BREATH SOUNDS | Blake Gregory
At two-thirty in the morning, my pager alarm shattered the stillness of the doctor’s workroom. My eyes burned from staring at a computer screen. The smell of stale coffee wafted from a corner table strewn with half-empty cups. I squinted down at my pager and read the message from a nurse: “Doctor, the patient in room 536 is having trouble breathing. Please come assess.” Routine though the call seemed, that page would upend everything I knew about being a doctor.
It was my sixth night shift in as many days and exhaustion had me moving at half speed. My limbs felt heavy when I stood up. I slogged toward the elevator as if wading through waist-deep water. Though I took my job seriously, my body ached for the comfort of my own bed.
As I waited for the elevator, I scanned the long list of patients I was covering that night. The woman in 536 was unfamiliar to me. The list had compacted her story into two lines: she was young—in her early forties— with advanced breast cancer. Earlier that day, her doctors placed her on “Comfort Care,” a treatment strategy reserved for patients at the end of life. The sole objective now was to keep her comfortable in her final hours. As I considered possible causes of breathing troubles in this patient, one diagnosis emerged as the most likely.
When people are close to death, they lose the ability to swallow and saliva pools in the back of the throat. Breathing becomes coarse, and gurgling accompanies each inhalation. Physicians refer to this as the “death rattle.”
The death rattle, alarming as it sounds, is not a sign of suffering. By this stage, patients are unconscious and lack awareness of their breathing. Loved ones, however, find the noise so distressing that doctors treat the symptom more for the family than the patient. Glycopyrrolate, an intravenous medication that dries up saliva in the throat, helps silence the haunting sound.
I was a newly-minted doctor, and those first months of my medical residency had been an immersion in death and dying. Death was so commonplace in the hospital it was almost mundane and repetition had begun to inure me to the horror of it. I was growing proficient at managing death’s relentless march.
As I strode down the hallway, I anticipated a routine clinical assessment: evaluate the patient, order the medication, and move on to others who needed my attention. I breezed by the brightly-lit nurses’ station and called out to the nurse: “I’m about to order glycopyrrolate for that patient.” The nurse, face lit by the glow of a computer screen, nodded nonchalantly.
The light grew dimmer as I made my way down the hallway. At the end, I found the room. I knocked on the door and entered, unprepared for what I would encounter.
The room was dark, illuminated only by a dim light running along the floorboard. As my eyes adjusted, I saw the patient lying still in a bed pushed up against the wall. With eyes closed, her unlined face was expressionless, as though she were in deep meditation. Many rounds of chemotherapy had left her completely hairless. An older woman, whom I inferred was the patient’s mother, stooped over the bed. Her hand grazed the patient’s cheek tenderly. The only sound punctuating the silence was a coarse gurgling emanating from the patient. I stood speechless in the doorway: I had just entered the hospital's loneliest room.
I had seen vigils for the dying before, but this one was different. Usually when a person is dying, friends and family rush to the bedside, traveling long distances on short notice to be there in the final moments. These impromptu gatherings are as much for the family as the patient. Most people agree that no one should keep a deathwatch alone.
And yet here was this woman, solitary witness to the death of her daughter: the daughter she had cradled as a baby, kissed goodbye on the first day of school, cheered as she crossed the stage to collect her college diploma. This mother now crouched alone in the dark, listening to the rattle of her daughter’s last breaths. The patient was beyond all help. Her mother was the one who needed comfort and care.
I took a few halting steps toward the bed. The door behind me swung shut, leaving us in near darkness. “Hello, I am coming to check on Eleanor. How is she doing?”
The mother looked up, hands trembling. It was clear she had been crying. Her words spilled out: “My daughter’s breathing is so loud. What’s happening? Is she in pain?”
A flood of shame washed over me as I realized no amount of glycopyrrolate could soothe the suffering in that room. The plan to dispatch a medication order and consider my job done had been a fool’s errand.
The situation demanded a different type of doctor. Medical school had not prepared me for this: I trained to treat patients, not their families. In the dark, I shuffled blindly toward the bed and sank into a chair across from Eleanor’s mother. Then, groping at my waistband, I did something I had never done before: I turned my pager off.
I placed my hand on top of Eleanor’s and said quietly, “I don’t think Eleanor is in any pain right now.”
The mother’s shoulders slumped and in one motion, she covered her face with her hands and wept. After a few moments, she took a ragged breath and laid her hands in her lap. Comforting words again eluded me.
As I looked over at the woman in the bed, I wished I had known her. What kind of person had she been? What was her story? I turned to her mother and said, “Tell me about your daughter."
The woman paused for a moment, staring down at the rumpled bed sheets. She reflexively reached out to straighten the blanket over her daughter’s legs. “When Eleanor was diagnosed with breast cancer, I fell apart. She stayed strong for both of us.”
Eleanor accepted her diagnosis and braved surgery, chemotherapy, and radiation. “She never complained about it,” the woman smiled, gazing at her daughter.
After several grinding months, doctors declared Eleanor cancer-free. She turned to advocacy for other women suffering from breast cancer. She organized fundraising events and threw herself into walks, raffles, and dinners to raise awareness. Her dedication made her much admired in breast cancer circles.
“Two years after they told her she was in remission,” her mother whispered, “Eleanor started getting back pain.” I bowed my head, realizing what this meant. Hearing Eleanor’s struggle made it hard to bear the inevitable conclusion.
“She tried to ignore it but the pain got worse.” A MRI showed that the cancer had returned. It was invading her spine, liver, and the lining around her lungs. More chemotherapy was futile but Eleanor tried it anyway, not yet ready to surrender.
Once it became evident that chemo was not touching the cancer and only causing horrendous side effects, “She just… let go,” the mother’s voice trailed off.
So Eleanor’s narrative ended, its conclusion so abrupt that I paused for a moment waiting to hear more. But there was no more: this was the story of life arrested in mid-arc, of hopes unfulfilled and work unfinished. We sat in silence. The darkness obscured my tears but the mother knew that I grieved with her.
Eleanor’s breathing grew quieter and the breaths came less frequently.
“How much time does she have left?” her mother asked.
“Not much time now,” I murmured.
“Thank you,” she said, hands now still. “Thank you for listening to Eleanor’s story.” She exhaled, the evenness of her breath a signal that she was prepared to face the end alone.
I squeezed Eleanor’s hand for the last time and walked out of the room. As I stepped into the hallway, the fluorescent lights above beamed like daylight. I reached down to my waistband and turned my pager back on. As I waited for the elevator, the sound of a new message beeped its trill: a new message, an invitation to participate in another person’s story.
One way to manage illness is to silence symptoms. When my pager summoned me to Eleanor’s bedside, I was determined to extinguish the sound of impending death. Ensuring a quiet exit seemed the compassionate thing to do.
Sometimes, though, healing lies in abiding with the noise: the stutter of breath faltering, the wail of a mother’s grief, the telling of a life’s story. Sometimes, a doctor’s charge is simple: to listen and to bear witness.
Blake Gregory is a primary care physician and the Associate Medical Director of an adult medicine clinic in Oakland, California. She believes in writing as a means of processing the joys and hardships of practicing medicine.