Paramedic Notes From The Inside
the collected personal baggage of working with death PART II
One of the hallmarks of a well written memoir or creative nonfiction piece is the ability of the work to stand on its own. Sometimes, however, back story is pivotal. This is one of those times. If you haven’t already read last weeks edition, I recommend you read that first.
There are a number of specific traits required if one is to be effective as a paramedic; patience, humour, adaptability, fitness, street smarts, keeping a level head, and quick thinking to name but a few. While dealing with a dead body often requires all of those things, it is above all else a very personal experience that no two paramedics handle alike. For me, there are two things stand out. Respect, and privilege. To be the one to pronounce someone dead requires respect for that once very alive and vital person, and it requires one to view their participation in a terminal event as a privilege. It is our job legally, and I believe spiritually (however one personally connects with that concept) to confirm that a life is no more.
Every terminal patient with a DNR, every beyond help trauma victim, and every bloated, smelly, decomposing-in-pools-of-putrid-fluid-piss and shit corpse we are tasked with confirming the death of, was a very short time ago, a living human being with a mother, father, and innumerable others who once cared for, loved, and needed that person. As human beings who will most assuredly be in that spot one day ourselves, to show another mortal shell anything less than the utmost respect, is to devalue life and render the job of saving it meaningless.
On that Saturday in mid November 2005, that human being was named Randy. He was 46 years old. We make a point of doing this first. Not focusing on trying to depersonalize an individual, instead we personalize them. As the first person to confirm someones death, I would never refer to them as a corpse, a body, or the deceased. Instead, I will refer to them by their name. So, when we find Randy, he is lying on his right side in his bed, his left hand tucked under his chin. By the strong scent in the room, his dark blue colour on the left side of his body which faces up, the violet hued lividity present in the dependent areas, the mottling in his face, extent of bloating present, and the degree of tissue breakdown all suggest that decomposition has been occurring for at least five days.
From The Coroner’s Act
For a critical care paramedic to make a determination of death, and then to legally pronounce someone as dead, there are specific things which are required. Confirmation of the absence of respiration, the absence of a palpable pulse, and a further assessment of direct cardiac auscultation with a stethoscope confirming the absence of an apical pulse over the heart for at least one minute. There are, however, four instances where those assessments are not required. Rigidity, Decomposition, Decapitation, and Trans-section.
From the moment we enter Randy’s apartment our powers of observation are on high alert. Besides the very easy monkey skill of noting decomposition, thus making a pronouncement of death, there is a story to be figured out here. For us, it’s a medical / social one. If it’s not, then it’s a criminal one, and with the first sign that may even be a possibility, our efforts come to an abrupt halt, and the experts, in this case the police, take over. In either case, it’s a story where everything is a potential clue. The state of the apartment, the position of Randy, the medications that are in his medicine cabinet, the medical history someone in the building may tell us, the art and photography on his walls, to the notes scrawled on paper beside the phone indicating when his next appointment at the Randolph clinic (HIV clinic) is set for. So it doesn’t take us long to figure out that Randy was a gay man with advanced HIV. His health had been getting worse lately, with several infections challenging his immune system. Shingles, CMV retinitis, a number of abdominal infections, thrush, and a recent diagnosis of Hodgkin's lymphoma. All of these in combination, or some of them on their own could possibly have lead to his death. But it is the empty bottle of Seconal on his bed side table that stands out above all else. The casings from 100 capsules lay on the floor and a glass with some residual liquid sits on the bedside table. He had been prescribed the medication five months ago, with no repeats. From the words on the bottle, it had been filled at Farmacia Delpo in Guadalajara, Mexico. The somewhat generalized and vague instructions on the bottle that read “take as required”, stand in ironic contrast to the state we find Randy in now. A state that lends a poignant accuracy to the term “as required”. Our patient didn’t simply pass away after a long illness, he exercised his personal agency, one of the only tangible things he had left, and decided when it was his time to leave this world.
I realize some will find that framing offensive, and I understand that suicide is messy, complicated, and in the vast majority of cases, tragic and preventable. And though I have no other reference to explain how I know and feel this, I can, through far too many experiences in strangely similar scenarios, confidently say that this man’s death was most likely an act of courage; a final ironic testament to what his life had once been.
While technically this is now a crime scene, as suicide is still illegal, treating an event such as this as a crime only makes an already sad, difficult, and unfortunate situation needlessly complicated and tremendously painful for those left behind. In the vast majority of cases I have been involved in, the police will usually conquer.
