Then Spoke the Thunder

by Shiban Ganju

Jack arrived in the hospital a few minutes after midnight. Next morning he was dead.

Death visits a hospital in sobs, shrieks or stoic silence. It stumbles with stroke, burns with feverish sepsis, crashes in with a fractured torso, stuns a teenager with drug overdose, rams the chest with a heart attack, relieves agonizing cancer, or just sneaks in sleep with stealth. In all its forms, death is a process.

“The awful daring of a moment's surrender
Which an age of prudence can never retract
By this, and this only, we have existed” (T S Eliot)

But Jack’s death was different.

He was healthy just two weeks back – he did no drugs, he exercised, he worked, he voted and he was in love. And now he was on life support. Plastic tubes and wires connected his body to bottles, monitors and an armory of medical gadgets. With his chiseled nose, calm countenance, eyes shut, long dark black hair sprayed on the white pillow, he looked pristine – even on the ventilator. His face reflected the golden hue of bile seeped into his skin. The feeble pulse, high fever, low blood pressure and delirious thrashing of limbs foretold gloom. The air of death hung heavy over his bed. And he was only thirty-three.

The process of death unravels in the molecules deep inside the cells and shatters emotions on surface. Irrespective of the first cause, the processes have a broad similarity. But all death is not dangerous. Some part of us is dying all the time without any harm to our physique or emotions.

Body cells have a life span: red blood cells live one hundred eighty days, platelets live for a week, intestinal lining rejuvenates in one to seven days. Approximately fifty to seventy billion cells die every day. Even in children under fourteen, twenty to thirty billon cells vanish daily. With this continual destruction and proliferation, in one year, we probably replace cell mass equal to our body weight.

Our cells also disintegrate with a programmed protocol that paradoxically keeps the body in state of health. Scientists call it apoptosis. When something goes wrong inside the cell, cell generates an appropriate biochemical signal, which triggers a sequence of biochemical processes: scaffold collapses, cell shrivels, nucleus condenses, DNA fragments and its membrane blisters. Enzymes dissolve the contents of a cell and break it into small sacks. Roaming scavenger white blood cells mop up the debris.

This process is protective and apoptosis gone wrong can unleash havoc like cancer. Apoptosis does not damage the body, which differentiates it from another form of cell death – the harmful necrosis. Infection, physical injury, poisons and lack of oxygen can provoke a cascade of reactions producing toxins that irreversibly damage the cell and also its surrounding tissue. Examples are: heart attack or paralytic stroke due to lack of oxygen and staphylococcus bacteria grinding normal tissue into an abscess. The sequence of chemical events in necrosis differs from apoptosis.

Necrosis can damage a single organ, which may not cause death unless the organ is life sustaining like heart or brain. Both these organs are extremely vulnerable to oxygen deprivation; a few minutes of anoxia or absence of oxygen damages the heart muscle, which looses it strength to pump oxygenated blood into the brain cells. Neurons deprived of oxygen collapse fast – within four to eleven minutes – causing irreversible brain death. The sequence of anoxia can also initiate from the respiratory center in the brain stem – the part of brain at its junction with the spinal cord, where the neck meets the skull. The center controls the depth and speed of respiration. Any damage to this center- as in head injury or stroke- will depress breathing and cause anoxia, which then damages other parts of the brain, heart and the rest of the body. Irrespective of the initiating event, anoxia seems to be one of the prominent determining events of cell death.

What happened?

Jack’s girlfriend, who had rushed him to the hospital, was trembling with fear. She squeezed the back of her left hand with her right.

“ He is stubborn. He has gallstones. He had stomach pain two weeks back but did not go to the doctor. He had low fever and his eyes turned yellow. Last week he passed stools like white pebbles. We thought he was passing the gallstones and he will get better. Then yesterday he had shakes and collapsed in the bathroom. I called 911.”

One of the stones had probably moved out of the gall bladder and was obstructing the flow of bile. That is why his stools were white. And now he had sepsis – infection in the blood.

Why didn’t he come earlier?

