Silverman

He woke up?

Joe Sills

Yeah. And I'm like, "Well, I'm really glad you came in for your armpit pain, because I think you're having a heart attack."

Emily Silverman

Wow. It seems different from a lot of the deaths that I've witnessed as a resident in the ICU, where I feel like people languish on life support for days, you know, weeks. And we don't see a lot of that—a lot of that like instant... perhaps as much as I think emergency room physicians see, or maybe I just haven't done enough time in the ICU?

Joe Sills

No, I think you're right. I think that you do get thinner slices of those experiences in the emergency department. You see... Because I will meet people that have been through that, like, been on the ward for a long time for a chronic illness or now on hospice and are, you know, are at the end of their life. But they come into the emergency department for whatever reason, because they can't manage their pain at home or they have some other deterioration that their family is worried about. So, then you kind of have to extrapolate, like, what that patient's life was, from just outside of the hour, like, couple hours, that you were able to get to know them.

Emily Silverman

Yeah, yeah. And I was thinking a lot about this, about just the way the body dies, and all of the different ways that the body can die, especially when this article came out, I think in The New Yorker, about a young woman who had a tonsillectomy gone bad.

Joe Sills

Yeah.

Emily Silverman

I don't know if you read this article.

Joe Sills

Yeah!

Emily Silverman

And underwent some sort of CPR and her brain came out of it, not quite alive, and not quite dead, basically. And she ended up on life support, I think, in her mother's apartment. And, for all intents and purposes, had been declared dead by physicians. But then later, actually ended up menstruating,

Joe Sills

Yeah.

Emily Silverman

...having her first period on life support. And I thought the article did a beautiful job of kind of bringing up the question of, what does it mean to die? Because, you know, the body is a collection of cells. And, you know, it could be that some of the cells are still working, and some of them aren't. And some of those cells might be in the brain, and some of those cells might be in the heart. And for me, I think it would be really jarring to have someone just kind of turn on and turn off like that. When I'm used to seeing the process happen a little bit more gradually.

Joe Sills

Yeah, I really liked that article, too. I think that I tend to, like clinically, I think of death in very narrow terms. Like, is there a pulse? Or is there not? And that's probably because there's a lot of... I feel a lot of pressure in medicine, and probably, especially in emergency medicine, to make critical decisions based on limited information. And a way of mitigating the pressure that you feel, and dealing with that uncertainty, is to simplify things. And you end up approaching patients very algorithmically. Like, is there a pulse? Like, yes or no, and then you might proceed from there. But, at least, like, clinically, like when I'm working, I don't have a whole lot of time to like, reflect on what, what that death really means—like more substantively.

Emily Silverman

You strike me as the type of person who is a deep thinker. And I wonder...

Joe Sills

That's generous of you. Thank you!

Emily Silverman

It's my sense. And I wonder if you ever feel a disconnect between that kind of simplified algorithmic thinking that you must use in the emergency department, "pulse or no pulse," and then kind of going down the forked algorithm like that, as compared to... sort of the more abstract thinking, the more philosophical thinking, that you showed us in the story that you told at our show?

Joe Sills

I don't think that it's, it's either one, really. I think that they're just like, different tools for different jobs. I write a lot. And to steal a line from Don DeLillo, "writing is a concentrated form of thinking," and I've always needed that.

Emily Silverman

What kind of writing do you do to process your other patient encounters?

Joe Sills

Um, I think that's just like, it's not really like, like, I'd probably just be doing it anyway. Like, if I weren't a doctor. I took a circuitous route through medical school and took a leave of absence to get a Masters of Fine Arts in fiction, and then eventually came back for the end of medical school. So, it's all, was like part of just like what I did.

Emily Silverman

Why did you want to do that or what was it that you wanted to do? Not to play the role of confused parent, but...

Joe Sills

Yeah, um, well, I think that I'm a lot like my parents. My dad was a doctor. He was an emergency medicine physician too.

Emily Silverman

Oh, wow.

Joe Sills

My mom's a visual artist.

Emily Silverman

Oh!

Joe Sills

So looking back, it was probably preordained that I just became the person that I became. I think that my interest in writing began a lot like other middle schoolers', who also wrote terrible, terrible poems. But, for whatever reason, that impulse persisted with me and continued through college, and then eventually through med school, into now.

