Authors: Sherwin B Nuland
How We Die (21 page)
Whether or not they do die, and whether enough of them die so that the patient is also killed, is determined by the duration of the shock. If it lasts long enough, it is always lethal. The
long enough
is, of course, a relative term. Just how long is long enough? It depends upon the degree of the circulation’s inadequacy. If flow is stopped completely, as in cardiac arrest, death occurs within minutes; if it is merely decreased to levels somewhat less than those needed for survival, dying takes more time and occurs at different rates in different tissues, depending upon how much oxygen their cells require. The brain being particularly sensitive to deficiencies of oxygen and glucose, it fails quickly; because its viability is the legal criterion of being alive, there is obviously a very narrow margin between mortality and continued existence in those people whose cerebral circulation is at all compromised. Interference with oxygen delivery to the brain is a factor in a wide variety of violent deaths.
long enough
is, of course, a relative term. Just how long is long enough? It depends upon the degree of the circulation’s inadequacy. If flow is stopped completely, as in cardiac arrest, death occurs within minutes; if it is merely decreased to levels somewhat less than those needed for survival, dying takes more time and occurs at different rates in different tissues, depending upon how much oxygen their cells require. The brain being particularly sensitive to deficiencies of oxygen and glucose, it fails quickly; because its viability is the legal criterion of being alive, there is obviously a very narrow margin between mortality and continued existence in those people whose cerebral circulation is at all compromised. Interference with oxygen delivery to the brain is a factor in a wide variety of violent deaths.
Although viability of the brain is currently the legal criterion by which mortality is determined, there is still usefulness in the time-honored way in which clinical physicians have always diagnosed death.
Clinical death
is the term used to encompass that short interval after the heart has finally stopped, during which there is no circulation, no breathing, and no evidence of brain function, but when rescue is still possible. If this stoppage occurs suddenly, as in cardiac arrest or massive hemorrhage, a brief time remains before vital cells lose their viability, during which measures such as cardiopulmonary resuscitation (CPR) or rapid transfusion may succeed in resuscitating a person whose life has seemingly ended—the time is probably no more than four minutes. These are the dramatic moments we read about and see portrayed on our television screens. Although the attempts are usually futile, they succeed just often enough that, under the appropriate circumstances, they should be encouraged. Because individuals most likely to survive clinical death are those whose organs are healthiest and who do not have terminal cancer, for example, or debilitating arteriosclerosis or dementia, their continuing existence is still possible and potentially most valuable to society, at least in terms of ability to contribute. It is for this reason that the principles of CPR should be taught to every motivated person.
Clinical death
is the term used to encompass that short interval after the heart has finally stopped, during which there is no circulation, no breathing, and no evidence of brain function, but when rescue is still possible. If this stoppage occurs suddenly, as in cardiac arrest or massive hemorrhage, a brief time remains before vital cells lose their viability, during which measures such as cardiopulmonary resuscitation (CPR) or rapid transfusion may succeed in resuscitating a person whose life has seemingly ended—the time is probably no more than four minutes. These are the dramatic moments we read about and see portrayed on our television screens. Although the attempts are usually futile, they succeed just often enough that, under the appropriate circumstances, they should be encouraged. Because individuals most likely to survive clinical death are those whose organs are healthiest and who do not have terminal cancer, for example, or debilitating arteriosclerosis or dementia, their continuing existence is still possible and potentially most valuable to society, at least in terms of ability to contribute. It is for this reason that the principles of CPR should be taught to every motivated person.
Clinical death is often preceded (or its first evidences are accompanied) by a barely more than momentary period termed the
agonal phase
. The adjective
agonal
is used by clinicians to describe the visible events that take place when life is in the act of extricating itself from protoplasm too compromised to sustain it any longer. Like its etymological twin,
agony
, the word derives from the Greek
agon
, denoting a struggle. We speak of “death agonies,” even though the dying person is too far gone to be aware of them, and even though much of what occurs is due simply to muscle spasm induced by the blood’s terminal acidity. Agonal moments and the entire sequence of events of which they are a part can occur in all the forms of death, whether sudden or following upon a long period of decline into terminal illness, as in cancer.
agonal phase
. The adjective
agonal
is used by clinicians to describe the visible events that take place when life is in the act of extricating itself from protoplasm too compromised to sustain it any longer. Like its etymological twin,
agony
, the word derives from the Greek
agon
, denoting a struggle. We speak of “death agonies,” even though the dying person is too far gone to be aware of them, and even though much of what occurs is due simply to muscle spasm induced by the blood’s terminal acidity. Agonal moments and the entire sequence of events of which they are a part can occur in all the forms of death, whether sudden or following upon a long period of decline into terminal illness, as in cancer.
