Randy J. Ferrance, DC, MD

I will never forget her first words to me: You mispronounced my name.

I remember stopping short, awkwardly looking down at the emergency room chart in my hands and wondering how I could have mispronounced Mrs. Wells. I'm sorry, how should I say your name? I asked her.

Kitty.

Ah. Miss Kitty? I tried. This is, after all, Virginia, and octogenarians here are renowned for their adherence to social niceties.

She shook her head, her frown showing just how hard she was working to be patient with me. Miss Kitty was a character on Gunsmoke, she told me. Well, actually, she was lecturing me. I have never had red hair, I don't own a saloon, and I sure as heck don't have Marshall Dillon to keep me company. Darn my luck.

She was my seventh admission that afternoon, with at least 2 more to follow, but I found a smile for her and started into my usual routine. So, what brings you to the hospital today, Kitty?

I was hoping to meet a cute young doctor, she told me. And I think I succeeded.

This was clearly not going to go quickly. We'll deal with your poor eyesight later. What about the shortness of breath that the nurse wrote on your chart? I did not even mention the audible wheezing or the pursed‐lip breathing I had heard from outside the curtain.

Oh, that's just a ploy, she lied. To get to the meeting the cute young doctor part.

In glancing at her fingers to look for clubbing, I noticed the golden band and the tiny diamond ring, both of which looked huge on her knobby fingers. Kitty, I gently scolded her, I don't have time to deal with jealous husbands.

She laughed as she absently twirled the rings around her finger. Carl won't mind, she told me. He's been dead 14 years now.

But you still wear his rings, I pointed out.

He brought this ring with him when he came back to me from France after the war, she told me, straightening the tiny diamond on her finger. It was all his private's salary could afford, so he gave me the ring and a magnifying glass, and he told me to never look at the ring without using the magnifying glass.

No, this was clearly not going to go quickly at all. But I was pretty sure I was not going to mind.

Over the next 4 days, Kitty and I got to know each other fairly well. Her chronic obstructive pulmonary disease exacerbation improved to the point that I could send her home, and she begrudgingly accepted my recommendation of oxygen at night.

Over the next 2 years, I admitted her 7 more times; to my frustration, this meant that she was seeing me more regularly than she was seeing her primary care physician. After her third admission, I found myself having to convince her that it was time to start using her oxygen continuously. When she came back for her fourth admission, I noticed the cane at her bedside. Are you having trouble walking now, Kitty? I naively asked her.

Of course not, she shot back quickly. This is just in case I see a man I want to get a closer look at. I just hook him around the ankle and pull him in.

That discharge was to a skilled nursing facility because she had no family and no one else to care for her. After her 3 months of skilled benefits, she transitioned to long‐term care, and the next time her emphysema acted up, she thanked me for the introduction to all those handsome gentlemen. On each day of that admission, she asked when I was going to let her out of the hospital. Each day, she made sure that I knew, meant missed opportunities for her to be able to figure out which of the male residents was meant to be Carl's successor.

Her sixth admission was for pneumonia, and we nearly lost her. I am still convinced that it was nothing more than her self‐described abundance of piss and vinegar that pulled her through.

When the emergency room called me less than a month later for her seventh admission, I knew that Kitty and I were getting awfully close to the end of our relationship. She was tired and weak and smaller even than she had been just a few weeks before.

I admitted her to the intensive care unit for the first time on that admission, and I made the mistake of telling her that it was because with her somnolence and with her wish that she not be intubated, I was flirting with the idea of bilevel positive airway pressure (BiPAP) ventilation. She managed to find enough wind to tell me that I should save all my flirting for her.

Three days of antibiotics, frequent bronchodilators, steroids, and as much BiPAP as she could stand did not net us much improvement. On hospital day 4, the intensive care unit nurse caught me before I knocked on Kitty's sliding glass door.

She wants to go home, Lucy told me.

We're working on it, I reminded her.

Lucy shook her head. No, she said. Home with a capital H. Heaven. Lucy relayed the conversation that Kitty had had with her. The one that my old friend had not had with me.

The one that I should have had with her.

I closed Kitty's door behind me and sat down at her side on the bed, noticing how she was drawing each breath as if she had to pay for it.

Lucy told me about your conversation, I said quietly, once Kitty had finally opened her eyes and found me. No more BiPAP, I understand. She nodded. I waited for her to say something more, but she did not. Why didn't you tell me, Kitty? I asked her gently.

She laughed; her laugh was a short, tired little thing that died in her throat. She reached from under the covers to pat my hand. I suppose, she said, that I didn't want to let you down. You always seem so proud of yourself when I come in here, gasping and coughing, and you get me well enough to go back home. She paused to blow off some CO₂ and find a sad smile for me. Time to let me go, she told me. Let me be with Carl again.

We talked for quite a while. Well, actually, I did most of the talking. She did not have the wind for it. I admitted to her just how embarrassed I was that she had had to bring this up to me. I have for quite some time been rather comfortable with the notion that death is not the worst thing that can happen to a patient. It was Dr. Tom Smith, at the Medical College of Virginia, who first introduced what was then a wide‐eyed, idealist medical student to the concept of a good death: snatching a victory for compassion from the jaws of a medical defeat.

Therefore, at Kitty's insistence, there was no more BiPAP. When her breathing became labored, we gave her just enough morphine to take the edge off her air hunger. Rather than round on her in the mornings, I simply sat with her.

