"I Pronounce This Patient Dead"
By Clifton Meador
It was my first night on call as a medical intern at Columbia Presbyterian. I was assigned to cover the private medical service in Harkness Pavilion. The year was 1955.
Harkness Pavilion was the hospital for the rich and famous of Manhattan and, I suppose, for much of the world at that time. Madame Chiang Kai-shek, for example, took over an entire floor when she came for her annual checkup. During the year of my internship, the private physicians admitted Elizabeth Taylor, Edward R. Murrow, Rex Harrison, and many other celebrities from Broadway, Hollywood, and the world of politics. It was one of the main U.S. hospitals for the royal families of Saudi Arabia.
I had lived all my life in the South, went to school there and medical school, too. New York City was a strange territory for me. Southerners were still looked down on as stupid and uneducated. The prejudice was at times palpable. I was a stranger in a very strange land.
Around 2 a.m., I was called to pronounce a patient dead. I jumped out of bed. We slept in our white uniforms, so we were always ready for calls.
After finding my way to the floor in Harkness, I met the nurse in the dimly lit hallway. She was very official, stern, and appeared to be older than my grandmother. Wearing a long white dress with a blue apron and large white nurse's cap, she was from another century. She looked like I imagined Florence Nightingale might have looked in her later years.
She peered over her glasses as she spoke to me. "Mr. Williams [not his real name] in room 553 quit breathing at 1:54 a.m. We need you to pronounce him."
This being my first official patient, my overriding fear was that I would make a diagnosis of death on a man who was still alive. In some Edgar Allen Poe-like ghoulish scene, I could imagine the poor man waking in horror in the morgue, calling out to some attendant, who would immediately call the chief resident, who would then call the chairman of medicine. I shuddered at the thought of being called into Dr. Robert F. Loeb's office to be told I that I could not tell a live person from a dead one. I would be banned forever and on my first night as a real doctor. I had only one thing on my mind when I walked into Mr. Williams' room: I would not make an overdiagnosis of death. I would make sure he was dead before I said he was dead. I had seen dead patients in medical school, but I had never had to say they were dead. My obsession with making an accurate diagnosis I am sure buried my deeper emotions of facing death. I displaced the thoughts that here was a person who only a few moments before was an alive human being.
I looked at the chest for several moments. No movement. Then I listened to his heart with my stethoscope for several minutes and at each valve area. No sounds. Then I felt for a pulse at his wrist, then his neck, then for a femoral pulse at his groin. Nothing. No pulse. I actually checked for rigor mortis, hoping to find it, but his joints were quite limber.
Then I remembered reading that after death, the arteries in the back of the eye change dramatically. I asked for an ophthalmoscope. While the nurse went for the scope, I went back over each pulse area, listened some more to the heart and even put my ear close to his nostrils, listening for any movement of air. I was becoming more and more confident that Mr. Williams was dead. More confident but still not absolutely sure. No half-dead person was going to get by me and wake up in the morgue.
I looked carefully through the ophthalmoscope and there they were—the small arteries lacing across the retina at the back of the eye with the telltale sign. The red cells had separated from the plasma in alternating dark and clear segments called "boxcars." I knew with certainty that Mr. Williams was dead. His blood had begun to separate.
I turned to the nurse and said, "Mr. Williams is dead."
She looked at me with a dour expression. "Well, aren't you going to pronounce him?"
I was taken completely off guard. What did she mean by "pronounce him"? Here I was in New York City in the inner sanctum of the rich and famous trying to assert myself—and feeling clueless. What strange culture had I landed in? I even wondered if I had missed something in medical school.
I stood up as tall as I could, turned to the nurse, looked at the chart to be sure I had the correct name, and said, "Mr. Jonathan S. Williams is dead."
She didn't budge. "I mean, aren't you going to pronounce him?" Her tone and demeanor were calm like I had omitted some routine step.
Now I was really puzzled. What did she want? What custom or ritual did she mean? Was calling someone dead in New York so different from that in the South? Was this some old world custom?
Finally, I looked around the room to be sure I was alone with the nurse and the dead patient. I then raised my arm and held my hand out over the dead body like some strange priestly ritual and said in my most official voice, "I pronounce Mr. Jonathan S. Williams dead."
With that, the nurse said, "Thank you." She turned and walked out of the room.
I followed her to the nurses station and entered my note in the chart, carefully documenting all the signs of death I had observed. If somehow Mr. Williams did wake up in the morgue, at least I had made sure I had documented his death.
To this day, I remain mystified by the events of that night. I have never encountered another nurse in more than 50 years who wanted a patient officially pronounced dead. I have told the story to many colleagues, and no one has ever had the same experience or offered a plausible explanation. Was she some strangely religious person? From some obscure cult?
Or worse, in the following years, did she tell her story over and over of the night she got some green intern from the South to actually stick his arm out over a patient and say, "I pronounce this patient dead." I can even imagine her collapsing into laughter as she told the story, repeating the punch line.
I will never know the truth about the night I made my first diagnosis of death, nor will I ever forget it.
Clifton Meador is a retired physician and professor of medicine at Vanderbilt Medical School, his alma mater. Read more about his years with Dr. Loeb in the Fall 2007 issue of this magazine.