Episode 46.1: Unimaginable Goodbyes

In lifetimes filled with every type of goodbye, some can be almost too painful even to contemplate.

The Last Chance Democracy Café
Episode 46.1: Unimaginable Goodbyes

by Steven C. Day

I don’t believe in omens; I never have. Believing in any form of premonition, after all, means accepting that our fates are at least in some fashion predestined, which is really more the philosophy of an old-time Calvinist preacher, than of a politically liberal tavern owner. I have to admit, however, that sometimes, when you look back, and you see just how clearly one event seems to foretell another, well, it’s hard not to wonder.

* * *

It had started out as an ordinary enough fall evening, as I headed out on my rounds to pick up Horace, Tom, Winston and Zach to bring them back to the café for our usual Wednesday night festivities. It was cold and overcast, with a small dusting of snow barely visible on the grass, and totally absent from the streets; with the wind calm, it wasn’t the sort of snowfall one would expect to cause any real damage — other than, of course, for the usual scattering of fender benders that seems always to accompany even a single flake of snow.

So it was a bit of a shock to see a dozen or so city vehicles, with flashing yellow lights, no less, sitting smack-dab in front of The Last Chance Democracy Café. After a momentary panic, while visions of exploding gas lines in the kitchen danced through my consciousness, I realized what the problem was; the old oak tree in the lot across the street from the café had come down, taking some power lines with it. It was blocking the street and traffic was backing up.

I know my way around this neighborhood like Bill Bennett knows his way around a $500 slot machine, so I had no trouble avoiding the mess by steering down the back streets to the rear of the café. After dropping everyone off, I walked slowly over to the edge of the street to get a better look, feeling slightly embarrassed about becoming one of the usual crowd of gawkers who surround every minor disaster. The crews were well along in their work, sawing the giant trunk into manageable pieces and then using heavy equipment to drag them over to the side of the road: Hauling them off was apparently to be the landowner’s responsibility.

The road was cleared within 30 minutes of my arrival, with the crews packed and gone soon after — leaving behind a huge mound of hacked up and broken wood, and a giant hole in the sky.

I really can’t explain why this scene made me feel as sad as it did. It wasn’t an attractive tree at all, missing one of its major branches — a casualty of an earlier storm — and in general looking worn out and even diseased, with a sickly yellow mold covering at least half of its trunk: For years, it had been more of an eyesore than a testament to God’s wonder.

But I’ll give it one thing: It was a survivor. Almost surely one of the oldest trees in the city, having stood perhaps 200 years, it had survived violent storms, lighting strikes, several sideswipes by cars and innumerable private landscaping and public urban renewal projects. And now it had been brought down by a mere dusting of snow.

* * *

An hour of conversation at the large round table did much to improve my spirits: It almost always does. The discussion hadn’t settled into any particular topic yet — that generally comes later; for now it was just the usual right-winger bashing. Winston was in rare form, enthusiastically arguing his new theory that Ann Coulter and Pat Robertson are actually the same person. It was tongue-in-cheek, of course, but he made a compelling case just the same.

As I was laughing, I happened to look over at Horace; something didn’t seem right. For one thing, he was holding himself more rigidly than usual, and he was stroking his left arm from time to time.

“Horace, are you feeling okay?” I asked across the table.

“Yeah . . . I’m fine,” he said with uncharacteristic terseness.

I thought he sounded just a little short of breath.

I followed up more forcefully, “Really, Horace, what’s going on?”

I guess there must have been concern in my voice, because everyone else at the table turned in his direction.

“I said I’m fine,” he replied irritably — again extremely uncharacteristic for Horace.

I was starting to get scared. “Turn up the lights,” I barked at Samuel, the bartender.

“Whoa,” “damn” and similar protests floated across the lounge as the lighting flashed from dim to ultra-bright in the flip of a switch.

Sometimes heart attacks are hard to recognize. Talk to any experienced emergency room doctor and they’ll tell you stories of the old guy who came in with nothing more than an earache, or of the middle aged women who complained of a toothache. And they’ll tell you that any pain from the belly button all the way up to the top of the head can, at least conceivably, come from the heart. Occasionally there isn’t even pain; just a little shortness of breath, or even nothing more than a strong sense of anxiety combined with a general feeling of not being well. This makes acute coronary syndrome, as they call it in the business, extremely hard to diagnose in some emergency room cases, a situation often made worse by the tendency of some patients, especially middle aged and older men, to understate and deny their symptoms.

