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February 4, 2016

The first time I saw a patient exhale her last breath

"A Thousand Naked Strangers: a paramedic's wild ride to the edge and back" is Kevin Hazzard's account of a decade responding to emergency calls in Atlanta. This excerpt is from the book's prologue.  

By Kevin Hazzard

I did nothing to save the first person who died in front of me. I simply stood watch and let her go. She was old and white and wasting away in a nursing home. Her death was unceremonious, but fast, and I was the only witness, earth’s final sentry, there to do nothing but close the gates as she slipped through.

I was only twenty-six when she died, but already I’d squandered away two lives — the first as a failed salesman, the other as a reporter in exile. EMS was an accidental third act. It was early 2004, centuries ago. When I look back, I find it hard to believe this death and countless others happened, that at one time my sole purpose was to be present, as either anxious participant or indifferent witness. As with much of my EMS life, the memory is fuzzy: soft light filtered through gauze. It’s only the details — the little ones that don’t seem to matter at the time — that carry on. So really, what I have is more sensation than recollection, more feeling than anecdote.

This is how it all feels to me now.

It’s my second night, and I’m partnered with a guy who never goes home. He’s a firefighter in the next county, but he’ll do anything for money and works a handful of part-time jobs. When he isn’t here or at the fire station, he sweats over the fryer at McDonald’s. Just before ten, we’re called to a nursing home for a sick woman. My partner is tired. He walks slowly, eyes to the floor, as we push the stretcher off the elevator and wander down the long corridor to the patient’s room. We ease alongside her bed. A nurse hovers in the background, saying the woman didn’t eat dinner, isn’t acting like herself, and needs to be seen. I take her blood pressure, her pulse, count her breaths. Her eyes are closed; her skin — white and crinkled like parchment paper — is dry and hot. My partner asks for her papers. We don’t ever leave a nursing home without papers. Most people in a nursing home can’t talk, and those who can don’t make sense, so even a question as straightforward as 'Who are you?' doesn’t yield usable results. So we get the papers, a thick manila envelope stuffed with everything from medical problems to next of kin. More important, it’s in this packet that we’ll find insurance information and whether or not there’s a do-not-resuscitate order.

Ostensibly, we’re here for the patient, but really all we care about is the DNR.

The DNR is the word of God Himself, written in triplicate and handed over not by Moses but by a big-boned woman in orthopedic nursing shoes. It’s in these papers that we’ll find answers to the uncomfortable questions that absolutely must be answered. What if she loses consciousness? What if she dies? Do I go all the way — CPR, electric shocks, slip a tube down her throat, drill a hole in her leg for medication? Or do I watch her swirl the drain until she disappears altogether? What does her family want? What would she want? The existence of this piece of paper, even its absence, means a lot. To everyone. At the hospital, the nurses will ask about it, and the doctors won’t look at us until we’ve answered. At her age, in her condition, everyone will agree resuscitation, even if it could be accomplished, would be cruel. So does she have a DNR? The nurse says she does, that it’s atop her packet, the first page in the stack. She leaves to get it.

And that’s when it happens. Before my partner — who’s leaning against the wall — coaxes his mass into action. Before I pull back the sheet. Before anyone addresses her directly. She opens her eyes — milky and unfocused — and tilts her head forward. Her lips part and then, without ceremony, she relaxes. Her last breath escapes. A single tear runs down her cheek.

I know instantly what’s happened. But is it really that simple? That easy? The nurse has just said the patient has a DNR, so that drilled-into-my-head-during-school compulsion to act doesn’t kick in. Instead, I spend the first few seconds staring into her vacant eyes, tracing the arc of that single tear — her final corporeal act — and marvel at this woman. Moments ago she was something to pity, bedridden and in a diaper. Now, plucked from her stained nightgown, she is cloaked in the wisdom of the ages. She knows why we’re here and, more important, what’s next. And if it’s not the black nothingness we’ve feared all along, then how small we must look to her now. In dying she has crossed over. Or hasn’t.

My partner, unaware she’s dead, has finally come to life. He motions for me to grab the other end of the sheet so we can move her onto our stretcher. I need to tell him, let him decide what comes next, but I don’t trust my own instincts. I’m brand-new at this, I’ve never watched someone die. My experience with the dead — recent or otherwise — is limited. If my partner doesn’t notice, then perhaps she’s not dead. The woman was hardly moving when we arrived and now looks no different. With a yank, we slide her over. He covers her with a sheet, buckles her in, starts pushing. I stare at her chest, her face, looking for signs of life that I know deep down I will not find. We grab her packet, and sure enough, the DNR is stapled to the top. We ride the elevator, step out into the cool night. With a sharp metallic click, the stretcher is snapped into the mount on the floor of the ambulance.

"I think she’s dead," I say.

My partner stops and looks not at her but at me.

I clear my throat, tell him I don’t think she’s breathing.

He climbs into the ambulance, looks, feels, deflates. In the absence of the DNR, he might do something, but it’s not absent. It’s right there, and this document, drafted and signed with the sole intention of clarifying this woman’s final moments, instead obscures our next move. Had she died in the nursing home, we’d leave her, but she’s here now. Dead on our stretcher. In our ambulance.

We have drifted into murky water.

He calls the nursing home. "We’re in the parking lot," he says. "Your patient is dead." "She’s in your ambulance," the nurse tells him, "she’s yours now." I stand outside while they argue. Our patient lies in state. What to do with her? The hospital doesn’t take dead bodies, nor does the nursing home. This woman has died and no one wants her. She is a corpse in limbo. My partner hangs up. Fumes. He goes back in to explain, to plead, to threaten. I’m not sure why, but he leaves me in the back with her.

I sit in the ambulance and stare into the woman’s half-open eyes. I grab the packet and flip through. If we are to keep each other company, I should at least know her name. Her birthday. Turns out she is eighty-eight.

There aren’t many things you can do in the back of an ambulance with a dead woman. My cooler sits in the corner, but no. I could talk to her, but frankly, she is so recently dead, so unchanged from before, I feel as if addressing her directly will wake her. Well, not her but the ghost of her, which is worse. This may sound foolish, but I can assure you that all except the most gruesomely killed or severely decomposed look as if they’ll sit up and begin talking at the slightest provocation.

I decide to call home. "Are you still awake?" I ask my wife.

She says she is. She broke down and started watching the latest episode of 'The Sopranos' without me. "You’re gonna love it." When I say nothing, she asks if I’m mad, and after a second I tell her where I am. Tell her that I’m alone with a woman I’ve watched die and who has become, thanks to my indecision, something of a refugee.

She asks how the woman died, and though I know this isn’t what she means, I say, "Peacefully."

---

Excerpted from A THOUSAND NAKED STRANGERS by Kevin Hazzard.
Copyright © 2016 by Kevin Hazzard.
Reprinted with permission of Scribner, a Division of Simon & Schuster, Inc.
Available on Amazon and wherever books are sold.

Listen to Hazzard discuss his book on the Inside EMS podcast.

About the author
Kevin Hazzard worked as a paramedic from 2004 to 2013, primarily at Grady Hospital in Atlanta. His freelance journalism has appeared in Atlanta Magazine, Marietta Daily Journal, Creative Loafing, and Paste. He is the author of a novel, Sleeping Dogs. He and his family live in Hermosa Beach, California.


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