Death ain’t for sissies, but neither is medicine. Still, how do you know when a patient is really dead—and where do you turn when you aren’t prepared to make the call? Does being there at the end inspire you to become an internist or send you running to an entirely different field? What does your response to patient loss say about you as a doctor? As a human being? This won't be on a Shelf exam. This test is for your gut.

Doctors Michael Coords, Christopher Carrubba, Daniel Maselli, and Sarah Coates address these questions with remarkable candor in our third episode, My First Patient Death. (To read Sarah’s MST blog post about what she wishes she knew about clerkships, click here.)

This is a transcript of the medical podcast, My First Cadaver — “Episode Three: My First Patient Death”

FAITH AERYN: When you sign up to deal in lives, death comes with the package. Sometimes peaceful, all too often traumatic, death is the the final score. But what do you do when the loss feels like your own? When the primary goal is to sustain life, how do medical schools prepare students for coping with patients' deaths? I’m Faith Aeryn, and you’re listening to “My First Cadaver.” Stories of grief, feelings of futility and doubt, and everything from humor to befuddlement to stark insights emerged through the lens of time and hindsight in the conversations I had for this episode. Today, we begin with Dr. Michael Coords and a little humor. Because, how do you really know if someone’s dead?

DR. MICHAEL COORDS: My first real patient death that I was the person who had to really call the death and it was up to me at that point was when I was an intern. One night I get a phone call on my Spectralink phone, which is a phone that only works in a hospital, and the nurse is like, “Please come, please come check them quickly! I don’t feel a pulse, I don’t feel a pulse!” So I’m running over there, I’m running over there and I get there and here I am the only doctor who comes in there because it’s like two or three o’clock in the morning and no one else is up. The nurses are all sort of pushing me to say, ya know, pronounce him dead and I’m scared as anything to pronounce him dead. I don’t have a stethoscope or anything like that. I mean, I didn’t really bring one. Doctors probably should have one…but what am I gonna do with it? Pretend to listen to lung sounds? Eh…I never knew how to use one of those things. So here I am all nervous and all I did was quickly try to feel for a radial pulse…and I’m like…I don’t know. I’m shaking him, like, ”Are you alive? What’s going on?” So here they are trying to pronounce him dead and I’m like…”Oh, ok, ok we’ll pronounce him dead” and I walk out and I’m like…this is really going to end bad if they’re not dead. What sort of doctor doesn’t know if a patient’s alive or not? So I’m looking all sweaty and tachycardic and once everyone leaves the room I’m going back in there and like poking him and trying to make sure that he’s really dead. And I’m telling the nurse, “Can we get a like…an EKG or something? I don’t know…really make sure?” His pulse ox isn’t reading. I’m checking his pulse ox and making sure it’s on well because I didn’t want to be the guy who pronounced someone dead when they really weren’t! Turns out, he really was dead. So then I wind up calling my senior on that night. So I call her up, she’s half asleep, it’s three o’clock in the morning and I’m like, “So…if a patient dies…what sort of paperwork do we need to fill out?” and she’s like, “Ummm…is there something I should know?” And I’m like, “No, nope… Just wondering. I’ve just gotta fill out some paperwork.” So I was nervous about that too because now I gotta fill out paperwork for a death thing and I hope I didn’t mess that up. Then my senior resident really didn’t even really question why I’m calling about a dead patient so…ya know…it’s always good.

FA: You’ll remember Dr. Christopher Carrubba from his intensely awkward ObGyn encounter. Here he is again.