But then there are also other patients who come in all but wearing a sign around their necks reading, “I’m having a heart attack.” And as I looked at Horace sitting there as pale as I’ve ever seen him, sweating profusely and clearly in pain, I almost thought I could see the outlines of that sign.

Winston spoke sternly. “Horace, does your chest hurt?”

“I think it’s just indigestion.”

“Your left arm . . . you’re holding it, does it hurt?”

“Not bad, I’m fine. It’s nothing.”

“Call an ambulance,” ordered Tom.

Horace sat up angrily in the chair. “I don’t need a damned ambulance! Just give me a minute! I’ll be fine, I tell you!”

“Call now!” Winston snapped his finger at Samuel, who reached for the phone.

“Fuck it! I tell you I don’t need a God damned ambulance! I’m going home!” Horace stood up and started to back away from the table.

I knew that hostility can sometimes itself be another sign of a heart attack. But I didn’t know what to do. The truth is, I was freaking out. Finally, I blurted, “I’ll make you a deal. No ambulance, but you’ve got to come with me right now in the van to the hospital to get checked out.”

“No, call 911,” Tom wisely insisted.

But I was committed. “No, it’s only five miles. It will be faster anyway. How about it, Horace, it’s that or the ambulance?”

Still looking angry, he relented. “Okay, fine, I’ll go . . . but you’ll see, you’re making a mountain out of . . . I’m fine. It’s just a little indigestion.”

I shouted something to Samuel about locking up, and a second later we were flying through the streets, Molly driving, with Tom, Winston, Zach and I in the back with Horace. I stared at him, the best I could in a dark van, the whole way to the hospital, as the headlights of approaching cars danced by in my peripheral vision.

And I just kept thinking: God, why was I so stupid? EMS could have been there in four minutes, maybe less, ready to handle anything. Now if he has an arrhythmia here in the van, he may be dead before we even get to the hospital. And it will be my fault. It will all be my fault.

* * *

Goodbyes are funny things. The word has so many different meanings depending on context. Some goodbyes are perfunctory, like the quick farewell before hanging up the phone, or the see you tomorrow to fellow workers as you head home for the night.

Other goodbyes grow out of irritation, as with a persistent telephone salesperson: “Goodbye, I said goodbye!” Slam!

Some are actually happy occasions, as when we bid adieu to relatives who have overstayed their welcome: “Goodbye! Thanks for coming! We love you! . . . Okay, they’re gone now, thank God!”

Then there are sweet goodbyes. Your little boy says goodbye to a little girl in his daycare class: “Bye, bye. See you ‘morrow.”

A lot of goodbyes are at least a little sad, of course: A good neighbor moves away; a child heads off to college.

And some can be sad and happy at the same time; a child is sad to be saying goodbye to a favorite teacher; but, hey, it’s summer time!

Then there are the goodbyes that crush the soul.

Of the five of us crammed into the back of the van, Zach and I had been the least abused by death so far. Not surprisingly for a 22-year-old, Zach had never lost anyone particularly close to him. And at age 50, while I was a little less of a virgin in the death sweepstakes having lost some friends and relatives along the way, I had never experienced the death of a person in my inner circle. Not someone like Horace.

Horace, Tom and Winston, on the other hand, had all paid the expected blood price for admission into the ranks of the elderly. It was Horace, however, who had paid the most dearly. Over his 74 years, he had survived the death of both of his parents, a brother and a sister, his son Lester, killed in Vietnam, his beloved wife, now three years gone, and, of course, numerous friends. The deaths of his son and his wife especially affected him; I knew that much. But beyond that Horace’s attitude about death was pretty much a mystery to me; he’s of the generation that doesn’t talk much about such things.

As I watched Horace’s dim outline bouncing up and down in the dark, as Molly busted every traffic regulation in the book rushing us to hope, one thing I did know for certain, or as close to certain as one can be about the contents of another’s inner spirit, was that death didn’t frighten him. He was, as they say, at peace with mortality.

I wish I could say the same. The truth is death scares the hell out of me. And not just my own. Because fate isn’t just stalking me; it stalks also the people I love.

Those are the unimaginable goodbyes — the ones you can barely make yourself even consider.

And one of the great cruelties of life, of course, is that the fact that some goodbyes are just too awful to even imagine, reduces not by one iota the certainty that they will, indeed, eventually come — and the very real possibility that they may come much sooner than we expect.