I would like to say that I was with Kitty when she died. It would bring the story full circle and give our relationship a clean beginning and a clean end. It would be good fiction.

However, it would also be a lie.

Lucy met me at her door again, just 3 days later, and told me about Kitty's quiet passing, in her sleep, just an hour before I had arrived for rounds.

I sat at Kitty's side one last time, holding her now cold hand. She was smiling.

At least, that is how I intend to remember that moment.

The bed sagged just a bit on the other side as I realized that Death had joined me. For those who have not had the pleasure, the part of Death is played by Gwyneth Paltrow.

We sat in silence for several minutes, Death showing me the patience that she had once told me she had.

I rarely see it.

How is she? I finally asked.

Better. She and Carl are catching up a bit. I nodded. He's giving her hell for losing that magnifying glass.

I could not help the smile. Carl was one lucky man.

She says thank you.

Whether it was true or not, it was nice for Death to say it.

She let me have a long stretch of silence before she felt the need to ruin our tender moment. You have any other business for me?

I growled a warning, and she smiled. That was a joke, Doctor. Lighten up a little, would you?

She turned to go, but I stopped her. Hey, I found a great quote for you. The last time that we had chatted, she had been lamenting the plethora of love lines and the paucity of good death ones:

Emily Dickinson, I told her.

Huh, she said, frowning and doing that thing with her eyebrow for which Gwyneth gets paid millions. Wonder why she thought I was a he?

I will never forget her first words to me: You mispronounced my name.

I remember stopping short, awkwardly looking down at the emergency room chart in my hands and wondering how I could have mispronounced Mrs. Wells. I'm sorry, how should I say your name? I asked her.

Kitty.

Ah. Miss Kitty? I tried. This is, after all, Virginia, and octogenarians here are renowned for their adherence to social niceties.

She shook her head, her frown showing just how hard she was working to be patient with me. Miss Kitty was a character on Gunsmoke, she told me. Well, actually, she was lecturing me. I have never had red hair, I don't own a saloon, and I sure as heck don't have Marshall Dillon to keep me company. Darn my luck.

She was my seventh admission that afternoon, with at least 2 more to follow, but I found a smile for her and started into my usual routine. So, what brings you to the hospital today, Kitty?

I was hoping to meet a cute young doctor, she told me. And I think I succeeded.

This was clearly not going to go quickly. We'll deal with your poor eyesight later. What about the shortness of breath that the nurse wrote on your chart? I did not even mention the audible wheezing or the pursed‐lip breathing I had heard from outside the curtain.

Oh, that's just a ploy, she lied. To get to the meeting the cute young doctor part.

In glancing at her fingers to look for clubbing, I noticed the golden band and the tiny diamond ring, both of which looked huge on her knobby fingers. Kitty, I gently scolded her, I don't have time to deal with jealous husbands.

She laughed as she absently twirled the rings around her finger. Carl won't mind, she told me. He's been dead 14 years now.

But you still wear his rings, I pointed out.

He brought this ring with him when he came back to me from France after the war, she told me, straightening the tiny diamond on her finger. It was all his private's salary could afford, so he gave me the ring and a magnifying glass, and he told me to never look at the ring without using the magnifying glass.

No, this was clearly not going to go quickly at all. But I was pretty sure I was not going to mind.

Over the next 4 days, Kitty and I got to know each other fairly well. Her chronic obstructive pulmonary disease exacerbation improved to the point that I could send her home, and she begrudgingly accepted my recommendation of oxygen at night.

Over the next 2 years, I admitted her 7 more times; to my frustration, this meant that she was seeing me more regularly than she was seeing her primary care physician. After her third admission, I found myself having to convince her that it was time to start using her oxygen continuously. When she came back for her fourth admission, I noticed the cane at her bedside. Are you having trouble walking now, Kitty? I naively asked her.

Of course not, she shot back quickly. This is just in case I see a man I want to get a closer look at. I just hook him around the ankle and pull him in.

That discharge was to a skilled nursing facility because she had no family and no one else to care for her. After her 3 months of skilled benefits, she transitioned to long‐term care, and the next time her emphysema acted up, she thanked me for the introduction to all those handsome gentlemen. On each day of that admission, she asked when I was going to let her out of the hospital. Each day, she made sure that I knew, meant missed opportunities for her to be able to figure out which of the male residents was meant to be Carl's successor.

Her sixth admission was for pneumonia, and we nearly lost her. I am still convinced that it was nothing more than her self‐described abundance of piss and vinegar that pulled her through.

When the emergency room called me less than a month later for her seventh admission, I knew that Kitty and I were getting awfully close to the end of our relationship. She was tired and weak and smaller even than she had been just a few weeks before.

I admitted her to the intensive care unit for the first time on that admission, and I made the mistake of telling her that it was because with her somnolence and with her wish that she not be intubated, I was flirting with the idea of bilevel positive airway pressure (BiPAP) ventilation. She managed to find enough wind to tell me that I should save all my flirting for her.

Three days of antibiotics, frequent bronchodilators, steroids, and as much BiPAP as she could stand did not net us much improvement. On hospital day 4, the intensive care unit nurse caught me before I knocked on Kitty's sliding glass door.

She wants to go home, Lucy told me.

We're working on it, I reminded her.

Lucy shook her head. No, she said. Home with a capital H. Heaven. Lucy relayed the conversation that Kitty had had with her. The one that my old friend had not had with me.

The one that I should have had with her.

