The Gray Zone

The Gray Zone

Outside the room where nurses were whispering loudly but respectfully she waited.
She was surrounded by taller and older aunts and uncles. The women clucked in their
thoughts like hens and the men said their peace boldly then walked seemingly away
like coyotes on a prowl returning to the circle after a lap to distance themselves.
She stood in the midst of all this chatter and swirl and felt dazed. The suddenness
of all the most horrible realities was overwhelming.

I rushed back to the hospital having gotten a call about a young lady 63 found down
arrested revived after 45 drawn out minutes of touch and go. She was now acidotic. I
reviewed the most important facts and then called to speak to the daughter en route.
I had to work quickly and needed to gauge the daughter and her ability to decide. I
wanted to give her time to consider and digest what I didn’t have to offer. While I
drove in we talked by phone.

“What was your name?”

“Katherine,” she replied softly.

Katherine, daughter and medical power of attorney.

“Let us begin Katherine,” I thought.

I introduced myself and reviewed what I knew about how her mom came to the hospital
and was now currently intubated on pressors and a bicarbonate drip with a pH of 6.9
still.

“Katherine there is ongoing issues evolving. She has organ failure and from what we
know likely brain damage. If you want me to try dialysis I can but I am not sure she
can handle it or if it will help. She is unstable and long term has poor prognosis
for recovery of any kind,” I said against the noise of my turn signal and the cars
around me. I drove the car habitually. I spoke the words equally seamless.

“I …. It happened so fast… She asked for a breathing treatment. My aunt…. My
aunt went to get it and then returned and she was slumped over. But… She did this
in April. She came in and one day she was ok then she was in the ICU then she did ok
and went home….she went home then,” Katherine stammered trying to sort events.

That event in April was similar indeed. She was an admission for COPD exacerbation
then an aspiration pneumonia that deteriorated intubated but never arrested. This
time she was at home when she played out the affair and capped off with an arrest.
This time… she had brain edema. I sighed. Katherine heard me sigh. I felt badly.
Katherine wouldn’t know my sighs. She might feel suddenly judged or condescended. I
wanted to explain to protect her. I sighed because I would have to tell Katherine
boldly the difference between that prior time, home free and this time, brain edema.
I pulled out the harsh sounding and stern reality stick my words became. I pulled
back to swing. I didn’t want to beat her with my words. I put the stick down.

“Katherine,” I softened, driving past a turn and circling around again as if lost,
“this is different.”

I gave her an ETA and told her to think and talk to the family and I would be in to
look at her mom. I was coming. I hung up. Focused on just driving. Turn signal.
Turn. Go. Turn. Go.

I arrived in the throws of mom becoming hypotensive again. As the nurses and
critical care doctor swiftly assessed and dosed more bicarbonate I found Katherine.

“Katherine?” I asked of one then another woman I saw worrying at a drawn curtain.

“She’s over here!” a wave from the left over to a gathering of family and uncertainty.

The circle opened up and there she stood. She had that childlike look in her eyes we
all get when our moms are sick. She had been crying and her hair was tied back in an
exhausted fuss. Strands of hair flew all over. Her tshirt didn’t match her shorts.
She had dressed in a panic. Her dry lips contrasted her wet eyes. I think she had
cried herself dehydrated.

HEENT: head spinning conjunctiva injected ringing noises blaring out in a high pitch
tone …

“I spoke to you on the phone,” I introduced. I shook her hand and told her my role
and agenda again. I shot immediately into the now.

“Your mother is coding right now. Her pressures are dropping. We are trying to
restabilize her. If we can I need to know do you want me to try to dialyze her? It
may not work. It may not even be possible if she gets again hypotensive. Do you want
me to try?” I pressed.

A tall barrel chested man stepped forward and said, “If she can’t wake up and walk
home let it go.”

The group mumbled agreeance.

A very short white hair woman with a cane and a head tremor stutters. “If she’s not
going to wake up… Let it go.”

I hear a nurse shout, “ok we have a pressure now!”

I turn and ask Katherine again, ” You want me to try?”

Katherine is glossed over. I imagine my voice sounds muffled to her and the tone
like a flat line ringing in her ears.

I touch her.

My voice drowns back in as she focuses her eyes to it now.

“Katherine,” I say, I’m talking over the business in the room and through her daze
like a rope thrown to her adrift, “I know because your mom did something like this
before and because she is young and it happened suddenly it feels gray but it is not
gray. Her ability to survive meaningfully makes this black and white,” I say. I want
her to be ok with a decision to stop now today next week 5 years from now.

Katherine puts her hands on her head and pulls her hair and face tensely back. “Ok,”
she says.

I feel the ambiguity.

“Ok what?” I think.

Now I must beat her with the “she’s dying stick”.

“Katherine, do you want me to tell them to stop?” I ask.

But before she can answer her mom is stable and there’s nothing to stop.

The gray zone sets in.

The brain edema is minimized in light of new brief stability gained with the eighth
ampul of bicarbonate.

It’s too early to stop for the team. It’s too early for Katherine to see straight.
The family gets swept away with trying again. The idea of trying everything is coded
and revived. The line goes in and my nurse flies in as I type and dictate. I’m
finishing my note and another ampul of bicarbonate is called for. She’s stably
unstable but I can’t confuse Katherine more.

Dialysis starts 40 mins after I arrive.  Record time. Only in training where we all
slept in a broom closet awaiting tragedy can we discuss, decide, thrust a line in,
and dialyze this fast. I’m happy it can play out fast. I feel reactive. I’m certain
I will fail but I have to fail to crawl out of the gray zone to the fresh  stench of
black.

My best nurse arrives. He is lighthearted. I am grateful for the joking because I
can’t handle the grief without this drug. I texted him en route “oh by the way I
know she has brain edema…. Don’t think I’m crazy.” Nephrologist are known to
dialyze the near dead. I don’t want that reputation. Dylan knows I dialyze the
living. Dylan knows I’m dialyzing Katherine her family and our team. I send the text
anyway because I feel wrong. I feel the gray zone choking me.

He replies, “Miserably is the only way to fail.”

Two hours into a slow high bicarbonate run she’s maxed out on three pressors with a
blood pressure bows down in the 70s.

“Death comes for us all; we can only choose how to face it when it comes”

— Robert Jordan

Katherine bravely calls it quits.

The team allows the white elephant to be seen. I get a call that Katherine drew a
white flag. I see her alone bearing a decision. I should’ve just told her I would
bear it and not dialyze her. I should’ve just said no to the moment. I don’t know
anymore. The gray zone has infected my judgement.

I am at home now away from the planning and reality of room 120B. I know I will not
see Katherine again. She will fade out as her mother’s name pales on my list in a
terminal withdraw. I don’t see a reason to call. I don’t think Katherine can
remember my role or my name.

“It all happened so fast,” Katherine reels in the quiet of heavy decisions made in
the center of a circle of hens and coyotes.

The gray zone lays like a blanket over the mother in the bed. From that late
afternoon over 5 hours the mother was dying and it was just not enough time to make
it feel black and white.

I call anyway. I can’t help it.

“Katherine,” I say as if her name calls her back to reality with strength, “It’s
black and white. You did it just perfectly. I’m sorry. It happens this way
sometimes. Let the gray darken.”

The night is coming over the long day.

Katherine decides on the terminal extubation and darkness falls.

“While I thought I was learning to live I have been learning to die.”
–Leonardo De Vinci

Sometimes it happens that way. The unsettledness defines the gray zone and for days
I question my moves and motives. For days I wish we knew better how to die without
misery.  Take the gray. There will be no true contrast to call closure upon.

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