The apparent struggles of the agonal moments are like some violent outburst of protest arising deep in the primitive unconscious, raging against the too-hasty departure of the spirit; no matter its preparation by even months of antecedent illness, the body often seems reluctant to agree to the divorce. In the ultimate agonal moments, the rapid onset of final oblivion is accompanied either by the cessation of breathing or by a short series of great heaving gasps; on rare occasions, there may be other movements as well, such as the violent tightening of James McCarty’s laryngeal muscles into a terrifying bark. Simultaneously, the chest or shoulders will sometimes heave once or twice and there may be a brief agonal convulsion. The agonal phase merges into clinical death, and thence into the permanence of mortality.
The appearance of a newly lifeless face cannot be mistaken for unconsciousness. Within a minute after the heart stops beating, the face begins to take on the unmistakable gray-white pallor of death; in an uncanny way, the features very soon appear corpse-like, even to those who have never before seen a dead body. A man’s corpse looks as though his essence has left him, and it has. He is flat and toneless, no longer inflated by the vital spirit the Greeks called
pneuma
. The vibrant fullness is gone; he is “stripped for the last voyage.” The body of the dead man has already begun the process of shrinking—in hours, he will seem “to be almost half himself.” Irv Lipsiner reenacted the deflation by blowing his breath out through pursed lips. No wonder we say of the recently deceased that they have expired.
pneuma
. The vibrant fullness is gone; he is “stripped for the last voyage.” The body of the dead man has already begun the process of shrinking—in hours, he will seem “to be almost half himself.” Irv Lipsiner reenacted the deflation by blowing his breath out through pursed lips. No wonder we say of the recently deceased that they have expired.
Clinical death has a distinctive look about it. A few seconds’ observation of the victim of cardiac arrest or uncontrolled hemorrhage will decide the appropriateness of attempts at resuscitation. Should any doubt remain, there are the eyes to consider. If open, they are at first glassy and unseeing, but if resuscitation does not commence they will in four or five minutes yield up their sheen and become dulled, as the pupils dilate and forever lose their watchful light. It is soon as though a thin cloud-gray film has been laid down over each eye, so that no one can look within to see that the soul has fled. Its rounded plumpness having depended on something no longer there, the eyeball soon flattens out, just enough to be noticeable. It is a flatness from which there is no rising.
The absence of circulation is confirmed by the absence of pulse—an observer’s seeking finger on the neck or groin detects no sign of a throbbing artery beneath, and the surrounding muscles, if they are not still in an element of spasm, have begun to assume the flaccid consistency of meat slabbed in a butcher’s display case. The skin has lost its elasticity, and that slight shine is gone which once gleamed in reflected recognition of nature’s light. At that point, life is over—no amount of CPR can retrieve it.
To be declared legally dead, there must be incontrovertible evidence that the brain has permanently ceased to function. The criteria of brain death currently being used in intensive care and trauma units are very specific. They include such signs as loss of all reflexes, lack of response to vigorous external stimuli, and absence of electrical activity as shown by a flat electroencephalogram for a sufficient number of hours. When these standards have been met (as when brain death is due to head injury or massive stroke), all artificial supports can be withdrawn and the heart, if not already stilled, will soon stop, ending all circulation.
When circulation ceases, cellular death can complete itself. The central nervous system goes first and the connective tissue of muscle and fibrous structures goes last. With electrical stimulation, it is sometimes possible to induce muscular contraction even hours after death. Some few organic processes, called anaerobic because they require no oxygen, will also continue for hours, such as the liver cell’s ability to break down alcohol into its component parts. The supposedly well-known fact that hair and nails will keep growing for varying periods of time after death is not a fact at all—no such thing happens.