I closed Kitty's door behind me and sat down at her side on the bed, noticing how she was drawing each breath as if she had to pay for it.

Lucy told me about your conversation, I said quietly, once Kitty had finally opened her eyes and found me. No more BiPAP, I understand. She nodded. I waited for her to say something more, but she did not. Why didn't you tell me, Kitty? I asked her gently.

She laughed; her laugh was a short, tired little thing that died in her throat. She reached from under the covers to pat my hand. I suppose, she said, that I didn't want to let you down. You always seem so proud of yourself when I come in here, gasping and coughing, and you get me well enough to go back home. She paused to blow off some CO₂ and find a sad smile for me. Time to let me go, she told me. Let me be with Carl again.

We talked for quite a while. Well, actually, I did most of the talking. She did not have the wind for it. I admitted to her just how embarrassed I was that she had had to bring this up to me. I have for quite some time been rather comfortable with the notion that death is not the worst thing that can happen to a patient. It was Dr. Tom Smith, at the Medical College of Virginia, who first introduced what was then a wide‐eyed, idealist medical student to the concept of a good death: snatching a victory for compassion from the jaws of a medical defeat.

Therefore, at Kitty's insistence, there was no more BiPAP. When her breathing became labored, we gave her just enough morphine to take the edge off her air hunger. Rather than round on her in the mornings, I simply sat with her.

I would like to say that I was with Kitty when she died. It would bring the story full circle and give our relationship a clean beginning and a clean end. It would be good fiction.

However, it would also be a lie.

Lucy met me at her door again, just 3 days later, and told me about Kitty's quiet passing, in her sleep, just an hour before I had arrived for rounds.

I sat at Kitty's side one last time, holding her now cold hand. She was smiling.

At least, that is how I intend to remember that moment.

The bed sagged just a bit on the other side as I realized that Death had joined me. For those who have not had the pleasure, the part of Death is played by Gwyneth Paltrow.

We sat in silence for several minutes, Death showing me the patience that she had once told me she had.

I rarely see it.

How is she? I finally asked.

Better. She and Carl are catching up a bit. I nodded. He's giving her hell for losing that magnifying glass.

I could not help the smile. Carl was one lucky man.

She says thank you.

Whether it was true or not, it was nice for Death to say it.

She let me have a long stretch of silence before she felt the need to ruin our tender moment. You have any other business for me?

I growled a warning, and she smiled. That was a joke, Doctor. Lighten up a little, would you?

She turned to go, but I stopped her. Hey, I found a great quote for you. The last time that we had chatted, she had been lamenting the plethora of love lines and the paucity of good death ones:

Emily Dickinson, I told her.

Huh, she said, frowning and doing that thing with her eyebrow for which Gwyneth gets paid millions. Wonder why she thought I was a he?

I will never forget her first words to me: You mispronounced my name.

I remember stopping short, awkwardly looking down at the emergency room chart in my hands and wondering how I could have mispronounced Mrs. Wells. I'm sorry, how should I say your name? I asked her.

Kitty.

Ah. Miss Kitty? I tried. This is, after all, Virginia, and octogenarians here are renowned for their adherence to social niceties.

She shook her head, her frown showing just how hard she was working to be patient with me. Miss Kitty was a character on Gunsmoke, she told me. Well, actually, she was lecturing me. I have never had red hair, I don't own a saloon, and I sure as heck don't have Marshall Dillon to keep me company. Darn my luck.

She was my seventh admission that afternoon, with at least 2 more to follow, but I found a smile for her and started into my usual routine. So, what brings you to the hospital today, Kitty?

I was hoping to meet a cute young doctor, she told me. And I think I succeeded.

This was clearly not going to go quickly. We'll deal with your poor eyesight later. What about the shortness of breath that the nurse wrote on your chart? I did not even mention the audible wheezing or the pursed‐lip breathing I had heard from outside the curtain.

Oh, that's just a ploy, she lied. To get to the meeting the cute young doctor part.

In glancing at her fingers to look for clubbing, I noticed the golden band and the tiny diamond ring, both of which looked huge on her knobby fingers. Kitty, I gently scolded her, I don't have time to deal with jealous husbands.

She laughed as she absently twirled the rings around her finger. Carl won't mind, she told me. He's been dead 14 years now.

But you still wear his rings, I pointed out.

He brought this ring with him when he came back to me from France after the war, she told me, straightening the tiny diamond on her finger. It was all his private's salary could afford, so he gave me the ring and a magnifying glass, and he told me to never look at the ring without using the magnifying glass.

No, this was clearly not going to go quickly at all. But I was pretty sure I was not going to mind.

Over the next 4 days, Kitty and I got to know each other fairly well. Her chronic obstructive pulmonary disease exacerbation improved to the point that I could send her home, and she begrudgingly accepted my recommendation of oxygen at night.

Over the next 2 years, I admitted her 7 more times; to my frustration, this meant that she was seeing me more regularly than she was seeing her primary care physician. After her third admission, I found myself having to convince her that it was time to start using her oxygen continuously. When she came back for her fourth admission, I noticed the cane at her bedside. Are you having trouble walking now, Kitty? I naively asked her.

Of course not, she shot back quickly. This is just in case I see a man I want to get a closer look at. I just hook him around the ankle and pull him in.