* * *

As we drove into the emergency department parking lot, I could tell immediately things were going to be nuts inside. Private cars were overflowing the designated spaces, with others still circling, looking for spots, and no less than three ambulances were parked in the ambulance zone.

This is one of the biggest difficulties in running an emergency room: You never know when you’re going to get swamped. An early Wednesday evening like this, for example, would generally be expected to be a comparatively slow time. The real craziness usually doesn’t get started until much later at night — especially during weekends. But you never know. And it can change on a dime.

Molly dumped us at the entrance and drove off in search of parking. As we hurried into the ER, we immediately encountered a line of five or six people already ahead of us waiting to check in at the triage desk.

I knew the drill well, from back in my days as a medical lawyer. First, the patient is seen at the desk, sometimes by the triage nurse, but often by an assistant, who takes down the patient’s name and complaint. Assuming it’s not an obvious extreme emergency, the patient waits in turn to be seen for the full triage; the triage nurse then obtains the history of the presenting complaint, takes the vital signs and codes the case into one of three triage categories: Emergent, urgent or non-urgent.

Emergent cases, those thought to pose a fairly immediate risk to life or limb, go back into the treatment area immediately, or nearly immediately, no matter what else is going on. Urgent cases are those involving serious conditions, but ones that are not thought to pose an immediate threat to life or limb; they also get priority, but on a busy night may still have to wait upwards to a couple of hours to be seen. Non-urgent cases represent everyone else; on a really busy night, non-urgents may have to wait six-to-eight hours or longer to be seen in some emergency rooms.

We had been standing at the back of the line for no longer than five seconds — ten tops — when Winston took matters into his own hands, walking up to the desk and announcing in a loud clear voice, “We have a 74-year-old man having a heart attack back here.”

At that very moment, in the small triage exam room right next to the reception desk, Mary Louise, a 43-year-old concert pianist with the local symphony, who five hours later would be diagnosed with gallstones, looked up to respond to a question from the triage nurse regarding the location of the pain: No one was there.

“What’s your name,” the triage nurse with the nametag that read, “Heather C., R.N.,” asked Horace in a business like voice.

“Horace. But I don’t need to cut in line. I’m fine.”

“Where does it hurt, Horace?”

“Really, I’m fine.”

“Tell me where it hurts?”

He pointed to his chest.

“Does it go into your arm?”

“A little, but I’m . . .”

“How long has this been going on?”

“Maybe 20 minutes. But it’s . . .”

Nurse Heather C. turned to speak to the unit clerk behind her. “Get a gurney please.”

Horace wasn’t quite ready to give up. “Really, I can wait my turn.”

“We don’t take turns here, Horace. People go back in the order they need to be seen; and you need to be seen now.”

And that was that. The nurse asked that only two of us go back with him. “It’s pretty crowded back there,” she said in the understatement of the young millennium. Molly, who had now arrived after parking the van, suggested Tom and Winston.

“No,” said Winston. “Steve and Zach should go.” I was a pragmatic selection; Winston knew I had some medical knowledge. He suggested Zach, I’m sure, because Zach was, well, in a very real sense, Zach had become Horace’s son.

* * *

There had always been something fine — inspirational, really — about Zach’s relationship with all three of the wise men, as I call them. He was a young, popular and initially entirely apolitical pre-dental student, who somehow allowed himself to fall under the spell of three cantankerous septuagenarians. And, my, how that relationship had changed everyone touched by it. Zach pumped life into the three “old timers” as surely as a good burst of helium pumps up a child’s balloon; and as for Zach himself, he had always been a fine young man, but now he was a fine young man with depth and fire.

Zach’s relationship with Horace, in particular, however, had always been something more. They were family.

But then, Horace was special to me, too. He, Tom and Winston generally only come into The Last Chance Democracy Café once a week, on Wednesday evenings, but they’re unquestionably the soul of the place. And Horace had always been the linchpin of the group: Without him, Tom and Winston would eventually drift away.

* * *

They didn’t take Horace all the way back to a patient room; they had to park him in the hall. All of the regular beds were full, the nurse told us. They’d try to get something open as quickly as possible, but it might be a little while. There were eight other gurneys in the halls — and those were the ones I could see. There may have been more.

This wasn’t actually all that surprising. Every well managed emergency department has an overflow plan: Designated places to store the extra bodies when the inn is full.