In most deaths, the heartbeat ends before the brain ceases to function. Particularly in sudden deaths due to trauma other than head injury, the cessation of heartbeat is almost always the result of the rapid loss of more blood than can be tolerated—the trauma surgeon refers to such a hemorrhage as
exsanguination
, which is a more elegant term than the more commonly used
bleeding out
. Exsanguination may be due to direct laceration of a major vessel or to injuries of blood-filled organs like the spleen, liver, or lung; sometimes the heart itself is torn.
exsanguination
, which is a more elegant term than the more commonly used
bleeding out
. Exsanguination may be due to direct laceration of a major vessel or to injuries of blood-filled organs like the spleen, liver, or lung; sometimes the heart itself is torn.
The rapid loss of approximately one-half to two-thirds of the body’s blood volume is usually sufficient to arrest the heart. Since total blood volume is equal to some 7–8 percent of body weight, a bleed of eight pints in a 170-pound man or six pints in a 130-pound woman can be enough to cause clinical death. With laceration of a vessel the size of the aorta, the process takes less than a minute; a tear in the spleen or liver might take hours, or even days, on those very rare occasions when constant ooze remains unchecked.
With the loss of the first few pints, blood pressure begins to drop and the heart speeds up in an attempt to compensate for the decreased volume of each stroke. Finally, no amount of internal readjustment can keep up with the losses—the pressure and volume of blood reaching the brain become too low to sustain consciousness, and the patient lapses into coma. The cerebral cortex fails first, but the brain’s “lower” parts, such as the brain stem and medulla, hold on a bit longer, so that respiration continues, though in an increasingly disorganized fashion. Finally, the near-empty heart stops, sometimes fibrillating before it does so. The agonal period then begins, and life flickers out.
This entire grim sequence of events—hemorrhage, exsanguination, cardiac arrest, the agonal moments, clinical death, and finally irretrievable mortality—was played out during a particularly vicious murder committed a few years ago in a small Connecticut city not far from the hospital where I work. The attack took place at a crowded street fair, in full view of scores of people who fled the scene in fear of the killer’s maniacal rage. He had never laid eyes on his victim before the instant of the savage onslaught. She was a buoyant, beautiful child of nine.
Katie Mason was visiting the fair from a nearby town, along with her mother, Joan, and her six-year-old sister, Christine. Accompanying them was Joan’s friend Susan Ricci, who had brought along her own two children, Laura and Timmy, about the same ages as the Mason kids—Katie and Laura, in fact, were fast friends and had been studying ballet together since they were both three. As they milled around with the crowd at a sidewalk sale in front of the local Woolworth’s, little Christine began tugging at her mother’s hand to attract her attention to the pony rides on the other side of the street, begging to be taken over there. Leaving Katie with the others, Joan and her younger daughter crossed the road toward the concession. Just as they reached the opposite sidewalk, Joan heard a hubbub from somewhere behind her and then a child’s shrill scream. She turned, dropped Christine’s hand, and advanced a few feet toward the sound. People were scattering in all directions, trying to get away from a large, disheveled man who stood over a fallen little girl, his outstretched right arm pummeling furiously away at her. Even through the haze of her frozen incomprehension, Joan knew instantly that the child lying on her side at the crazed man’s feet was Katie. At first, she saw only the arm, then realized all at once that in its hand was clutched a long bloody object. It was a hunting knife, about seven inches long.
Using all his strength, up and down, up and down, in rapid pistonlike motions, the assailant was hacking away at Katie’s face and neck. In an instant, everyone had fled—murderer and victim were suddenly alone. Unhindered at his frenzied work, the man first crouched and then sat alongside the child, chopping with those ceaseless plungings of his ferocious arm. As the pavement reddened with her child’s blood, Joan, by then also alone, stood about twenty feet away, rooted there by disbelief and horror. She would later remember that the air seemed too thick to let her move through it—her body felt warm and benumbed, and she was enveloped in a dreamy mist of insulation.
Except for the ferocious chopping of that unremitting arm coming down again and again on the silent child, there was almost no movement in the entire unearthly scene. Anyone watching from inside the Woolworth’s or the refuge of some other concealment might have seen a grotesque tableau of madness and slaughter being enacted on that soundless street.