That discharge was to a skilled nursing facility because she had no family and no one else to care for her. After her 3 months of skilled benefits, she transitioned to long‐term care, and the next time her emphysema acted up, she thanked me for the introduction to all those handsome gentlemen. On each day of that admission, she asked when I was going to let her out of the hospital. Each day, she made sure that I knew, meant missed opportunities for her to be able to figure out which of the male residents was meant to be Carl's successor.

Her sixth admission was for pneumonia, and we nearly lost her. I am still convinced that it was nothing more than her self‐described abundance of piss and vinegar that pulled her through.

When the emergency room called me less than a month later for her seventh admission, I knew that Kitty and I were getting awfully close to the end of our relationship. She was tired and weak and smaller even than she had been just a few weeks before.

I admitted her to the intensive care unit for the first time on that admission, and I made the mistake of telling her that it was because with her somnolence and with her wish that she not be intubated, I was flirting with the idea of bilevel positive airway pressure (BiPAP) ventilation. She managed to find enough wind to tell me that I should save all my flirting for her.

Three days of antibiotics, frequent bronchodilators, steroids, and as much BiPAP as she could stand did not net us much improvement. On hospital day 4, the intensive care unit nurse caught me before I knocked on Kitty's sliding glass door.

She wants to go home, Lucy told me.

We're working on it, I reminded her.

Lucy shook her head. No, she said. Home with a capital H. Heaven. Lucy relayed the conversation that Kitty had had with her. The one that my old friend had not had with me.

The one that I should have had with her.

I closed Kitty's door behind me and sat down at her side on the bed, noticing how she was drawing each breath as if she had to pay for it.

Lucy told me about your conversation, I said quietly, once Kitty had finally opened her eyes and found me. No more BiPAP, I understand. She nodded. I waited for her to say something more, but she did not. Why didn't you tell me, Kitty? I asked her gently.

She laughed; her laugh was a short, tired little thing that died in her throat. She reached from under the covers to pat my hand. I suppose, she said, that I didn't want to let you down. You always seem so proud of yourself when I come in here, gasping and coughing, and you get me well enough to go back home. She paused to blow off some CO₂ and find a sad smile for me. Time to let me go, she told me. Let me be with Carl again.

We talked for quite a while. Well, actually, I did most of the talking. She did not have the wind for it. I admitted to her just how embarrassed I was that she had had to bring this up to me. I have for quite some time been rather comfortable with the notion that death is not the worst thing that can happen to a patient. It was Dr. Tom Smith, at the Medical College of Virginia, who first introduced what was then a wide‐eyed, idealist medical student to the concept of a good death: snatching a victory for compassion from the jaws of a medical defeat.

Therefore, at Kitty's insistence, there was no more BiPAP. When her breathing became labored, we gave her just enough morphine to take the edge off her air hunger. Rather than round on her in the mornings, I simply sat with her.

I would like to say that I was with Kitty when she died. It would bring the story full circle and give our relationship a clean beginning and a clean end. It would be good fiction.

However, it would also be a lie.

Lucy met me at her door again, just 3 days later, and told me about Kitty's quiet passing, in her sleep, just an hour before I had arrived for rounds.

I sat at Kitty's side one last time, holding her now cold hand. She was smiling.

At least, that is how I intend to remember that moment.

The bed sagged just a bit on the other side as I realized that Death had joined me. For those who have not had the pleasure, the part of Death is played by Gwyneth Paltrow.

We sat in silence for several minutes, Death showing me the patience that she had once told me she had.

I rarely see it.

How is she? I finally asked.

Better. She and Carl are catching up a bit. I nodded. He's giving her hell for losing that magnifying glass.

I could not help the smile. Carl was one lucky man.

She says thank you.

Whether it was true or not, it was nice for Death to say it.

She let me have a long stretch of silence before she felt the need to ruin our tender moment. You have any other business for me?

I growled a warning, and she smiled. That was a joke, Doctor. Lighten up a little, would you?

She turned to go, but I stopped her. Hey, I found a great quote for you. The last time that we had chatted, she had been lamenting the plethora of love lines and the paucity of good death ones:

Emily Dickinson, I told her.

Huh, she said, frowning and doing that thing with her eyebrow for which Gwyneth gets paid millions. Wonder why she thought I was a he?

She is not, however, without a certain, well, grim sense of humor.

The voice throws you at first. It's deceptively mild and calm, more Gwyneth Paltrow than James Earl Jones. To the best of my knowledge, however, Gwyneth Paltrow has never shown up in a patient's room wearing a hooded black robe and sporting a scythe.

Hmm, bad case of sepsis, huh? she asked.

I was still cleaning up from the central line, so I tried to get rid of her gracefully. Now's not really a good time. That line always seems to work with pesky administrators.

Death, however, would not be dissuaded. HIV positive for nearly 10 years now, flirting with CD4 counts in double digits, rising viral load the past 3 years. Picked a bad time to have her gallbladder go bad on her, didn't she?

Or a bad time to pick a surgeon who was less than fastidious about his sterile fields, I muttered.

Death, however, chose to ignore me. Ventilator, pressors, antibiotics. She reached for the girl's right hand, attached as it was to an arterial line blood pressure monitor, and somethingdamn, if it didn't look like a scarabfell out of the robe and then scrambled across my patient's chest, right next to my newly placed and oh‐so‐deftly sutured plastic catheter, ducking away from the light.

Hey, that was my sterile field, I complained. I, unlike the aforementioned surgeon, had been fastidious about it. I hoped the scarab was sterile, at least.