A young, squat, round faced doctor, with blond hair, who looked almost old enough to be able to legally drink beer, walked up and spoke. “Hi, I’m Doctor Dugan . . .”

Even in the midst of my anguish and panic, I couldn’t help but wonder how many times a day during his career this probably 30-year-old baby faced healer, with the unfortunate last name of Dugan, had been jokingly referred to as Doogie Howser, M.D.

“. . . So you’re having some chest discomfort?”

“Yeah, a little.” The fight was out of Horace. I’m sure he had actually known the score all along: Now, he was finally admitting it to himself.

“We need a monitor on this patient, stat.”

“They’re all being used . . .” replied a nurse with the nametag of Janet L. R.N., who had taken over for Heather C., who had returned to the triage desk.

“Take one from the patient in 4B, he’s stable . . . But I want vitals every five minutes.”

“Horace,” began Dr. Doogie Howser (he was Doogie Howser to me for the rest of the evening), “we need to check you out on the EKG monitor, but you have most of the classic signs of an acute cardiac event. Really, regardless of what the EKG shows, we will need to take you to the cath lab and have one of the cardiologists check out your heart and your coronary arteries. Do you understand?”

“Yes, I do.”

“And I’m sorry to have to tell you this, but we’re totally swamped tonight . . .”

“I noticed.”

“Right. We have three other coronary cases going; so it’s going to be awhile before we can work you in. But we’ll keep you monitored in the meanwhile; give you some medicine to help fight clotting and something for the pain. And we’ll give you a little oxygen to help you breath.”

“Okay, thanks doc.”

“Now, I have to tell you, the medicine I’m proposing giving you carries a small risk of causing a cerebral bleed, or in other words a stroke. And if that happens it can be fairly devastating. I think it’s clearly in your best interests to take it, but I need your consent.”

“Do what you have to do.”

Another nurse, whose nametag I didn’t notice, wheeled up the mobile EKG monitor; she quickly unbuttoned Horace’s shirt and attached the leads.

Dr. Doogie Howser studied the monitor for a few moments. “Yeah, there’s evidence here of significant cardiac ischemia, all right . . . that means not enough blood is getting to your heart . . .”

The first hint of fear appeared in Horace’s voice, as he asked, “So, it’s a heart attack then?”

“It’s an acute coronary event, almost certainly. Whether it’s a full fledged myocardial infarction we won’t know until the cardiac catheterization is completed. Try to take it easy, we’ll know soon enough.” Then he was off seeing other patients.

To me, Horace seemed worse. Frankly, I was scared to death and I knew Zach must be too. “It’s going to be alright,” I told him, trying with all my might to sound like I really believed it.

* * *

Parked next to us in another gurney in the hall was a two-year-old girl named Sarah, there with her mother, Judy. Following a six hour wait, Sarah had actually made it all the way into one of the patient rooms; but she was quickly evicted when a more serious case needed the space. That’s another part of the routine of emergency room management; when a patient is taking up space needed for a more critical patient, they get bumped — even if they’ve been waiting for hours.

Sarah had been suffering from vomiting and persistent diarrhea for several days from rotavirus, and she had now become badly dehydrated. An IV bolus was running. Dr. Doogie Howser, while checking on Sarah, right after leaving Horace, had chastised Judy mildly for waiting so long to seek help. “If you’d gotten her to the doctor earlier this might all have been prevented,” he told her, probably a little more sternly than he intended. “Now, we’re going to have to admit her overnight for observation.”

I was standing only three feet away; Judy was crying. She was very young, a single mother I later learned, no more than 21 or 22, with long unkempt brown hair, big bluish green eyes and a pasty complexion. She looked deathly tired, even more so than everyone else there in the ER, with dark rings around her eyes and sagging shoulders. Actually, she sort of reminded me of Maggie, the woman who used to clean the café and who was killed when she fell asleep driving home from one of her other jobs.

I wanted to say something to make Judy feel better.

“Don’t let it get to you too badly,” I said. “The same thing happened to one of my sons once. He was throwing up all the time from some bug just like your daughter . . . I mean, I know it’s just awful. We took him to the doctor right away, but the suppositories they gave him didn’t help. I guess sometimes they don’t. And he became dehydrated and we had to take him in to the hospital for an IV.”

“Thanks.” Judy rubbed the tears off her cheeks.

“And here’s another thing. An IV for a dehydrated child, as awful as putting it in is . . . I can tell you from personal experience, it’s nothing short of a medical miracle. I know your daughter, ah . . .”