DR. CHRISTOPHER CARRUBBA: We were on cardiology. Maybe this will sound like some black humor but I remember meeting this guy, ya know, we admitted him in the ED and he just looked like a fuckin’ gargoyle. And he was breathing like one and talking like one and was this cross between a gargoyle and this crotchety old man. That was just like, any time you asked him a question, “What the fuck did you say? What the fuck did you say?” And then I think maybe it was hospital day two or three my eventual wife…was…ya know fiancée at the time…in town visiting because we were doing long distance that year while she finished up med school. I just remember kind of having that like ya know, I’m in a hurry to get out of here mode. Making sure everything was done, crossing all my t’s getting everything out. This guy had been healthy, stable, doing pretty well despite being admitted for a heart failure exacerbation. For some reason we had ordered an afternoon BMP on him. Ya know, basic metabolic panel. We were diuresing him a lot, I think it was probably just to make sure he wasn’t getting hypokalemic. Somewhere in there, I never remembered to look to see if it was back and I don’t really think that I told anybody else like, “Hey, take a look at this.” Over the course of the night this guy had cardiac arrest, got intubated, multiple rounds of CPR all night. Ya know, you just come walking in that next day and you see that this guy just kinda went to shit. Tubes in and out of everywhere, had gotten CPR all night. And our fellow comes up, grabs me, pulls me aside, shows me the lab and he was like, “ What is this? What the fuck did you do?” And there was just that overwhelming sensation of, “Oh shit… I did something wrong. I messed this up.” The thing is, later, it comes back the lab was actually an error. He didn’t have hypokalemia that I missed and didn’t tell anybody about. It was just a total lab error. But it never went away. It never went away that this person died and it was my fault. And… I like… I don’t know… I’m not really somebody that gets that upset, but multiple times throughout the day I had to go to the bathroom cause I was like on the verge of crying. There was always that thing that stuck with me that, regardless, it was my fault and now it’s just something where I can never get past it. I always have to check the labs two or three times. And I think it really is one of those things that makes you, probably, a better doctor for it because…I think beforehand I could be a little haphazard and I really could let things slide and knowing what that felt like really like..never went away for me. Ya know?Never really went away.

FA: Let’s go to Dr. Daniel Maselli with more on his first patient death.

DR. DANIEL MASELLI: My first patient death. It was on my internal medicine rotation. And it was on a weekend, like this beautiful fall day and I remember driving past this flea market and thinking, “Oh, that’s awesome. I’m gonna go check out that flea market when I get out early.” And I’m totally leading the witness here because, spoiler alert, I didn’t get out early that day. Instead, I found that my team was unaware — they were unaware of this policy of med students being let out early and as a third year medical student I was not ready to advocate for myself. Because these… you know, you want to impress your team, you want to get good grades, so you can do well so you can go be a resident, be a good resident at a good residency and then get a job and then pay off your debt and get married and get a dog. Which is the ultimate goal, I think, of all of this…the dog part of that. And I was super psyched to go be able to go show off my medical skills in this medicine rotation so I was not going to say, “May I please be excused because of the policy that UMass has in place?” So instead, I stayed quiet around 1, 2 p.m., the time that I thought that I would be being dismissed. And around 3, we were paged down to the emergency department because we had two admissions. One was an elderly woman with a GI bleed so she, somewhere in her gut, there was a source of bleeding and it was not stopping. And the other, was a gentleman who was fine until a couple weeks ago when he really just started getting very short of breath. He was a smoker. They took x-rays of his lungs and CT scans of his lungs and they were just…man…they were cobwebbed with the spread of cancer like nothing I’d ever seen. It looked like it had even gone down to the liver to metastasize. The tubes that were keeping this man alive by pumping oxygen into his lungs, they were just…ya know…they were working overtime. They were just barley keeping him hanging on. He was out and this woman who was in a GI bleed was out too. They were…they just didn’t have enough mentation to be aware. So I didn’t even really get to meet them. I mean I was present, but I never heard them speak to me and that’s always kind of a bummer. Especially for someone going into internal medicine where histories are just such a rich important part of your experience. But what really got…I mean the thing that got to me about that night…like it wasn’t the patient’s death. To be honest, I was dismissed around 9pm before either patient had died. They actually died sometime early in the morning the next day, both of them. But the part that just got me was the…the families. Because the families were the ones I had interacted with, were the ones I had interviewed to take the history. For this gentleman with the lung cancer, his wife was present and she was calling her children to come say their final goodbyes. Meanwhile that old lady’s family was already in the midst of kind of saying their own. The most salient memory for me was to see her husband…her husband kind of do this…this solemn march around the ICU. He couldn’t be in the room with his wife, it was too much, so he was sort of just walking around the room with the support of a cane or the support of a grandson. That just killed…that got me…that was such a sad image and you really realize that when you’re a treating patients you are treating their entire families. I thought well ok, I don’t know the patient in front of me but I certainly know all of these living patients who are related to this woman in a GI bleed or this man with lung cancer. To see them suffering and to feel kind of powerless to do anything about it. I mean even as a…even if I weren’t this third year clownishly oversized medical student like I…wouldn’t really be able to do anything as a resident there’s not much you can do medically at that point except for comfort Which is still something. But I, yeah, I remember that…seeing that older gentleman walk around the ICU just…that’s when I knew things were really going bad and I dismissed myself to go into the bathroom and just cried into fistful of paper towels because man…that was powerful. I uh…I was not ready for that on that day. You know…I am grateful that I did get to stay those extra hours. That my team didn’t dismiss me when I thought I was going to be dismissed. Obviously I missed the flea market but it was a really moving part and a very instrumental part in solidifying this concept that internal medicine is where I want to go because being around these patients and their families in this time of need and comforting them when…even when medicine is just out the window. There’s nothing more you can do but just being there for them like my residents and the attending were. Man…that was…that was a very powerful thing. So that was…yeah…that was the first patient death was two and I wasn’t even present for it and I didn’t even know the patients really and yet it still sits with me as one of the most moving experiences of my medical school career.