Emily Silverman

I was definitely one of those middle schoolers who wrote terrible poems.

Joe Sills

Yeah.

Emily Silverman

I recently was home and I digged up

Joe Sills

Ah, yeah!

Emily Silverman

a poem I wrote about Monica Lewinsky.

Joe Sills

Yes!

Emily Silverman

And it was written from her point of view.

Joe Sills

Amazing!

Emily Silverman

Like it was... it was, like, sympathetic to Monica Lewinsky. Anyway, a lot of kind of passionate, bad poetry that came out of me around that.

Joe Sills

That sounds like great poetry!

Emily Silverman

It's funny that we're talking about bad, angsty poetry, because there was a part of your story that almost implied a poetry in the job of being an emergency room physician. And it's when you talk about the practiced, scripted art of telling someone that their loved one has died. And I think the way you say it is, "It's a musical refrain with three beats." And it's, "I'm so sorry, to tell you this." Pause. "Your husband has died." And, you know, I probably should have more scripts than I do. I think around death and dying, for sure. But I... if anyone has any, please feel free to send them my way. I would love a script for how to handle situations where people would like pain medicine that, you know, that maybe it isn't appropriate to prescribe. I struggle sometimes to find the words, it's just very hard to look someone in the eyes and say no, when they're telling you, "I'm in pain. Give me this medicine."

Joe Sills

Yeah.

Emily Silverman

Which is not to say that I don't treat people's pain. I do. But you know, there are difficult situations, especially when you're dealing with people who have substance use disorders. But it's something I've been thinking a lot about. I think, you know, just being a nice person in medicine sometimes isn't quite enough. And these interpersonal interactions, whether it's telling someone, "No, you can't have another IV Dilaudid dose," or, "I'm so sorry," pause, "your husband has died"—these things that we have to say and that we repeat over and over again. I'm interested in the idea that we might be able to teach and learn scripts around these things. And I wonder if that's something that you've ever thought about as well?

Joe Sills

That's such a good idea. No, I haven't really thought about it. I think that I end up relying on those scripts in a similar way that I rely on like algorithmic simplified ways of thinking. Like for, for me, it's more of a starting point. But, at least gives me, like, a point, a portal of entry into that conversation. And then, based on, on that person's reaction, I can feel out where to proceed from there.

Emily Silverman

I'd like to talk a little bit about the Lazarus phenomenon, which is the phenomenon that's described in this story. Can you share with the audience? What is the Lazarus phenomenon so that they can better understand what happened in the room with that patient and his wife?

Joe Sills

Yeah, the Lazarus phenomenon, I guess, I've read that the more clinical term for it is the "delayed return of spontaneous circulation", is when circulation or pulses restart after resuscitative efforts have ended—typically, like five or 10 minutes later. And it's a rare event, so it's not really well understood. And they had five patients if I remember right, and none of them survived. So never, at least when it's been studied, has it led to survival as an outcome.

Emily Silverman

And so, this happened to you. You were in the room,

Joe Sills

Yeah.

Emily Silverman

and, you know, you had told Mark's wife that Mark was dead, and then you feel his pulse flickering against your fingers. You see him lift his head, "as if reaching for the surface of a lake," you say.

Joe Sills

Uh huh.

Emily Silverman

So, what was going through your mind in that moment?

Joe Sills

Terror. Yeah, just just blank terror.

Emily Silverman

Was it like Frankenstein terror? Like this, "It's alive," kind of terror, or was it more like, "I'm embarrassed" terror?

Joe Sills

Yeah. Yeah. Yeah.

Emily Silverman

The latter.

Joe Sills

Yeah. Isn't that, I think that there's something self-selecting about medicine, about people in the medical field who are highly motivated by public humiliation or failure. So, I think that that was like what, like, that is, that's a big mistake. Like, that seems like something pretty fundamental that you should be able to do, is determine whether your patient is a) alive or b) dead. Yeah. And there's not really an algorithm for that. So, I really didn't know what to do.

Emily Silverman

I think it's interesting how uncomfortable we get when we feel embarrassed, or, like, we don't know—whether it's, you know, "I'm so sorry, Mrs. Jones, I prescribed you the wrong dose of the wrong medicine," you know, or something like that, disclosing an error. Or something as silly as, like, farting in front of a patient.