Splinter hemorrhages, Death noted with obvious glee, taking particular interest in the little streaks of blood under my patient's fingernails. Septic emboli. Death seems to have Gwnyeth Paltrow's laugh along with her voice. It's a light and airy thing, almost like a favorite wind chime. That laugh could almost make you think Death had a heart. Endocarditis, she said fondly. One of my favorites.

Almost make you think she had a heart.

Go away. I tried to look more busy than worried, but I didn't think she was buying it.

It's been a good month for me here in the ICU. Heck, you yourself have 4 kills. Why don't you throw in this one and call yourself an ace?

Very funny. Now get out. I would imagine it's best not to lose your temper with Death. Or with any of the other three Horsemen of the Apocalypse, for that matter. Didn't anyone ever tell you it's poor form to make fun of your host? You're in Donna Smith's house now, buddy. Don't be dissin' my nurse manager.

Come on, she pushed. She's pathetic, she's tired, she lives alone in a tiny room in a forgotten crack house that she pretends is her apartment, and her parents haven't taken her calls for years.

Donna? I asked. That was some serious disrespect.

Don't go all medical student on me. I was talking about your patient, she explained evenly. She'd be better off with me anyway. You know that.

She can be persuasive when she might be right. Death and I have been having similar conversations all the way back to my surgical rotation as a third‐year medical student. Although she has never been above making the easy score, she typically only makes serious plays for patients who, in all honesty, just might be better off heading with her beyond the vale. That's not my decision to make, I told Death, tweaking the pressors. I have this thing about systolic blood pressure less than room temperature. By being here, she's placed her life in my hands, I said, staring down into what almost looked like a lifeless face. Until and unless I have a compelling reason to do otherwise, I will do whatever is necessary to ensure she comes out of this thing as well as she can. I turned to look Death in those beady little eyes. Even go 15 rounds with you, if that's what it takes.

There was a moment of silence, during which I began to think that perhaps I had made my point. Rock, paper, scissors? Death asked with a hopeful lilt.

I sighed. Damn, but she was persistent. I don't gamble with death. That's something my mommy taught me, way back when I used to think I'd be able to fly if I jumped from that really tall tree on the hill.

Oh, come on. Your patient in the next bed did. Overdosed on Ativan with a fifth of Johnny Walker Black as a chaser? Now there's a lifestyle choice I can find myself endorsing.

I was out of witty comebacks. Everyone deserves another chance, I told her, my eyes fixed now on the hollowed, closed eyes of my patient in the ICU bed. Evenor maybe even especiallymy patient in the next bed. I don't know what it was about his life that had driven him to the lifestyle choices he had made. There's a part of every physician that thinks that he or she can make that difference in a patient's life. All too often, though, we see enough repeat business to learn, the hard way, that we rarely make the kind of differences we'd like to. With a little luck, and no small amount of medical diligence, both my patients would survive this hospitalization.

But would they survive their next?

Would there be a next?

Would this be the time they'd turn the corner?

I had to hope so, because I still consider myself far too young to be any more cynical than I already am.

What about your partner? Death asked suddenly.

No, I said with something I hoped sounded like authority. You can't have her either.

No, I meanhow about I work a deal with her? She's young, she's impressionable, she's idealisticwe could make it not your fault.

She's got enough to do; please just leave her alone.

The hood shook slowly back and forth, so I assumed she was shaking her head. Or her skull. Whichever. Look, you wouldn't even have to do anything, that sweet, seductive voice told me. Just head back to your call room for a few minutes. Turn off your pager.

I don't know why we're even having this conversation, I groaned. We both know that you're just a hallucination caused by way too little sleep and way too much caffeine. Last call night I caught myself discussing the relative merits of high‐frequency jet ventilation with Galen.

Galen, Death reflected, suddenly nostalgic. Highly overrated, a positive trait in a doctor if you don't mind my saying so. Has an ego that would make an orthopedist seem humble.

You're lying, I decided.

Yes, I am. And you're stalling. Her voice suddenly became a whole lot more James Earl Jonesish. I'm taking the septic chick with endocarditis. You can lose all the sleep you want, she still goes Home with me.

I glanced over the drips one more time. I've just added norepi. That's a whole bag full of bite me that says differently. So back off, sweetheart.

As with most true medical emergencies, I was too busy thinking ahead to realize just how much trouble my patient could have been in at that moment.

Now morning, like her fever, has broken.

The sun, for those that haven't noticed, gives off a beautiful red glow as it rises over Boot Hill. I got to see it from the rocking chair in my patient's room. Nurse Donna was finishing the night's vital sign flow sheet, politely pretending she hadn't heard me snoring away the past 15 minutes. I was trying to decide if that odor drifting into the room was someone's attempt at coffee or melana. Donna smiled politely at me as I rubbed the Sandman's crud out of my eyes. It was a very Chicago Hope kinda moment.

If I'd been playing a doctor on TV, I'd have made some reassuring comment about how my patient had made it through the night, and so she was now out of the woods. Uh‐huh. With Death sneaking up behind me, my bite‐me norepinephrine wasn't going to be weaned just yet.

Good morning, I greeted.

She seemed a bit put off that I had heard her sneaking in. But then, Death is not exactly graced with kitty‐cat feet.

You never turned your pager off. She said it like an accusation. The way my wife does.

Never do. An answer my wife doesn't appreciate, either. My patient's still with me, I said, managing to keep the victory dance out of my voice. Pressure is better, heart rate is lower, fever seems to have broken.