Though Joan was certain the macabre scene would have no end, her fixed immobility could not have lasted more than a few seconds, but during that seeming protraction of time she saw the knife repeatedly enter her child’s face and upper body. Two men suddenly appeared from somewhere beyond the margins of the tableau and grabbed at the killer, shouting as they tried to wrestle him down. But he could not be deterred—with psychotic determination, he kept stabbing at Katie. Even when one of the men began aiming powerful heavy-booted kicks at his face, he seemed not to notice, though his head was being knocked from side to side by the force of the blows. A policeman ran up and seized the knife-wielding arm; only then did the three men manage to subdue the struggling maniac and pin him to the ground.
As the crazed attacker was pulled off Katie, Joan rushed forward and took her daughter into her arms. Turning her gently over from her side onto her back, and looking into that lacerated little face, she said softly, “Katie, Katie” as if she were cooing to a cradled babe. The child’s head and her neck were covered with blood and her dress was soaked in it, but her eyes were clear.
She was gazing at me and beyond me, and there was a warm feeling in me. Her head had fallen back. Then I raised her a bit, and I thought she was still breathing. I spoke her name a few times and told her I loved her. And then I knew that I had to take her to a safe place—I had to get her away from this man, but it was already too late. I lifted her up in my arms. I carried her that way a short distance, and then I thought, What am I doing? Where am I taking her? I got on my knees and very gently put her down. Her chest began heaving and she started to vomit blood. It came out in such huge amounts, constantly—I didn’t think she would have so much blood in her; I knew she was emptying out the blood in her body. I screamed for help, but there was nothing I could do to stop the vomiting.When I had first gone to her, I saw some glimmer in her eyes, almost like some sort of recognition. But by the time I laid her on the ground, her eyes had a different look. Even when she was vomiting blood, they had changed to a more glassy look. When I first went to her side, she still looked alive—but not anymore.There was no look of pain in her eyes, but instead it was a look of surprise. And then when things changed, she still had that expression on her face, but her eyes had glazed over a little bit. A woman came over—I guess she was a nurse. She started CPR. I didn’t say anything, but I thought to myself, Why is she doing that? Katie is not in her body anymore. She’s behind me, up there above me, and floating. Her life isn’t inside her anymore, and she’s not coming back. Her body is just a shell now. At that point, everything was different than it had been when I first went to her side—I had an awareness that my daughter had died. I felt she was no longer in her body, that she was somewhere else.The ambulance came, and they lifted her out of the pool of blood and tried to force air into her lungs with an Ambu bag. Her eyes were still wide open and she still had that glassy look. The look on her face was a look of utter surprise, like “What’s happening?” It was a combination of being helpless, confused, and surprised, but definitely not a look of horror, and I remember being relieved that it wasn’t, because I was looking for any sense of relief at that time. . . .Later, I went through months and months of asking myself, How much pain did she feel? I needed to know that. I saw her bleed all the blood out of her body when she vomited. Her chest and face were covered with cuts and gashes. She must have been moving her head from side to side, struggling to get free of this man. Later, I found out that he had appeared from nowhere and pushed Laura aside. He had grabbed Katie’s hair and thrown her to the ground. It was Laura who screamed, not Katie. I had to know what she went through, what she felt. . . .Do you know what it looked like? It looked like a release. After seeing him attacking her that way, it gave me a sense of peace to see that look of release. She must have released herself from this pain, because her face didn’t show it. I thought, Maybe she went into a state of shock. She looked surprised but not terrified—as terrifying as it was for me, it wasn’t that way for her. My friend Susan saw the look, too, and said that maybe Katie had given up, but when I told her I thought it was a look of release, she said, “That’s it, you’re right!”We once had a portrait of her made, and it’s that same look that she has in her eyes. They were wide but not in a state of terror—it looks almost like an innocence—an innocent release. As her mother, amidst all of that blood and everything else, it was actually soothing to look into her eyes. There came a point when I was with her that I felt like she was out of her body, floating up there looking down on herself. Even though she was unconscious, I felt that somehow she knew I was there, that her mother was there when she was dying. I brought her into the world and I was there when she was leaving—in spite of the terror and horror of it, I was there.
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