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Barry, the senior paramedic, was at the head of the gurney as they wheeled into the trauma bay of our ER. “This guy shot himself,” Barry said. “It’s a mess. It’s a goddam mess.” One of the other paramedics pumped on the guy’s chest while a firefighter fumbled to undo the yellow straps securing him to their gurney. 

Barry wiped his forehead with the back of his wrist, careful to keep the blood on his gloved hand from touching his face. “He stood there in the kitchen, told his mom, ‘I’m going to shoot myself,’ and then, BOOM.” Barry snorted, and shook his head. “Couldn’t intubate him so we’ve been using the bag ventilator. Sorry, Doc.” 

“No problem,” I said. “Let’s move him over to our stretcher.” 

Barry raised his voice and counted, “One, two, and three.” The paramedics and fire fighters heaved the man over to our bed. They pulled their narrow gurney out of the room, trailing a monitor lead on the floor.

 The nurses snapped cardiac monitor wires onto the man’s chest and wrapped a blood pressure cuff around his arm while I tried to slip a plastic tube down his throat and into his windpipe. His head jostled with the rhythm of chest compressions and blood and vomit welled up into the back of his mouth. I tried to clear it out with a suction catheter, but it kept getting plugged with bits of yellow-white cheesy stuff. “Bag him up some,” I said to the respiratory therapist. “I’m going to try to suction him with straight tubing; maybe it won’t get clogged.” 

As she squeezed the bag to force air into his lungs, a flatulent sound and a fine red mist came from a bullet hole just above his ear. “Damn!,” The respiratory therapist said, “what’s that?” 

I stood and stared, perplexed by the small bloody geyser coming out of the side of the man’s head with each squeeze of the Ambu-bag. Then it occurred to me. The bullet must have angled down through his skull and brain and then through the roof of his mouth. I pulled the face piece off, and looked into his mouth. Sure enough, there was a jagged hole through the soft palate. 

I looked over at the paramedics. “How long’s he been down?”

Barry looked at his watch. “25….30 minutes.” 

“Did he ever have a pulse?”

Barry shook his head no. 

“This isn’t a survivable injury.” I looked around the room, at each person. “Unless anyone has any other ideas, I’m going to call it.”  It is a team effort, and I like to give everyone a chance to speak up before ending resuscitation.

Beth looked at the clock on the wall. “Time of death 07:52.” She spoke clearly, and loudly, so everyone would document the same time of death. 

“Good job, everybody,” I said. “This guy was just too dead.” I looked at the paramedics standing in the doorway, watching. “Who tried to intubate him?” 

Barry raised his hand, and looked at the floor. “I couldn’t see anything from all the blood and vomit.” He looked up at me. “We decided to load and go.” 

“You did the right thing.” I stripped off my gloves and the paper disposable gown. “Bits of brain kept clogging the suction catheter.” I clapped his shoulder. “You were right to scoop and run.”

He looked down at his feet. “Thanks.” 


I had just completed the Death Certificate when Beth came over. “The sister’s in the family room,” she said. 

I looked up. “Anyone else?” 

“Just her.” 

“Let me go to the bathroom; then we’ll go talk to her.” 

I went to the bathroom, splashed my face, made sure there was not any blood on my scrubs, and went back out to the nurses’ station. 

Beth and I walked to the family room. A thin woman sat with her knees together and her hands in her lap. Her face was calm.

I sat in the chair next to hers and introduced myself. “You are his...” 

“Sister,” she answered.

“Do you know what happened today?” 

“Tucker’s been talking about shooting himself for years,” she said in a soft voice. “Today, he told Mama he was going to do it. Mama told him to talk like he had some sense.” She took a deep breath. “Tucker put his gun to his head and shot himself.” 

“I’m sorry to have to tell you, but in spite of all that the rescue squad, and nurses, and doctors could do, we couldn’t save him.” 

She stared at my face with a blank look, no reaction. 

Until you use the word “dead,” or “died,” some families cling to the hope that the void looming into their lives is not really there. Until you say “dead,” their daughter, son, husband, wife, lover, friend, may still be alive. 

“We did our best,” I said, “but he died.” 

She raised her shoulder in a gentle shrug. “Tucker’s been talking about this for the last few years. He drinks. His liver’s gone, his pancreas’s gone, his kidneys are going, he hasn’t worked in years.” She shook her head. “He just stays around Mama’s house, drinks, and talks about killing himself. Mama’s torn up about it, but we figured it would happen sooner or later. I just hate that he did it in front of her.” She gestured toward the floor. “You know, right there in her kitchen.”