Death is patient, death is kind, she warned.

It took my postcall mind a moment to wrap itself around that one. Isn't that supposed to be Love? I asked her.

The shoulders of the robe shrugged. Love gets all the cool lines, she complained. What do I get? Be not proud, nothing's for sure but me and taxes, Yea, though I walk through the valley of the shadow of me, give me liberty or give me me. She turned to face me. I like that one, by the way.

Never fails to bring a tear to my eye. I'd give her that. She had lost the patient, I could afford to be gracious and throw her a bone. As long as said bone didn't belong to one of my patients.

Death was silent for a long moment. Well, I'm outta here, she finally decided. What about you?

I've got a few more hours. Rounds, orders, more rounds, discussions with families, likely more rounds

I thought I could hear a wry grin in her voice. Well, you be careful driving home, she suggested. It'd be a shame if you fell asleep at the wheel. And then ended up on my doorstep.

Damn.

She is not, however, without a certain, well, grim sense of humor.

The voice throws you at first. It's deceptively mild and calm, more Gwyneth Paltrow than James Earl Jones. To the best of my knowledge, however, Gwyneth Paltrow has never shown up in a patient's room wearing a hooded black robe and sporting a scythe.

Hmm, bad case of sepsis, huh? she asked.

I was still cleaning up from the central line, so I tried to get rid of her gracefully. Now's not really a good time. That line always seems to work with pesky administrators.

Death, however, would not be dissuaded. HIV positive for nearly 10 years now, flirting with CD4 counts in double digits, rising viral load the past 3 years. Picked a bad time to have her gallbladder go bad on her, didn't she?

Or a bad time to pick a surgeon who was less than fastidious about his sterile fields, I muttered.

Death, however, chose to ignore me. Ventilator, pressors, antibiotics. She reached for the girl's right hand, attached as it was to an arterial line blood pressure monitor, and somethingdamn, if it didn't look like a scarabfell out of the robe and then scrambled across my patient's chest, right next to my newly placed and oh‐so‐deftly sutured plastic catheter, ducking away from the light.

Hey, that was my sterile field, I complained. I, unlike the aforementioned surgeon, had been fastidious about it. I hoped the scarab was sterile, at least.

Splinter hemorrhages, Death noted with obvious glee, taking particular interest in the little streaks of blood under my patient's fingernails. Septic emboli. Death seems to have Gwnyeth Paltrow's laugh along with her voice. It's a light and airy thing, almost like a favorite wind chime. That laugh could almost make you think Death had a heart. Endocarditis, she said fondly. One of my favorites.

Almost make you think she had a heart.

Go away. I tried to look more busy than worried, but I didn't think she was buying it.

It's been a good month for me here in the ICU. Heck, you yourself have 4 kills. Why don't you throw in this one and call yourself an ace?

Very funny. Now get out. I would imagine it's best not to lose your temper with Death. Or with any of the other three Horsemen of the Apocalypse, for that matter. Didn't anyone ever tell you it's poor form to make fun of your host? You're in Donna Smith's house now, buddy. Don't be dissin' my nurse manager.

Come on, she pushed. She's pathetic, she's tired, she lives alone in a tiny room in a forgotten crack house that she pretends is her apartment, and her parents haven't taken her calls for years.

Donna? I asked. That was some serious disrespect.

Don't go all medical student on me. I was talking about your patient, she explained evenly. She'd be better off with me anyway. You know that.

She can be persuasive when she might be right. Death and I have been having similar conversations all the way back to my surgical rotation as a third‐year medical student. Although she has never been above making the easy score, she typically only makes serious plays for patients who, in all honesty, just might be better off heading with her beyond the vale. That's not my decision to make, I told Death, tweaking the pressors. I have this thing about systolic blood pressure less than room temperature. By being here, she's placed her life in my hands, I said, staring down into what almost looked like a lifeless face. Until and unless I have a compelling reason to do otherwise, I will do whatever is necessary to ensure she comes out of this thing as well as she can. I turned to look Death in those beady little eyes. Even go 15 rounds with you, if that's what it takes.

There was a moment of silence, during which I began to think that perhaps I had made my point. Rock, paper, scissors? Death asked with a hopeful lilt.

I sighed. Damn, but she was persistent. I don't gamble with death. That's something my mommy taught me, way back when I used to think I'd be able to fly if I jumped from that really tall tree on the hill.

Oh, come on. Your patient in the next bed did. Overdosed on Ativan with a fifth of Johnny Walker Black as a chaser? Now there's a lifestyle choice I can find myself endorsing.

I was out of witty comebacks. Everyone deserves another chance, I told her, my eyes fixed now on the hollowed, closed eyes of my patient in the ICU bed. Evenor maybe even especiallymy patient in the next bed. I don't know what it was about his life that had driven him to the lifestyle choices he had made. There's a part of every physician that thinks that he or she can make that difference in a patient's life. All too often, though, we see enough repeat business to learn, the hard way, that we rarely make the kind of differences we'd like to. With a little luck, and no small amount of medical diligence, both my patients would survive this hospitalization.

But would they survive their next?

Would there be a next?

Would this be the time they'd turn the corner?

I had to hope so, because I still consider myself far too young to be any more cynical than I already am.

What about your partner? Death asked suddenly.

No, I said with something I hoped sounded like authority. You can't have her either.

No, I meanhow about I work a deal with her? She's young, she's impressionable, she's idealisticwe could make it not your fault.

