I was taught in medical school that pneumonia is the friend of the elderly.It helps ease the transition from this life to the next.
She was 94 years old. The family insisted that she was living independently at home. Apparently her independent living did not include eating, as she appeared to be a thin-skinned bag of bones. By the time I got to her in the ICU she had already been put on the ventilator. Why you would put a 94 year old on the vent escapes me. Her respiratory failure would have been a perfect way to die: progressive obtundation, coma, death. The ER doc had talked to the family, who I guess was impaired in some way, and wanted "everything possible done". Of course, the fault is ours. As her doctor of the moment, the ER doc should have said "I'm sorry. There's nothing we can do. It's her time to die."
The ICU room was darkened and I saw no need to turn up the lights as I examined her. Her bones stuck out everywhere. She had very little hair but still had her teeth. She did not respond during the exam. As I leaned in to listen to her heart I felt the now familiar shift in air pressure and heard a rasping laugh.
I pulled one of the earpieces of my stethescope out of my ear and without turning to see what would only be a shadow at the corner of my vision, I said "Yeah, yeah. I know. She's all yours. But not for a little while. Have some respect."
His voice had too much air whistling over ancient, inhuman vocal cords. "Why do they fight it so? Is life in this small, dreary world so precious?"
"It has its moments."
The presence shifted closer for a moment and then seemed to recede to the edges of the room. "Her moment is gone. You work on her body but she has already left it."
I put the earpiece back on and listened to her heart. The rhythym was regular, but the blood flowing over her 90 plus years old, calcified valves made a roaring sound with each beat. A systolic murmur, likely from the aortic valve.Her neck veins were flat, suggesting that she did not have fluid overload and that her respiratory failure was not from congestive heart failure. I shifted to her lungs and heard the whistling, prolonged expirations of inflammed, swollen airways. I made a note to myself that she would need iv steroids and inhaled bronchodilators. When I took off the stethescope and stood up I heard the rustle of robes, the creak of leathery skin.
"You still here? No famine or pestilence somewhere else in the world that requires your attention?"
"I am everywhere.Waiting."
"Yeah, well, fuck that. You'll have to wait a little longer on this one."
The laugh again and then gone.
I sat by the computer and checked her labs. They had swabbed her nose for culture and the rapid antigen for influenza A was positive. So we had an explanation for her lung problems. A classic case of real influenza. People toss the word flu around, most often referring to a viral upper respiratory tract infection or viral gastroenteritis. But this was influenza. The same disease that had allowed the Angel of Death to harvest souls wholesale during the pandemic at the beginning of the 20th century, and intermittently over the decades.
The ER notes said she hadn't been to a doctor in several years and that meant she hadn't had the flu vaccine. Might not have mattered much as it seems that this year's vaccine was an antigenic miss, meaning it didn't prevent the strain of virus currently making the rounds. I wrote orders for tamiflu twice a day down the feeding tube and sat down to dictate a note. It was late and I figured I'd save the inevitable family meeting for the morning. I couldn't imagine the type of dysfunctional psychopathology that would result in tormenting the family matriarch during the final hours of her life.
The car barely started, having been out in the minus 15 degree weather of a Minnesota February night, but eventually fired up after several tense tries. I hunched over the wheel, and drove with muscles clenched, waiting for the engine to generate some heat. And then the Angel was back. The soft laugh, the thickening of the air.
"Fuck you." I ventured half-heartedly.
"You did well tonight." came the rasp. "She lives yet."
"Gee, I'm touched by your compliment, but could you kiss off for awhile. Someone might see me talking to my self."
"I am here. You are not alone. We are two sides of a struggle, two sides of a border. A struggle that you will always lose and I will always win, sooner or later. Sooner or later they are all mine."
I reached down to turn up the radio. "I fight the fight as long as they want me to. I don't decide who lives or who dies, but if they want to hang on to their sorry ass lives a little longer, I try and make it happen."
The Angel's presence faded and my shoulders relaxed. Maybe it was the heat finally coming on, or maybe I get a little tense in the presence of death incarnate.I took the exit off the highway and turned into my street, controlling a small skid with the nonchalance of a northerner driving in February. The tires crunched up the driveway and through the opening garage doors.
Upstairs, bed, sleep.