DR. SARAH COATES: So I, in my medicine clerkship, my general medicine month was on a step down unit which is basically an intermediate level of care between the intensive care unit and regular general medicine floor. So my patients were sicker than most of the students who were on general medicine.

FA: That’s Dr. Sarah Coates, a graduate of the Weill Cornell Medical College.

SC: So we got a man, an 85 year old gentleman come in who had been in really good health for most of his life and he had a pulmonary embolism over Christmas and this was a couple months later. And just, since he had the pulmonary embolism he just kind of went downhill. What they came to find out through imaging was that it wasn’t just that he had a P.E. he had this underlying restrictive lung disease which is this fibrosis, this harding of the lungs. It’s really hard to treat and people tend to go downhill really fast. What was crazy was that he had been fine until he had this one trigger that was wrong with his lungs and then everything else kind of came uncovered. And I think it was just so hard for the family to understand how someone could go from being so healthy to all of a sudden having a really serious lung disease that’s supposed to take years to, kind of, accumulate and manifest. Trying to explain to them what restrictive lung disease even was was something that I found challenging. I tried to do it and I would get up on the whiteboard and I would say like, “This is what your lungs are doing. They’re having a hard time expanding and that means it’s really hard for you to breathe when you move even a little bit” And that was exactly what he was experiencing. Over the course of two weeks with us he just precipitously declined and I just remember…there was this one moment where we could have done a diagnostic test to confirm that he had this type of disease. That would have required us to go in and take a biopsy sample but since he was DNR/DNI (Do not resuscitate or intubate) the pulmonology team, who said that they wouldn’t treat the disease unless they had a biopsy, they didn’t want to go get a biopsy because if something were to happen during the biopsy we wouldn’t be able to help and you would feel as though you triggered the situation that lead to his death. So we were in this catch 22 where we couldn’t treat him with the big guns unless we had the tissue but they didn’t want to get the tissue because he was DNR/DNI. And so they’re just letting him slip away. Maybe I’m over simplifying this in hindsight but at the time it just seemed so like Alice in Wonderland weird to me. On top of that, people were saying like, “There’s no need to like draw stuff on the board for them. It’s not necessary to go into such detail about what’s going on. We’re not even sure what we’re going to do about it so them understanding it more is not gonna help.” That was one of those moments where you just feel so powerless and yet you get this sense that your the only one who really cares. As self righteous as that sounds, I think that’s what third year feels like a lot. So I was there as he declined and when I went away on a Friday night I was hugging his daughter and telling her goodbye cause I was not going to be there the next day. It was my day off. But I just remember, on my day off, checking the patient record from home while I was doing USMLE world questions and watching as notes were getting dropped from like the palliative care team and the ethics team and the morphine was being ordered which meant that they were going to try to ease his pain at the end of life. It was clear what direction was going just from watching the notes getting dropped in the chart electronically. I felt so weird and selfish and creepy because I thought, “I’m gonna get there and he’s gonna be gone. I just wanna be there. Like, I know this guy so well I should be there when he dies. That’s not cool.” I get in the next morning on a Sunday and he’s still alive but only hanging on and umm…he dies a few hours later that morning. It was so hard to watch cause his daughter…she…just lost it. And…umm…she was like crawling on his bed and…and…screaming like, “Daddy! Daddy! Daddy!” And I’m just like…I’m losing it. My intern, I don’t know how the hell he’s keeping it together but I’m like trying not to move but tears are streaming down my face…and..and…then…the family leaves the room and we have to do the death exam. The death exam is…it’s not horrible…but it’s brutal. Like it’s…it’s very much in your face. It’s like going back to the anatomy lab almost cause you’re doing things that you would never do to a live waking human. You’re squirting water on their face or touching their eyeballs with cotton or jerking their head from side to side to see if their eyeballs respond. And it’s so…surreal to have that connection with someone and then you have to treat them like a cadaver and basically confirm that they are no longer alive. I was crying while I was doing it and the whole time I thought to myself like, “This is why I can’t do this! This is why I have to be a dermatologist!” I’m just way to emotional to handle this day in and day out and if I am not too emotional…I don’t want to get to a point where I’m so hard that this doesn’t affect me this way. Like…how does anybody do this? We ended up coming out of the room and confirming his death and…and…the daughter, I’ll never forget, she just said to me like, “I’m so glad you were here. I’m so glad you were here.” And I’m thinking, “Me being here didn’t make a difference. He was already gone when I got in this morning. He was already almost there.” But I think it just kind of showed me she knew how much I tried to make them feel like they knew what was going on. As helpless as I felt during that whole situation that communication that she had with me mad me realize, even if I didn’t teach them exactly what was going on, even if I felt frustrated the whole time, she was noticing. She was grateful to feel like she could talk to someone on the team. It’s moments like that that make you feel really conflicted. It’s like I said, I can’t imagine how anyone could do this over and over. But then I thought to myself, maybe they need people who are so emotionally invested to do jobs like this. But ultimately I decided that that level of intensity was not something that would allow me to function professionally on a day to day basis. I think it was just too hard to get so close to people and then watch them die.