Joe Sills

Yeah.

Emily Silverman

How do you feel like we are doing as a medical community around being transparent with our patients about our mistakes?

Joe Sills

I don't know. But, I suspect, not well. I think the sense of shame is too heightened. How do you think we're doing?

Emily Silverman

I probably agree with you. But I think we're making strides. I remember when I was in medical school, we actually had a role playing session about error disclosure. And it was just with actors. And the error that we were disclosing was that we had given the patient 1000 times the dose of the chemotherapy, because the decimal point had been moved. And I remember we had to sit in front of this actor and say the words, "I'm so sorry, Mrs. Jones, I gave you 1000 the dose of the chemotherapy" or something along those lines. And even though it was just a role playing exercise, it was so emotional for me. It wasn't even real, but I just had such trouble getting the words out. I found the training helpful. Later in my residency, I did accidentally prescribe a woman double the dose of Bactrim. It was an antibiotic. I was supposed to give her one tab twice a day. And I accidentally ordered two tabs twice a day. And she called because she was having some side effects. She felt, she described, like, that she had 20 cups of coffee. And when I looked back at the computer and realized what I had done, this role-playing exercise came back to me. And I was able to use that exposure or that experience, to then disclose to her, "I'm so sorry, that was my mistake, I ordered you double the dose." But of course, I hung up the phone and my face turned red and I started crying. And my husband had to comfort me and it was like this big thing.

[MUSIC]

Emily Silverman

So, a lot of what we've talked about so far is the dark, heavy side of emergency medicine—telling people that their loved one has died, the stress. But I'd love to hear a little bit about why you chose to go into emergency medicine and what are some things that you love about being in the emergency room?

Joe Sills

Yeah, yeah. Because, because you're right, a lot of it is, like, not quite as acute. There's some days where I'm draining abscesses and putting on splints. And that's great, too. I think that one of the things that I like about it is that I'm a relatively introverted guy, and it's an easy way to be around people, especially people that I wouldn't typically meet in my social sphere. So, I really like that. There's a sort of clichéd saying about emergency medicine that it's the most exciting 15 minutes of every specialty, where you get to draw on, like, obstetric knowledge, and pediatric knowledge, and internal medicine knowledge. But you don't have to do other stuff that I'm just not as interested by, like managing high blood pressure over days or weeks or longer. And I like that. I like that my dad was a doctor—an emergency medicine doctor. And it always sounds a bit uncreative saying that, like, "Yeah, like, my dad's a doctor, so, so am I". But I think that my dad, that I think a lot like my dad does—like both my parents do—and so it's kind of nice to go through what he must have been going through when he was my age. And to think about, like, how, like, oh, this is probably how like his, his approach was to making, like, the decisions that I have to make or how he would have handled that. I was raised on a steady diet of gruesome bedtime stories as a kid.

Emily Silverman

Really?

Joe Sills

Oh, yeah, yeah, stuff that was fascinating to my six year old self. That I'm sure had a lot to do with my early indoctrination towards medicine. Like the, like the guy that was attempting some yard work, but put an axe through his foot, or the occasional heavy machinery mishap. And I learned later that my dad was kind of worried about whatever emotional damage he was permanently inflicting on his child. But those were the stories that I demanded at the time.

Emily Silverman

Do you think you'll, now that you have a three week old baby at home? Do you think you'll be sharing the gruesome stories?

Joe Sills

If she wants to? Like I think that I'll probably do what my dad does. And if she wants to hear them, then I will probably tell them to her in what I hope are not psychiatrically damaging increments, and will then worry like what sort of permanent damage did I just inflict on my daughter, just like my dad did about me. And then they'll probably end up being fine.

Emily Silverman

And then she'll transmit it to her children and it'll just be...

Joe Sills

And, yeah, the cycle will perpetuate, yeah.

Emily Silverman

a Sills family tradition

Joe Sills

Yeah, it could be on our crest.

Emily Silverman

with some with some angsty poetry on the side.

Joe Sills

Oh, geez. Yeah.

Emily Silverman

Well, thank you so much, Joe, for coming to speak with us more about your story. And I look forward to reading more of your gruesome stories in the future.

Joe Sills

Yeah. Thanks for having me. Appreciate it.