The hardest goodbyes are those left unsaid

I pushed the button to open the emergency room’s automatic doors and made my way past the central workstation to the doctor’s office. This night, the usually energetic and boisterous staff was subdued.

Changing for my shift, I figured we’d had a “bad outcome case.” Many cases that show up in the emergency room evolve around profound changes and sometimes unexpected goodbyes for patients and their families. Such goodbyes are difficult and painful. Hardest are those that loved ones never get the chance to say.

Tonight, the profound change and unexpected goodbye was ours.

Dan Campbell, the physician whom I was relieving, walked into the doctor’s office and closed the door behind him. He said he had terrible news.

Mark Rathke, our colleague and medical director, had been at a conference in Florida with his family. A blood vessel in his brain had ruptured during a break between lectures.

He was now in an intensive-care unit somewhere in Florida.

He might not make it, Dan said.

Mark had such a gentle demeanor about him that he never had a patient complaint in 10 years -- and he was always subtle and forgiving when the rest of us did.

He was a dedicated dad and husband, loved a game of basketball and lined up his golf shots with precision and unmitigated preparation.

I sat there for some time, unable to move or think or even cry.

But patients were waiting to be seen. As if on automatic pilot, my body found its way to the patient chart rack. Exam room 4 -- someone with abdominal pain. I ordered some blood work and an ultrasound to check for gall bladder problems. Then, a little girl with a sore throat. I wrote a prescription for antibiotics. Exam room 1 -- a patient with serious chest pain. I ordered tests and treatments for a potential heart attack.

We waited for word of Mark’s status. The phone finally rang. Shelly, our health-unit coordinator, answered it. We all stopped and watched in silence.

She didn’t say anything for some time. Tears began to well up in her eyes. We all knew Mark had died.

She finally hung up the phone.

All that was composed and contained in the staff finally broke open. Work ground to a halt as we all began to grieve. No one could function.

Thankfully, patients already in the full ER were stable and resting, and incoming ambulances were diverted to other local hospitals. We migrated to the central workstation and together sat and wept.

Twelve minutes amazingly passed without any phone calls, radio transmissions or change in the patients under our care. Then, abruptly, the doors of the department swung open and a father carrying his young daughter broke the solemn silence.

She was having an asthma attack.

I reached for my stethoscope, telling the nurses to put the girl in an exam room and to call for some breathing treatments. Then I took a deep breath, slowly exhaled and walked toward the father and daughter as the nurses directed them to the examination stretcher. Shelly moved back to her station and placed the call. The other nurses stood, and then made their way back to check on the other patients.

The ER that Mark had directed for nearly a decade slowly wound back to life. As if in defiance of his death, we all went back to work as best we could.

Later, we learned more details of how Mark had died. During one of the conference breaks, he had gone back to the hotel room where his wife and son were waiting. He opened the door, went inside and sat down on the bed. He visited for some time with his wife, Margo, his son Sam, and a friend of Sam’s who was with them. After a few minutes, he said goodbye. On his way out the door, heading back for the next lecture, a small blood vessel in his brain broke and he collapsed.

Years later, I still often think of that small blood vessel. It seemed to have all the time in the world to decide when to weaken and rupture.

In some ways, it seemed to know exactly what it was doing. In a universe that is so arbitrary and unpredictable, that little blood vessel -- in its precise timing -- gave Mark the gift of being able to say goodbye.

The hard part was that the rest of us wanted the same chance.

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J.W. Carter practices life and emergency medicine in Duluth, Minn. He may be reached by e-mail at joel_dlh@yahoo.ca