I see dead people

It's a strange life we lead as physicians, when we have such close contact with the dead and dying. In a way, it's akin to being a soldier or a mortician. Our natural fear of death diminishes every time we perform CPR on yet another 95-year-old nursing home patient who comes into the ED triple-zero, and without a valid DNR. And yet there are still some cases that leave me in awe of death.

For three years I worked in the ED of the Arroyo Grande Community Hospital in the lovely central coast of California. In this fabulously lush area, even commuting to work is a pleasure. There's a beautiful stretch of Highway 1 near Pismo Beach that I passed several times a week. On my way to a night shift, I got to watch the sun set into the Pacific.

As I made the drive one evening, an accident stopped traffic. I left my car to offer assistance to the EMS personnel. Three ambulances, a fire engine company, and several police officers were on the scene. A car had crossed the midline of the highway and caused a small pile-up. An elderly man in one car was dead, apparently from a head or neck injury. A woman from the second car was lying on the highway surrounded by first responders. She looked to be in her mid-40s and was yelling in agony, complaining of pain on the right side of her chest and trouble breathing. Listening with my stethoscope, I heard decreased lung sounds on that side, but there was no crepitus, flail chest, or evidence of a penetrating injury. Her blood pressure and oxygen saturation were normal, and she had no obvious tracheal deviation. The EMS personnel had given her oxygen and put a C-collar on her. I helped them roll her onto a backboard. Borrowing a phone, I called ahead to my hospital and told my partner that I suspected a pneumothorax, and warned him that I was going to be late for my shift.

Kneeling in the median, with her family looking on from the shoulder of the highway, I realized that it was one of the hardest things that I have ever had to do. Eerily, the girl didn't seem to have a mark on her. At that point, I didn't think there was much I could do; she had probably been lying there for 20 minutes, and the likelihood of reviving her now seemed very, very low. I pronounced her. I may have closed her eyes; I don't remember. I did ask the medic for a blanket to cover her. Feeling sick to my stomach, I got back in my car and drove to work.

A gruesome accident, two dumbfounded doctors

A few years later I moved farther south, working for a group that had a contract with a small hospital in Santa Ynez. It was a very small hospital with a four-bed ED, and once or twice a month I drove up for a 24-hour shift. To get there, I drove west on a two lane highway that winds through San Marcos Pass and the Cachuma Lake Recreation Area into wine country. On the way back, I'd come over the pass and get a view of the ocean that took my breath away.