As a boy growing up in a small town in western Pennsylvania, I never gave much thought to the concept of a kiss. My family was very loving, and I gave and received kisses to my family members without hesitation. It was simply a sign of affection that was unencumbered by societal norms. I continued to give and receive kisses from my wife and kids in the same nonchalant manner. That is, until one night, on shift.

I work in the ER of a medium sized town in southern Oregon. Here, I see a reasonable mix of medical and traumatic emergencies with a fair amount of pediatrics, obstetrics and geriatrics.

It’s late into my shift, perhaps an hour to go before I finish. The next morning, I am leaving for a much-anticipated vacation with my family to Disneyland. I’m just trying to make it to the end of this shift. Then, the radio call comes in: “Helicopter en-route, thirty-two-year-old male, gunshot wound to the head, thought to be self-inflicted, airway has been a nightmare, still has a pulse, be there in three minutes.”

At this point in my career I don’t find myself getting nervous about these cases like I used to. I’ve realized that most situations are going to play out in the way nature intended. I realize that I can only control so much. I know my abilities and try to stay focused on the immediate, critical tasks. In this case, it sounded the like the airway was going to be the initial challenge.

The usual prep ensues. Respiratory therapists arrive to help me setup. Nurses pull the trauma packet and prep IV’s, cardiac monitor, pulse-oximetry. And then, we wait. The staff is visibly nervous anticipating the unknown. Despite the expertise that each staff member brings, it’s the unknown that can make even the best medical providers feel a sense of angst. I sometimes try to use these opportunities to remind myself and the staff of a few guiding points. First, we can’t control everything. We weren’t there when the shot was fired, we are simply trying to make the best of a bad situation. Second, the staff is quite skilled and needs to remain confident in those skills. Third, minimize the number of individuals in the room and only speak when necessary. This helps decrease the chaos that is sure to ensue. And lastly, and perhaps most importantly, I tell the staff that I believe in them. And I do.

The patient rolls in. He looks horrible. His head has an entry wound at the right temple area and an exit at the contralateral temple. Both sides of his head are swollen. Blood is everywhere. It is caked in his hair and on his head. It covers his face, neck and shoulders. His mouth is full of blood that we aggressively suction. We go through the initial assessment. The primary trauma survey is straightforward. Focus on airway, breathing and circulation followed by neuro assessment and exposure. The airway stops us.

He has an endotracheal tube in place, but the paramedics had to cut the top off due to limited space on the helicopter. It is not functioning well and needs to be replaced with a longer tube that will stay secure. At first, I try to look with our Glidescope. This is a fiberoptic laryngoscope that visualizes the vocal cords and projects the image to a 7” LCD screen. No go. Too much blood for the fiberoptic scope–once it smears you can’t see anything. I then look with the traditional laryngoscope. Surprisingly, after a lot of suctioning, I can see his vocal cords. If I let up on suctioning, the fast running blood blocks my view. I do my best to quickly pass the tube before the field teems with plasma once again. As the scope approaches the cords, the blood forces me to pass the tube blindly. I hope it is still in the appropriate location. Confirmatory measures look good. A repeat chest x-ray shows the depth of placement to be adequate. Looking back at the patient, his face remains a bloody mess, but at least the tube is in.

Next, I am anxious to get the patient to the CT scan. I want to see the extent of intracranial and facial trauma. However, his vital signs (blood pressure, pulse, etc.) begin to deteriorate. While unstable, we can’t transport him the short distance from the ER trauma bay to the CT scanner across the hall. His blood pressure is rising to a very high level and his heart rate is decreasing; a phenomenon known as the Cushing Response. This is usually a bad sign since it generally means that the pressure inside the cranial vault is so high that the brain tissue is being compressed and is beginning to herniate through the bottom of the skull. This almost universally leads to death. There are things that can be done to try to counteract this situation. You can raise the head of the bed 30 degrees, you can administer a medicine called Mannitol which helps drain that pressure and you can optimize ventilations which decreases the volume of blood delivered to the brain, thus relieving pressure. None of this usually works, but we must try.

I order it, but it doesn’t matter. His heart begins to slow further and eventually we lost his pulse. His cardiac rhythm shows flatline. We begin treatment with powerful cardiac drugs–starting with epinephrine. For a period of time, his heart begins to fibrillate. We attempt to shock his heart with electricity and use medicines designed to stabilize the heart such as Amiodarone. Eventually we get his heart rhythm back to a normal rhythm, but despite this, his pulse does not return. He goes in and out of various non-perfusing rhythms. Essentially, he receives a lot of medicine, but is not experiencing a return of an adequate pulse.

As I was ordering these treatments, I am told by the nursing staff that the wife and family have arrived. She wants to know where to put them. I freeze. A wave of nausea comes over me as I envision the drama that might occur. In 2000, the American Heart Association recommended the option of Family Presence During Resuscitation (FPDR). Although the studies from academic centers showed that families want to be present and would make the same choice again, it has been slowly adopted in the medical community. As I finished residency, I was fortunate to train at a center that encouraged this option. I will admit that I was uneasy with the idea at first. Let’s be real, you are working on a critically ill patient who is actively coding, and their family member is standing over your shoulder watching your every move (or so it seems). As time went on, I became more and more comfortable with the practice and have attempted to practice it on most, but certainly not all, occasions. I try to gauge the psychological coping skills of the family members as well as the patient’s specific situation to predict whether it is a reasonable option. We usually have around fifteen seconds to make this decision.

