by Ray Fowler, MD
Copyright Jan 1, 1988

(Time in Space Home)

            Morning’s rough edge gave way against smooth caffeine’s nudge. All about the emergency department gave typical homage to new day’s responsibilities: Cleaning, stocking, and rearranging.

            The lateness of yesterday’s medical miseries continued its grip upon my own freshness, and I growled awake slowly in my corner, sifting mail and auditing charts, murmuring musings about how hard it is to bounce into the routine day after day.

            Into the early slowness walked an old man with chest pain, whom I presently followed into Room 2. The chart bore the name “Erwin Martin”, and to Mr, Martin I strode.

            “Hey there,” I opened. “Hey yourself,” he replied. On these even terms I now explored the history of this 80 year-old farmer who’d sat the night with a constant, non-radiating anterior thoracic pain, unrelated to inspiration. He lived alone, fended for himself, and had no other medical problems. The last few years had been lonely, after the death of his wife of 45 years, with whom he’d had the best years of his life. Now, he just marked the time every day, keeping house and tending his garden. We talked on, quietly, as I examined him, becoming relaxed and acquainted moment by moment. He’d even brought along his harmonica, and later played a tune for us all.

            A bit of a gardener myself, I asked him about his crop. He’d been nursing lovingly throughout the spring 378 tomato plants. Last night he’d not come straight away to the hospital because he’d been putting up the last four gallons of the tomato harvest. He’d stayed up the night, boiling jars, slicing away, and screwing on lids. When he was finished, he then called his daughters and told them about his pain.

            His daughters promptly fetched him to emergency. After completing my examination, noting a basically normal physical, normal vital signs, and a normal EKG but a suspiciously widened superior mediastinum on AP chest, I took the daughters aside for a moment. I shared my fear that Mr. Martin suffered from aneurysm and of our need to promptly evaluate this condition with a CT scan.

            These women were silver-headed and sensible, and their confidence in my workup gave warmth to my fervor. “Dr. Fowler, you do whatever you think best,” they agreed.

            The ladies left for the waiting room as Mr. Martin rolled out the door to the CT suite. And, waiting for the elevator, lying quietly on the stretcher, Mr. Martin stiffened suddenly, suffered a convulsion, and stopped breathing.

            We covered the thirty yards back to the critical room in a few seconds, assisting ventilation and completing a primary survey. He was unresponsive and not breathing, and he had no pulse. The remainder of his exam was noncontributory. We lashed him with tubes: Breathing, fluid, vasopressors. The narrow-complexed tachycardia on the monitor; the disappearing heart tones; Mr. Martin’s age; the specter of a ruptured aorta flashed ominously in my mind, and his incipient death seemed undeniable.

            My grief was mounting. There was simply nothing to be done. I had the family brought to the conference room, and shortly I hurried in to share this troubled news. Looking at them fiercely, I said, “Mr. Martin has taken a desperate turn for the worse. He’s stopped breathing, and I can’t find a pulse. We’re doing all we can, but I’m afraid his great blood vessel has torn. Wait here, I’ll be back when I can.”

            With that, I whirled around and made for the door. As I turned away, one of the daughters, tearful and frightened, a handkerchief clenched tightly in one hand, caught my coat by her other, and asked, “Dr. Fowler, will he die?”

            “I think so,” I whispered in a choked voice, my own tears starting. And so I left, wiping my eyes on my coat as I hurried down the hall.

            The cardiologist called back, echoed my own suspicions, reflected with me on the hopelessness of the situation, and agreed that if Mr. Martin remained unresponsive to resuscitation, it was best to stop.

            And, that was in fact what happened. From the moment of arrest, Mr. Martin was gone. We tried a few other tricks, but it was as if a greater substance had removed the being of this smiling figure from before us even as we watched. Eventually, we stopped.

            With a foggy sense of dullness, my legs heavy as I walked, I returned to the conference room. As I entered and shared my awful news with the family, I couldn’t contain my sadness, and we all cried together for that old man living alone, for his night alone in misery and yet with his last duty, and for ourselves who were now less complete in his absence.

            Presently, the dark clouds cleared a bit, and some element of composure returned. The nurses and supervisors came with their papers and things, and such details as had to be tended got done. I finished my chart and looked up to observe the full chart rack and backed up patient flow.

            A moment later, though, I saw the daughters as they moved from Mr. Martin’s room, having shared a last quiet moment with him before he was moved away. I noticed the harmonica on the counter and slipped it into the hand of one of his daughters.

            We spent a last minute together, a final hug for each. And, as I said goodbye and was about to take my leave of them, the nearest of the daughters said softly to me, “Don’t worry, Dr. Fowler, we’ll take care of those tomato plants.”

            Knowing that I’d been granted a sacred privilege to have met that man and his family at this critical point in their lives, I squeezed their hands, picked up a stack of charts, and moved to the next room.