She's got enough to do; please just leave her alone.

The hood shook slowly back and forth, so I assumed she was shaking her head. Or her skull. Whichever. Look, you wouldn't even have to do anything, that sweet, seductive voice told me. Just head back to your call room for a few minutes. Turn off your pager.

I don't know why we're even having this conversation, I groaned. We both know that you're just a hallucination caused by way too little sleep and way too much caffeine. Last call night I caught myself discussing the relative merits of high‐frequency jet ventilation with Galen.

Galen, Death reflected, suddenly nostalgic. Highly overrated, a positive trait in a doctor if you don't mind my saying so. Has an ego that would make an orthopedist seem humble.

You're lying, I decided.

Yes, I am. And you're stalling. Her voice suddenly became a whole lot more James Earl Jonesish. I'm taking the septic chick with endocarditis. You can lose all the sleep you want, she still goes Home with me.

I glanced over the drips one more time. I've just added norepi. That's a whole bag full of bite me that says differently. So back off, sweetheart.

As with most true medical emergencies, I was too busy thinking ahead to realize just how much trouble my patient could have been in at that moment.

Now morning, like her fever, has broken.

The sun, for those that haven't noticed, gives off a beautiful red glow as it rises over Boot Hill. I got to see it from the rocking chair in my patient's room. Nurse Donna was finishing the night's vital sign flow sheet, politely pretending she hadn't heard me snoring away the past 15 minutes. I was trying to decide if that odor drifting into the room was someone's attempt at coffee or melana. Donna smiled politely at me as I rubbed the Sandman's crud out of my eyes. It was a very Chicago Hope kinda moment.

If I'd been playing a doctor on TV, I'd have made some reassuring comment about how my patient had made it through the night, and so she was now out of the woods. Uh‐huh. With Death sneaking up behind me, my bite‐me norepinephrine wasn't going to be weaned just yet.

Good morning, I greeted.

She seemed a bit put off that I had heard her sneaking in. But then, Death is not exactly graced with kitty‐cat feet.

You never turned your pager off. She said it like an accusation. The way my wife does.

Never do. An answer my wife doesn't appreciate, either. My patient's still with me, I said, managing to keep the victory dance out of my voice. Pressure is better, heart rate is lower, fever seems to have broken.

Death is patient, death is kind, she warned.

It took my postcall mind a moment to wrap itself around that one. Isn't that supposed to be Love? I asked her.

The shoulders of the robe shrugged. Love gets all the cool lines, she complained. What do I get? Be not proud, nothing's for sure but me and taxes, Yea, though I walk through the valley of the shadow of me, give me liberty or give me me. She turned to face me. I like that one, by the way.

Never fails to bring a tear to my eye. I'd give her that. She had lost the patient, I could afford to be gracious and throw her a bone. As long as said bone didn't belong to one of my patients.

Death was silent for a long moment. Well, I'm outta here, she finally decided. What about you?

I've got a few more hours. Rounds, orders, more rounds, discussions with families, likely more rounds

I thought I could hear a wry grin in her voice. Well, you be careful driving home, she suggested. It'd be a shame if you fell asleep at the wheel. And then ended up on my doorstep.

Damn.

She is not, however, without a certain, well, grim sense of humor.

The voice throws you at first. It's deceptively mild and calm, more Gwyneth Paltrow than James Earl Jones. To the best of my knowledge, however, Gwyneth Paltrow has never shown up in a patient's room wearing a hooded black robe and sporting a scythe.

Hmm, bad case of sepsis, huh? she asked.

I was still cleaning up from the central line, so I tried to get rid of her gracefully. Now's not really a good time. That line always seems to work with pesky administrators.

Death, however, would not be dissuaded. HIV positive for nearly 10 years now, flirting with CD4 counts in double digits, rising viral load the past 3 years. Picked a bad time to have her gallbladder go bad on her, didn't she?

Or a bad time to pick a surgeon who was less than fastidious about his sterile fields, I muttered.

Death, however, chose to ignore me. Ventilator, pressors, antibiotics. She reached for the girl's right hand, attached as it was to an arterial line blood pressure monitor, and somethingdamn, if it didn't look like a scarabfell out of the robe and then scrambled across my patient's chest, right next to my newly placed and oh‐so‐deftly sutured plastic catheter, ducking away from the light.

Hey, that was my sterile field, I complained. I, unlike the aforementioned surgeon, had been fastidious about it. I hoped the scarab was sterile, at least.

Splinter hemorrhages, Death noted with obvious glee, taking particular interest in the little streaks of blood under my patient's fingernails. Septic emboli. Death seems to have Gwnyeth Paltrow's laugh along with her voice. It's a light and airy thing, almost like a favorite wind chime. That laugh could almost make you think Death had a heart. Endocarditis, she said fondly. One of my favorites.

Almost make you think she had a heart.

Go away. I tried to look more busy than worried, but I didn't think she was buying it.

It's been a good month for me here in the ICU. Heck, you yourself have 4 kills. Why don't you throw in this one and call yourself an ace?

Very funny. Now get out. I would imagine it's best not to lose your temper with Death. Or with any of the other three Horsemen of the Apocalypse, for that matter. Didn't anyone ever tell you it's poor form to make fun of your host? You're in Donna Smith's house now, buddy. Don't be dissin' my nurse manager.

Come on, she pushed. She's pathetic, she's tired, she lives alone in a tiny room in a forgotten crack house that she pretends is her apartment, and her parents haven't taken her calls for years.

