Handoffs

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.