“He does not like doctors.”

Jack had started with a curable disease. Gallstones had blocked his bile duct – the passage that connects gall bladder with intestines. Bile had backed up into his blood and seeped into all the tissues of his body – including skin and eyes – and colored them yellow with jaundice. Hordes of Bacteria that had infected his gall bladder were now racing and raging through his blood stream. The rapacious toxins had overwhelmed his immune defenses and were plundering the organs, which were succumbing one by one. The battle was nearing the end with multi organ system failure. Jack was dying. Curable had become incurable.

“Drip drop drip drop drop drop drop
But there is no water”

The phone rang. It was Jack’s mother. She was driving and was about two hours away.

”How is he now?”

He is very sick. We have difficulty maintaining his oxygen and blood pressure. His kidneys are not working now.

“Will he get better?”

Don’t know. We will try our best. We will wait for you to reach here. Drive carefully. The roads are slick with ice.

Obstinate death leaves no room for argument or compromise. But its banal finality is neither spontaneous nor easy. Mental moat barricades the mind from the attack of the inevitable emotional trauma. Denial says it can’t happen. Anger seeks a target to blame. Anxiety and confusion shout: why? Ensuing clarity plunges into grief. And the inevitable reality incessantly demands closure. Death drills a hole through the emotional shield and forces a reluctant acceptance. Healing time softens the scabrous edges but the hole never fills. A void stays.

But Jack was not dead – not yet. He was in coma. Parts of his brain were still working. A flashlight shinning directly into his eyes would make his pupils contract. His eyes would turn if his head were shaken from side to side. A cotton swab touching his cornea would make his eyes blink.

If he were taken off the respirator the carbon dioxide level would rise in the blood, which would stimulate his respiratory center and may initiate agonal breathing. And an electroencephalogram would still show some electric activity in the brain. If he were brain dead and not in coma, his brain would neither respond to accumulated carbon dioxide nor show any electric activity.

But it was just a matter of time – unless a miracle intervened. His organs were failing rapidly.

Jack had no urine output in last two hours.

Challenge him with 500 ml of normal saline

Jack’s pressure is sixty.

Start him on Levophed

Oxygen sat is falling.

How much O2 is on?

Thirty percent

Try fifty. Suction him.

What is the O2 sat now?

It is better. Ninety-two. The heart rate is forty.

Give him atropine.

It is his mother on the phone.

Hello Mrs. Morris, Jack is not doing well. His kidneys are failing, he is on a ventilator, and his blood pressure is low. His heart has slowed down. We are trying but it does not look good.

He has V tach. It is flat now.

Call the code

“Code blue ICU bed six – code blue ICU bed six – code blue ICU bed six”

Pump his chest.

Up the oxygen. Go hundred percent.

Get a blood gas,

One amp of bicarb.

Atropine

Shock him.

One more.

Try again.

Hold. What is the rate?

Twenty.

Oh God! It is flat again.

Keep pumping.

Any one keeping time?

Yeah, it’s been fifteen minutes.

Get his mother on the phone.

Mrs. Morris I am sorry your son has taken a bad turn. Hello — hello — hello! Can you hear me?

It has been a flat line for thirty minutes. Shall we quit?

No. Zap him again. We keep going. Don’t stop. Damn it! He is only thirty-three!

“After the torchlight red on sweaty faces
After the frosty silence in the gardens
After the agony in stony places
The shouting and the crying
Prison and palace and reverberation
Of thunder of spring over distant mountains
He who was living is now dead
We who were living are now dying
With a little patience “ (TSE)

*************

That day an ambulance screeched to a halt in front of the ER. It carried a mid aged woman.

She had died in a car crash. Brought in dead.

”What is that sound high in the air
Murmur of maternal lamentation
Who are those hooded hordes swarming
Over endless plains, stumbling in cracked earth
Ringed by the flat horizon only
What is the city over the mountains
Cracks and reforms and bursts in the violet air
Falling towers
Jerusalem Athens Alexandria
Vienna London
Unreal” (TSE)

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