Before we notify the coroner and make our pronouncement, I find a black leather address book beside the glass on Randy’s night stand. From a time when day-timers were the rage, his contacts are organized by year, not name. However there is a curious pattern. Beginning in the early 80’s in the list of names, largely male, there are one or two with a single line through them. The names with the lines increase in number each year, until you reach the early 90’s and notice the names with lines begin to outnumber the names without. A pattern that continues until two years ago, when names just simply stopped being recorded. For anyone who knows a gay man of my generation, the experience of what those lines represent is not lost on them. It’s nothing less than a road map to the trajectory of a crisis that for gay men, has been experienced for the past 30 years on a scale previously only seen in war time. It has been 30 years of multiple, successive losses over time, each loss often unresolved before the next one hits. All of it playing out with a backdrop of a largely non-supportive and intolerant greater society. As I’ve said before, everyone has a boiling point. A human being can only take so much. If you were in Randy’s shoes, can you honestly say that you wouldn’t consider the option?
“You okay?” Brie asks me, her hand on my shoulder.
“I’m good, thanks.”
Both of us know my assessment is perhaps a little off. Self aware enough to know I am too close to this to accurately gauge where my head is at, I let Brie take the lead on this one. Which she does seamlessly and without the need for discussion. We’ve been here before, her and I. In the same scenario, as well as the times when the roles have been reversed, when I have been the one to offer a reprieve and take the lead. So I’m relieved that my partner knows this much about me. Knows that as a gay man in my thirties, I’m pretty much an expert at riding this specific rodeo.
It is the second week of January, 1982. I am in Montego Bay, Jamaica. In that more than relaxing, drool on the pillow, semi conscious state, I am the definition of content. Lying on a lounge bed, the legs embedded in white sand, every so often a wave will graze the underside of the bed and I smile. Why not? I am fourteen, on a beach in Jamaica, with a full week left before returning to snow, cold, and the second half of my first year in high school.
Turning my Sony Walk-Man on to block out that reality intrusion, then settling into the melodic and mildly manic voice of Laura Branigan belting out Gloria, I returned to my newly discovered hobby of scouting out the men, all the while attempting to be a pillar of fourteen year old discretion. Gloriously failing at both.
Since that week some thirty four years ago, that song has not only been a vivid and welcome beach memory from my early teens, but centred in so much more over the years that followed. Most prominent, a visceral connection to many, many dead, gay men. The gay dance hit of 1982 will always be ironically connected to the darkest days of AIDS.
Dr. Gotlibe is the chief coroner for the city, and tonight he is the on-call physician, covering for one of the junior doctors. Even though the police are not pursuing this as a crime, because it is a suspected suicide the coroner will need to attend the scene. As the pronouncement and paperwork for declaring death will have been completed by us, he can focus on what the law mandates. That is an intensive forensic exam of both the body and the scene, looking for any information to suggest this was not a suicide.
Randal Gotlibe is a soft spoken man, somewhere in his late fifties, with an appearance not dissimilar to Mr. Rogers, he is the kind of man who can put anyone at ease. Complete with the trademark cardigan, always with a genuine smile, he has the slow, easy cadence of a man who knows himself exceedingly well, but doesn’t feel the need to prove it to anyone. When he talks to you, it is direct, and you feel as if you are the only person in the room. Over the past two years Brie and I have slowly gotten to know this man and trust his judgement implicitly, as he does ours. It’s not always that way with a coroner. The relationship can be just as easily adversarial, lacking in trust from attempts at maintaining turf. It is precisely because of the relationship we have with him, that when he arrives on scene and will have many tasks to occupy his time, he will ask us if we are comfortable notifying the next of kin. It may sound counter-intuitive, but for some reason, receiving a call from the paramedic who discovered your loved one had passed, can be easier for many to take than to receive that same call from the cities top “death doctor”. A little bit less jarring, I suppose. When you consider what I mentioned earlier about how Brie and I view our presence at a death as an honour and a privilege, it shouldn’t be difficult to see why it’s a request we willingly accept. As Brie is on the phone with Gotlibe, I know from her responses that is what we have been asked to do. But tonight, I am thankful that expectation will fall to Brie.
Summer, 1985 was my first real introduction to all that HIV would be in my life. At sixteen, I had spent three months in LA with my uncle Roger and his partner, my “other uncle”, Anderson. Besides my own father, Roger and Anderson would prove to be the defining male figures in my life. My uncle seemed to have it all; athletic, handsome, the trademark crooked smile just adding to his charm, he was a successful film professor at USC. He was also the first person I knew to be proudly and unapologetically, openly gay.
It was a defining summer, one that marked the first easy steps into the world as an out, gay person. I had finally told another human being my secret, and Roger, by telling me he had a form of cancer that was common to gay men, was preparing me in advance for his death. I would learn later from Anderson that Roger had been told it would be six months at the most. It turned out to be five years.