Donna? I asked. That was some serious disrespect.

Don't go all medical student on me. I was talking about your patient, she explained evenly. She'd be better off with me anyway. You know that.

She can be persuasive when she might be right. Death and I have been having similar conversations all the way back to my surgical rotation as a third‐year medical student. Although she has never been above making the easy score, she typically only makes serious plays for patients who, in all honesty, just might be better off heading with her beyond the vale. That's not my decision to make, I told Death, tweaking the pressors. I have this thing about systolic blood pressure less than room temperature. By being here, she's placed her life in my hands, I said, staring down into what almost looked like a lifeless face. Until and unless I have a compelling reason to do otherwise, I will do whatever is necessary to ensure she comes out of this thing as well as she can. I turned to look Death in those beady little eyes. Even go 15 rounds with you, if that's what it takes.

There was a moment of silence, during which I began to think that perhaps I had made my point. Rock, paper, scissors? Death asked with a hopeful lilt.

I sighed. Damn, but she was persistent. I don't gamble with death. That's something my mommy taught me, way back when I used to think I'd be able to fly if I jumped from that really tall tree on the hill.

Oh, come on. Your patient in the next bed did. Overdosed on Ativan with a fifth of Johnny Walker Black as a chaser? Now there's a lifestyle choice I can find myself endorsing.

I was out of witty comebacks. Everyone deserves another chance, I told her, my eyes fixed now on the hollowed, closed eyes of my patient in the ICU bed. Evenor maybe even especiallymy patient in the next bed. I don't know what it was about his life that had driven him to the lifestyle choices he had made. There's a part of every physician that thinks that he or she can make that difference in a patient's life. All too often, though, we see enough repeat business to learn, the hard way, that we rarely make the kind of differences we'd like to. With a little luck, and no small amount of medical diligence, both my patients would survive this hospitalization.

But would they survive their next?

Would there be a next?

Would this be the time they'd turn the corner?

I had to hope so, because I still consider myself far too young to be any more cynical than I already am.

What about your partner? Death asked suddenly.

No, I said with something I hoped sounded like authority. You can't have her either.

No, I meanhow about I work a deal with her? She's young, she's impressionable, she's idealisticwe could make it not your fault.

She's got enough to do; please just leave her alone.

The hood shook slowly back and forth, so I assumed she was shaking her head. Or her skull. Whichever. Look, you wouldn't even have to do anything, that sweet, seductive voice told me. Just head back to your call room for a few minutes. Turn off your pager.

I don't know why we're even having this conversation, I groaned. We both know that you're just a hallucination caused by way too little sleep and way too much caffeine. Last call night I caught myself discussing the relative merits of high‐frequency jet ventilation with Galen.

Galen, Death reflected, suddenly nostalgic. Highly overrated, a positive trait in a doctor if you don't mind my saying so. Has an ego that would make an orthopedist seem humble.

You're lying, I decided.

Yes, I am. And you're stalling. Her voice suddenly became a whole lot more James Earl Jonesish. I'm taking the septic chick with endocarditis. You can lose all the sleep you want, she still goes Home with me.

I glanced over the drips one more time. I've just added norepi. That's a whole bag full of bite me that says differently. So back off, sweetheart.

As with most true medical emergencies, I was too busy thinking ahead to realize just how much trouble my patient could have been in at that moment.

Now morning, like her fever, has broken.

The sun, for those that haven't noticed, gives off a beautiful red glow as it rises over Boot Hill. I got to see it from the rocking chair in my patient's room. Nurse Donna was finishing the night's vital sign flow sheet, politely pretending she hadn't heard me snoring away the past 15 minutes. I was trying to decide if that odor drifting into the room was someone's attempt at coffee or melana. Donna smiled politely at me as I rubbed the Sandman's crud out of my eyes. It was a very Chicago Hope kinda moment.

If I'd been playing a doctor on TV, I'd have made some reassuring comment about how my patient had made it through the night, and so she was now out of the woods. Uh‐huh. With Death sneaking up behind me, my bite‐me norepinephrine wasn't going to be weaned just yet.

Good morning, I greeted.

She seemed a bit put off that I had heard her sneaking in. But then, Death is not exactly graced with kitty‐cat feet.

You never turned your pager off. She said it like an accusation. The way my wife does.

Never do. An answer my wife doesn't appreciate, either. My patient's still with me, I said, managing to keep the victory dance out of my voice. Pressure is better, heart rate is lower, fever seems to have broken.

Death is patient, death is kind, she warned.

It took my postcall mind a moment to wrap itself around that one. Isn't that supposed to be Love? I asked her.

The shoulders of the robe shrugged. Love gets all the cool lines, she complained. What do I get? Be not proud, nothing's for sure but me and taxes, Yea, though I walk through the valley of the shadow of me, give me liberty or give me me. She turned to face me. I like that one, by the way.

Never fails to bring a tear to my eye. I'd give her that. She had lost the patient, I could afford to be gracious and throw her a bone. As long as said bone didn't belong to one of my patients.

Death was silent for a long moment. Well, I'm outta here, she finally decided. What about you?

I've got a few more hours. Rounds, orders, more rounds, discussions with families, likely more rounds

I thought I could hear a wry grin in her voice. Well, you be careful driving home, she suggested. It'd be a shame if you fell asleep at the wheel. And then ended up on my doorstep.

Damn.