Joan Didion - The Year of Magical Thinking

It is the blight man was born for.

We are not idealized wild things.

We are imperfect mortal beings, aware of that mortality even as we push it away, failed by our very complication, so wired that when we mourn our losses we also mourn, for better or for worse, ourselves. As we were. As we are no longer. As we will one day not be at all.

Elena’s dreams were about dying.

Elena’s dreams were about getting old.

Nobody here has not had (will not have) Elena’s dreams.

Time is the school in which we learn, / Time is the fire in which we burn : Delmore Schwartz again.

I remember despising the book Dylan Thomas’s widow Caitlin wrote after her husband’s death, Leftover Life to Kill. I remember being dismissive of, even censorious about, her “self-pity,” her “whining,” her “dwelling on it.” Leftover Life to Kill was published in 1957. I was twenty-two years old. Time is the school in which we learn.

At the time I began writing these pages, in October 2004, I still did not understand how or why or when John died. I had been there. I had watched while the EMS team tried to bring him back. I still did not know how or why or when. In early December 2004, almost a year after he died, I finally received the autopsy report and emergency room records I had first requested from New York Hospital on the fourteenth of January, two weeks after it happened and one day before I told Quintana that it had happened. One reason it took eleven months to receive these records, I realized when I looked at them, was that I myself had written the wrong address on the hospital’s request form. I had at that time lived at the same address on the same street on the Upper East Side of Manhattan for sixteen years. Yet the address I had given the hospital was on another street altogether, where John and I had lived for the five months immediately following our wedding in 1964.

A doctor to whom I mentioned this shrugged, as if I had told him a familiar story.

Either he said that such “cognitive deficits” could be associated with stress or he said that such cognitive deficits could be associated with grief.

It was a mark of those cognitive deficits that within seconds after he said it I had no idea which he had said.

According to the hospital’s Emergency Department Nursing Documentation Sheet, the Emergency Medical Services call was received at 9:15 p.m. on the evening of December 30, 2003.

According to the log kept by the doormen the ambulance arrived five minutes later, at 9:20 p.m. During the next forty-five minutes, according to the Nursing Documentation Sheet, the following medications were given, by either direct injection or IV infusion: atropine (times three), epinephrine (times three), vasopressin (40 units), amiodarone (300 mg), high-dose epinephrine (3 mg), and high-dose epinephrine again (5 mg). According to the same documentation the patient was intubated at the scene. I have no memory of an intubation. This may be an error on the part of whoever did the documentation, or it may be another cognitive deficit.

According to the log kept by the doormen the ambulance left for the hospital at 10:05 p.m.

According to the Emergency Department Nursing Documentation Sheet the patient was received for triage at 10:10 p.m. He was described as asystolic and apneic. There was no palpable pulse. There was no pulse via sonography. The mental status was unresponsive. The skin color was pale. The Glasgow Coma Scale rating was 3, the lowest rating possible, indicating that eye, verbal, and motor responses were all absent. Lacerations were seen on the right forehead and the bridge of the nose. Both pupils were fixed and dilated. “Lividity” was noted.

According to the Emergency Department Physician’s Record the patient was seen at 10:15 p.m. The physician’s notation ended: “Cardiac arrest. DOA — likely massive M.I. Pronounced 10:18 p.m.”

According to the Nursing Flow Chart the IV was removed and the patient extubated at 10:20 p.m. At 10:30 p.m. the notation was “wife at bedside — George, soc. worker, at bedside with wife.”

According to the autopsy report, examination showed a greater than 95 percent stenosis of both the left main and the left anterior descending arteries. Examination also showed “slight myocardial pallor on TCC staining, indicative of acute infarct in distribution of left anterior descending artery.”

Iread this paperwork several times. The elapsed time indicated that the time spent at New York Hospital had been, as I had thought, just bookkeeping, hospital procedure, the regularization of a death. Yet each time I read the official sheets I noticed a new detail. On my first reading of the Emergency Department Physician’s Record I had not for example registered the letters “DOA.” On my first reading of the Emergency Department Physician’s Record I was presumably still assimilating the Emergency Department Nursing Documentation Sheet.

“Fixed and dilated” pupils. FDPs.

Sherwin Nuland: “The tenacious young men and women see their patient’s pupils become unresponsive to light and then widen until they are large fixed circles of impenetrable blackness. Reluctantly the team stops its efforts…. The room is strewn with the debris of the lost campaign…”

Fixed circles of impenetrable blackness.

Yes. That was what the ambulance crew saw in John’s eyes on our living room floor.

“Lividity.” Post-mortem lividity.

I knew what “lividity” meant because it is an issue in morgues. Detectives point it out. It can be a way of determining time of death. After circulation stops, blood follows the course of gravity, pooling wherever the body is resting. There is a certain amount of time before this pooled blood becomes visible to the eye. What I could not remember was what that amount of time was. I looked up “lividity” in the handbook on forensic pathology that John kept on the shelf above his desk. “Although lividity is variable, it normally begins to form immediately after death and is usually clearly perceptible within an hour or two.” If lividity was clearly perceptible to the triage nurses by 10:10 p.m., then, it would have started forming an hour before.

An hour before was when I was calling the ambulance.

Which meant he was dead then.

After that instant at the dinner table he was never not dead.

I now know how I’m going to die, he had said in 1987 after the left anterior descending artery had been opened by angioplasty.

You no more know how you’re going to die than I do or anyone else does, I had said in 1987.

We call it the widowmaker, pal, his cardiologist in New York had said about the left anterior descending artery.

Through the summer and fall I had been increasingly fixed on locating the anomaly that could have allowed this to happen.

In my rational mind I knew how it happened. In my rational mind I had spoken to many doctors who told me how it happened. In my rational mind I had read David J. Callans in The New England Journal of Medicine: “Although the majority of cases of sudden death from cardiac causes involve patients with preexisting coronary artery disease, cardiac arrest is the first manifestation of this underlying problem in 50 percent of patients…. Suddencardiac arrest is primarily a problem in patients outside of the hospital; in fact, approximately 80 percent of cases of sudden death from cardiac causes occur at home. The rate of success of resuscitation in patients with out-of-hospital cardiac arrest has been poor, averaging 2 to 5 percent in major urban centers…. Resuscitation efforts initiated after eight minutes are almost always doomed to fail.” In my rational mind I had read Sherwin Nuland in How We Die: “When an arrest occurs elsewhere than the hospital, only 20 to 30 percent survive, and these are almost always those who respond quickly to the CPR. If there has been no response by the time of arrival in the emergency room, the likelihood of survival is virtually zero.”