When the time did come, I was there, as were my parents. We arrived in LA within fifteen minutes of each other, me arriving from university in Montreal, my parents from a vacation in Hong Kong. We arrived at Roger’s Santa Monica home in time for him to open his eyes and say goodbye. He died less than half an hour after our arrival. Roger’s was the first death I had been witness to. It is an experience I can remember every detail of to this day. From the smells in the room, to the light from the window. Most of all, I recall the outpouring of love and support from all those close to him. At the time I couldn’t understand how his friends and loved ones could live through this crisis day after day and be so incredibly strong. It was a strength that literally defined the term. Today, I know exactly how they did it. They did it because they had no other choice.
As Brie makes the necessary calls, I am reminded of what I describe above. It is a story I last told at Anderson’s funeral in 2001 where I gave the eulogy. As I wait for Brie to finish up, and as I wait to finish this shift that seems like it will never end, I think of every loss that I have known because of this plague. It’s hard to believe, really. But again, and as I’ve said before, everyone has a boiling point. A human being can only take so much. I guess I have yet to find mine.
Coming out in 1987, HIV was something that informed my sexual reality and awakenings. Since that time it has infected and taken my friends, killed my best friend and a former partner, and been the cause of far, far too many funerals I have spoken at and deaths I have stood in witness to. HIV is a cultural phenomenon that has informed my relationships, my view of morality, my experience of compassion, and it has provided me with a far too intimate understanding of the true nature of good and evil. It has birthed and nurtured my political leanings, and has fuelled an uncompromising activism in a once unwilling participant.
For those of us that have been in the middle of this nightmare from the early years, we are united by three things. One, a distinct lack of awareness of what is was like before, either through not being there, or it being too painful to remember.
Two, we share a protective unwillingness to try and imagine what it will be like when it’s over. For me, imaging a day without HIV on the surface seems perfect. But when I actually try and think of it, well, it is as unfathomable a concept as it would be attempting to swallow the sun.
Third, we are left with the unanswerable question of why we have been spared, and the guilt and disconnection that comes along with that question. Though no one talks about it openly, on the rare occasions we do feel comfortable to bring it up with one another, we will talk for hours. What about? About the experience of 30 plus years of unrelenting death. Don’t ask about a cure, because there was none. But please, add in more death. Sure, there were the dangling carrots of treatments and supposed cures, followed by failures of same, rinse, repeat. Add in grieving and more grieving, eventually experienced as a learned art.
There was the requirement of having to face, often out of a life threatening necessity, what it was to be a true friend, and then without hesitation being called on to actively engage that. I’ve learned what it is to support another fully and without condition. Or, perhaps it’s coming face to face with the truth of just how much pain one human being can endure. Because when your wasted and sick friend shits himself in the grocery store that you’ve taken him to because he hasn’t left his apartment in six weeks, what other option is there but to offer him an embrace and take him home?
I have taken a distinct change of direction in this piece intentionally, to hopefully illustrate that we all bring our own experiences of death to the work of trying to save a life. I came to mine, one death at a time. When and how we are reminded of that is intensely individual.
I left the medical field after twelve years, for several reasons. For a long time, it was not just work, it was a calling. No, not a religious calling in any sense, but a distinctly spiritual one, grounded in the complexities and unknown answers to the question of what it means to be human. At the time, it was one of the only ways I knew how to be fully present. The irony being that when one is fully present in the world, and fully present in the moment, the thing that we conceive of as self is nowhere near.
When I was young, seven I think, my mother and I held a funeral for a snail I had claimed as a pet. A burial at dusk, from a boat in the Adriatic Sea. Later, I would bury the birds that flew into our windows, hamsters who had run out of time, and Frisky, my dog and the first friend I had known. But when I was seven, I’d also carry a bouquet of orchids and practice walking like a groom (and yes, occasionally the bride). I understood nothing of the deeper elements of death or sex, but it was the solemnity of ceremony that intrigued me. My first funerals were also weddings.
I suppose what I have learned from working in the field, as well as my experience living in the shadow of a plague as if I were on a high wire act, balancing over top the gulf that is both life and death, is how very similar both of those experiences often are. Because anytime a patient looked into my eyes and said, “I think I am dying”, chances are they were right. One of the most important lessons I have learned is when to pull out all the stops and do everything in my power to halt that active process from occurring. The other, was to understand when the most heroic and profound thing I could offer someone was my compassion and humanity, in equal measure. Not often, but occasionally it was my job to to bring someone as far as I could, and then gently let them go. In either case, I would begin by looking into their eyes, taking their hand, and assuring them I would be there for as long as they needed me.
Or, in the case of Randy, to stand in witness of, and for him, when he was gone.