Was this a reasonable option? Hard to say. The patient had just attempted suicide and the shock of the trauma may be too much for most to bear. I decide to talk to the family just outside the curtain of the trauma bay where I can still keep my finger on the pulse of the ongoing code and interact with the family. I am hoping this will allow me ample opportunity to assess the family. The wife is in her early thirties, brown hair, combed in a straight style reminiscent of the late 1960‘s with matching granola attire right down to the Birkenstocks. Despite her tears, she appears more determined than most individuals faced with this daunting situation. The parents were in their mid-fifties and appear to be the antithesis of their daughter-in-law. They are dressed in business attire and could hardly stay standing due to the understandable stress of the situation. After a short interaction it is clear that the wife may be able to enter the trauma bay, but the parents would likely do better outside the room. As soon as I suggest this, they look at each other and agree.

I open the curtain to the trauma bay and lead her in. She is trying to remain strong and I notice that she is holding on to stationary objects as she passes them. I offer her a chair and she declines. She goes to the head of the bed and is visibly searching for a way to connect or touch her husband, who is now underneath a tangle of IV’s, cardiac telemetry wires, ventilator tubing and pacemaker pads. An ER tech is standing on a step stool leaning over the patient to perform chest compressions. Every time he compresses the chest, the patient billows down in a V like fashion and then recoils afterward-causing blood to splatter. Most of the staff have blood on their pants and shoes at this point. The floor is soaked, and staff are throwing down towels to soak up the slippery plasma. Two respiratory therapists are at the head of the bed bagging the patient.

It is apparent that she doesn’t quite know how to connect with her husband–but needs to–in a concrete, physical way. Her eyes continuously scan the upper portion of his body looking for a way to interact, but, finding none, looks sad and perplexed. She leans over her husband’s face, a few inches from the endotracheal tube exiting his mouth and whispers, “I’m here, I love you.” She remains in this awkward position as the code continues.

As time goes on, it becomes clear that our efforts are futile. The patient’s heart has not been beating for some time despite receiving multiple rounds of cardiac medicines in order to revive him. Although it is clear to the ER staff and myself that he is not going to respond to additional efforts, I don’t yet have the heart to terminate the code with the wife at the bedside. Even though he is, in all reality, already dead, my pronouncement of the time of death would be the signal to the wife that her husband is really deceased. I dread this moment and wish another ER doc could have been working this code instead of me. I wait and continue the resuscitation a few minutes longer until the staff are about to revolt. Despite how uncomfortable this moment would inevitably be, it is time.

I turn to the staff and ask my usual, preparatory inquiries: “Does anyone have any thoughts or further recommendations about how to treat this patient?” I further enquire, “Does anyone objects to terminating the resuscitative efforts?”

It is at this moment that the patient’s wife turns to us. She realizes that the moment is imminent. She knows that this would be the last time on this earth that her husband would be officially alive. She then turns back to her husband and positions her head nose to nose with him. She whispers, “I’m here. I love you.” Then, with the endotracheal tube exiting his mouth and blood caking his face and lips, she leans in and kisses him on the lips. It is genuine, affectionate and unburdened by what anyone thought. She makes the connection with him that she so badly needed since she entered the trauma bay. She does it on her terms despite the insanity of the circumstances. This was a sincere sign of affection that was unencumbered by societal norms. The room is silent with the exception of the ventilator hum. No one dares speak. Despite the variety of backgrounds represented in this room, we are all sanctified by the same spirit. It is a holy moment. You can tell that she wants it to last forever and in some small way we do too, but she realizes the impracticality of that unverbalized request. She finishes her kiss and turns toward us. She looks right at me and nods her head gently, acknowledging the inevitable.

I call the code at 0131 hours. I thank everyone for their efforts. I ask the nursing staff to clean and prep the body for the parents to come in. Multiple nurses are assisting the wife. She is cared for with deep respect.

I’ll never know what events led to such a profound feeling of desperation strong enough to cause this man to kill himself. What I do know, without hesitation, is that he was loved on this earth by at least one person. And now, as I kiss my wife or kids ‘goodnight’ or ‘good morning’ or ‘just because,’ I do so with a slightly different tenor. I understand, with a little more depth, what a kiss can signify.

Lee Milligan was raised in Erie, Pennsylvania and graduated from George Washington University School of Medicine in 1997, and UCLA Emergency Medicine internship/residency in 2000. He graduated with a degree in Spanish from the University of Utah. During his 20+ year ER career, he has worked as an Attending Emergency Physician in several locales including Rogue Regional Medical Center (trauma center in Medford, OR), Ashland Community Hospital and Three Rivers Hospital in Grants Pass, OR. In addition to his clinical duties, he has pursued a separate professional endeavor of optimizing technology within the healthcare space and has held various roles including Medical Director of Informatics, Chief Medical Information Officer and now currently serves as the Chief Information Officer for Asante Health System. Dr. Milligan met his wife Jennifer in graduate school, and she is a certified PA in Allergy & Asthma; together they are raising 4 children: Sean, Jake, Molly and Danny. In his free time, he enjoys writing and spending quality time with his family in the Pacific Northwest outdoors—hiking, road bicycling and riding motorcycles.