We stared at the floor together. 

I could not think of anything to say that would help her. Sometimes sitting quietly seems the most respectful thing to do. I waited several minutes and then gestured toward Beth. “Beth will help with the arrangements: telephone, funeral home, friends and family. Do you want to see his body?” I kept my voice gentle, and matter-of-fact. “Some people do, and some people don’t. Either way is okay.” 

The sister shook her head. “I already saw it at home.”

I glanced over at Beth. She raised her eyebrows, but did not speak.

I looked back at Tucker’s sister. “Is there anything we can do for you?”

“Call any funeral parlor you want.” She stood. “I gave my name and phone number to the lady at the desk. Is there anything else I need to sign?”

“Not that I know of.” I stood, too. 

“Okay.” She turned and walked out the door.

Beth and I looked at each other. 

“Damn.” I said. “That was easier than I expected.” 

“No shit.” She shook her head and frowned. “She’s in denial.”

“Either that, or the guy had been such a problem for so long that he finally wore her out.” Alcoholism, organ failure, suicide threats – those things get tiresome after fifteen minutes in the ER. I could not imagine dealing with them at home day after day. Although Beth and I had been prepared to be with Tucker’s sister through her first moments of pain, I was relieved when she walked out so abruptly. I would not have to sit in a room full of his family, would not have to watch them make helpless little gestures with their hands, begin to ask a question, and then murmur to a stop.


After someone has been murdered in gang violence, the family is angry; angry with the killer, at the nurses and doctors who did not bring him back to life, angry with everyone. The room buzzes with rage. With a suicide, the family is usually quiet, subdued, and tentative. 

That night, I was grateful that Tucker’s sister had taken it so calmly, and had left so quietly. I had been spared a portion of pain. Of course, she had not been spared anything, neither had their mother. Suicide is an aggressive act; it unleashes a burden of guilt on everyone who survives. Many of us cannot imagine a life so painful and hopeless that suicide seems the least painful option, yet up to a third of us will consider it at least once during our lifetime. Why do it in front of your own mom? That seemed too hostile to consider. 

Perhaps those of us who somehow get through the dark moments, and stay to take the risks of living instinctively resent those who bail out, leaving us to face their sisters’ empty faces. I was angry with Tucker because I felt like I had failed him, mucking about in his blood and brains trying to stick a plastic tube down into his lungs. 

I resented him for leaving such a mess, and I disliked myself for resenting him; it seemed like Tucker had enough going against him without my antipathy. Suicides are often an attempt to escape an excruciating psychic pain. Psychic pain from which there is no relief. Psychiatrists have developed a test to measure hopelessness, a trait that predicts 91% to 94% of suicides. Many who kill themselves can literally see no other solution. A man who survived jumping from the Golden Gate Bridge said, “ I still see my hands coming off the railing… I instantly realized that everything in my life that I’d thought was unfixable was totally fixable – except for having just jumped.”

Part of the deal about being an ER doctor is that I sometimes have to care more about people than they do themselves. Like the guy who swallows an entire bottle of Tylenol, or the woman who slashes her wrists, or the guy who takes all his antidepressants and sits in the car while it runs. Patients are in pain, and I am supposed to care about them. I usually do. When my compassion has been all used up, and I am running on empty, I fake it as best I can, until I find something that humanizes them.


Beth and one of the other nurses washed Tucker’s body, wrapped it in a sheet, and zipped him into a plastic bag. One of the nursing assistants rolled him down to the morgue. The ward clerk asked Carlos, from housekeeping, to mop the floor. The smears of Tucker’s blood were a biohazard, a potential broth of AIDS and hepatitis that had to be cleaned up. Walking backward, Carlos swabbed the floor, the mop fanning out smoothly, side to side. When he was done, the floor had a subtle sheen; ready for the next damaged person the paramedics would bring us. 

I did not know who would clean the kitchen floor in Tucker’s house. His sister or maybe his mother would. Would she scrub every inch of her kitchen floor, trying to expunge all traces of shock and pain she was left with?  Perhaps she would hesitate, as if a spotless kitchen floor would be a betrayal, an erasure of Tucker’s existence, as if she had discarded his birth certificate, or a grade-school picture, or a lock of hair she had saved from his first haircut.

This essay is an excerpt from Paul Austin’s book Something For the Pain: Compassion and Burnout in the ER (W. W. Norton & Company)

 

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