“Sarah, what a pretty name . . .”

“Thank you.”

“Anyway, I know she’s a little lethargic now, but give it a little while and you’ll be amazed at the difference. You’ll have your old little girl back.”

I didn’t mention what a travesty it is that every year literally millions of children die in so-called Third World countries because they lack access to this simple life saving technology. Although it’s usually my tendency to preach about such things to anyone who’ll listen, and many who would prefer not to, I didn’t think she needed to hear that right then.

“So stop crying,” I told her with a smile.

She forced a small smile in return, but it didn’t last. “It isn’t just that. The thing is, I wanted to take Sarah to the doctor. I really did. But I don’t have the money. And now, my God, I suppose this is going to cost as much as six or seven hundred dollars . . .”

I didn’t have the heart to tell her it was going to be at least three times that amount.

“. . . and there’s no way I can pay that. It might as well be a million dollars.”

Everyone has heard about how emergency rooms are being clogged up with uninsured patients with conditions that could more properly be treated in a doctor’s office, because they simply can’t afford to obtain medical services in other ways. What many don’t realize, or at least think about, is that while it’s true that emergency rooms, unlike private doctors and clinics, can’t turn away uninsured patients, they do charge for their services — services that are much, much more expensive than comparable services would have been if provided in a doctor’s office, especially at an earlier point in the illness, before the patient became as sick. And hospitals, many struggling to survive, try to collect these charges. They demand payments, and if money isn’t forthcoming, they will sometimes sue people, take judgments and garnish wages. Which means, of course, that our nation’s dysfunctional health care delivery system doesn’t just deprive the poor of quality care, though it certainly does that; it also inevitably pushes them further and further into permanent debtor status. And now with so-called bankruptcy reform, their ability to get out from under that mountain of debt has been greatly impaired.

* * *

I had, of course, been keeping a close eye on Horace, who had been chatting a little with Zach, trying, I think, to make him feel less frightened. I decided to take the opportunity to sneak out to update the others. Walking into the waiting room was like walking onto the set of some later generation Mad Max movie, broken bodies everywhere. There was a woman, presumably suffering from a severe case of the flu, lying on a gurney moaning, while a fatigued companion loyally held under her chin one of those little hospital vomit bowls, shaped sort of like a crescent moon. Two babies, probably both with ear infections, were screaming inconsolably, as their parents, looking like particularly anguished zombies, paced back and forth with them. A teenager with a blown knee was sitting in the corner; another with a broken arm was perched two rows to the North, while Mary Louise, our concert pianist from the triage room, was sitting two seats away in excruciating pain from her gallbladder attack. And there were others. All waiting to be seen; waiting for that magical ticket into the back.

Welcome to Wednesday evening in the ER, the one place in the entire American health care system where, in its own crude way, democracy rules: We’re all equals there; businessmen and working poor alike, all desperately waiting for help.

I gave Molly, Tom, Winston and the at least a dozen other regulars and employees from the café who had come to the hospital on their own, a quick update. “We really don’t know much yet. He still seems to be holding his own. It’s taking forever.”

Then I turned to walk back into the treatment area. The second I passed through the large double doors the sight inside hit me like a tank slamming into a cardboard box: a crowd of medical providers was gathered around Horace. Zach was standing three paces back, seemingly in shock. As I ran up to him, the nursing director, at least that’s who I think it was, intercepted me and led both of us into a tiny closet like room, called the “family quiet room,” with a small couch and two straight back chairs. “Some one will be in to update you,” she said hurriedly, then left.

Zach stared at me in disbelief, as he started to say, “He just collapsed without warning. We were talking . . ,” Zach was starting to cry. “. . . We were talking, he was okay, and then just all of a sudden his neck jerked back and his eyes rolled up into his head. Some alarm went off, I think, and a bunch of people were all over him. I think he’s dead, Steve. I really think he’s dead.”

We could hear the commotion in the hall — commotion to us; another day at the job to them. “Clear,” somebody shouted. Then the crack of the defibrillator.

Zach and I were still staring at each other, each with a look of complete powerlessness: A look being shared by two people who were only beginning to struggle with the possibility of a huge hole in the sky.

* * *

When not busy managing a mythical café, Steven C. Day lives with his family in Wichita, Kansas where he has practiced law for 25 years. Contact Steven at scday(AT)buzzflash.com.

© Copyright Steven C. Day. WGAw #974001

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