FA: You know, it’s a funny thing about death...it’s not that funny. And sometimes it’s not as easy as you’d think. It can be hard to die. For the patient the family. And even the medical team. It can be grueling and long and drawn out and tedious and it’s always, always sad. It’s a wonder the planet isn’t overflowing with dermatologists. Or podcast hosts. It takes a special person to be there at the end. To hold the hands and check the pulse. To do the death exam. To sign the forms. To do that job. Even on a random rotation as a medical student or an intern, awaiting dismissal, dreaming of dogs and flea markets — an accidental witness to the end of a world. It takes special people to share those moments of intimacy, of recognition and understanding. Of accepting what kind of person you are and what kind of doctor you will be. So maybe the funny thing about death is how much you can learn about the rest of your life.

Thank you to Doctors Michael Coords, Christopher Carrubba, Daniel Maselli and Sarah Coates.
The My First Cadaver Team
Papa Claire Music & Compulsion Music
Our Nerf-blasting friends at Salted Stone
And special thanks to Robert Meekins who is not a doctor.

Stayed tuned for Episode 4: My First Oh My God No Fucking Way, coming soon to a listening device near you.

And remember, guys: Don’t jokingly pretend to fall into the Grand Canyon, or you could become someone’s first cadaver.

MC: Ya know…it’s always good.

FA: I take it you weren’t the one who was responsible for doing the death exam?

MC: No, no no not the pathology but I pronounced them dead and I filled out the paperwork. I was just hoping that they actually were dead I guess. I mean, based on what my poking them and trying to feel for a pulse. I mean…maybe they were passed out and they’re on beta blockers or something…ya know?

MST AD: This episode of “My First Cadaver” was sponsored by your friendly neighborhood Med School Tutors. Join our tutor ranks and pay it forward while you pay it off.  Let Med School Tutors be a part of your origin story. Together, we can save the world.