At Darkest Hour, There’s Comfort in Knowing the ER Is There

The salesman came in by ambulance, dying. His daughter trailed the gurney, tears shining on her face, and we locked eyes just as they hook-turned into a side room. She gave me a look of embarrassment, and then they were gone.

Embarrassment? It was out of place, so unexpected that I stopped in mid-sentence and went straight for the room, coming face to face with the nurse as she came out. He’s DNR, she said, comfort care only, end-stage cancer in home hospice--good luck. She pushed the chart at me as my world tilted on her words and settled deflated against the fading ticks of her shoes down the hall.

I read his name and shook my head. Each person finds comfort in his own way, sometimes in places we don’t expect. Because they had come to us, I would do my best--though I could never imagine finding peace in a place like this. Emergency rooms are uncomfortable places for comfort care, and we turn no one away.

As I examined him, the daughter explained in a blast of sadness how the cancer had spread until UCLA’s best oncologists grudgingly surrendered, how he had fought through an experimental treatment at another hospital and how two weeks ago he had decided to go home. He wanted to die in the house where his daughters had been born, with his two girls and his wife nearby, in his own bed. He made his last deal, and he was happy with the terms.

Only now, when the moment was near, he was in a 12-by-8-foot room in a windowless basement emergency room waiting for me to give him enough morphine to make him senseless. Someone backed out of the deal, and here he was, covered in sweat, each breath like the tearing of cloth.

I wanted to run. I felt more like an intruder than a doctor. There wasn’t much I could do for him, his wishes were clear, and the family was coming right behind. The daughter sobbed, we just couldn’t do it, watch him die--we got scared so we came here, to UCLA. Please forgive me, she said to him; please help him, to me. Then she held his hand, a daughter’s face buried in her father’s chest, crying a last apology to the first, most important man in her life.

I told her that I would make him comfortable, which was true, and that everything was going to be all right, which was a lie. Then I left the room wondering why they had come to a place where neither wanted to be, to a doctor who hated this part of his job. I was no expert in death or dying, and the emergency room was the wrong place for the salesman to die. I leaned my head back to rest against the wall, and I could hear her crying, on the other side.

The nurse came with morphine, and I curved out past the waiting room and up the hall, each room with a patient, each different. They followed my passing white coat, eyes pleading, each believing the answers were somehow nearby, in this person and place. They shared a faith in the place, from the homeless girl beaten on the beach to the Bel-Air lawyer with gallstones.

The salesman and his daughter had come when everything else had fallen apart. As she said, where else could they go? They gave themselves to us, I think, so they could turn fully to him. We may lose trust in government, schools and even most of medicine itself, but the emergency room remains the final stop. We are open forever--on holidays and when buildings fall and planes crash. Even when we don’t do much, everyone knows we are always there. For some, that is all we can offer, and it is enough.

When I was a very young man, at Christmas I would go home to the western Pennsylvania town where my parents still live. Trafford is a small place with red-brick streets that hasn’t changed much in a century. I had a peculiar tradition--on Christmas Eve, long after midnight, I would take a walk through the streets, feeling like a ghost, both detached from and reassured by the place, by the sense that no matter what happened the town would be there quietly going about its business behind the warm light of the windows--if I needed it. I had faith in the place. I still do.

People have that same faith in the emergency room. Even when we can’t help them medically, we help them because they know we are there.

Five minutes later, the salesman was dead.

As I walked down the hall toward the room, the daughter rounded the far corner with her sister and mother under her arms. We locked eyes again, and this time she smiled. Smiled? I took my cue and headed for the room.

Next to his deathbed, they hugged me as though I had actually done something other than watch him die. I wished I could have helped more. She smiled again and said that sometimes, just being in the right place was enough--and for a second it was Christmas morning in Trafford, and I knew exactly what she meant.

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Mark Morocco is an emergency medicine doctor at UCLA Medical Center and at Los Angeles County/Olive View Medical Center. He is also the medical supervisor for the television shows “ER” and “Third Watch.”