Wow. Just, wow. Good thing I’m a little drunk.

I suppose it was fitting that today Ben exhorted me to go the Bay Area once I’ve served my sentence completed my residency down here in S.D. While ostentatiously there are several reasons why I would want to stay here, there really was only one, and as of 7:59 p.m., I’ve come to realize once again that such reasons are always perilous.

There is a part of me that is gnawing upon itself in agony, wondering why I keep getting trapped in these temporal loops of complete, utter despair. There is another part of me that is perversely rejoicing, because it saw this coming from miles away, like an ICBM arcing towards its target with the utmost accuracy.

My mom grilled me again this past weekend about whether or not I have a girlfriend. I hate that question. I hate it a lot. Enough to make me not want to come home very often. But it must be endured. As I’ve mentioned a multitude of times, my mom really wants grandkids. I don’t know why she keeps bugging me about them. My brother and my sister are both in long-term relationships. Let them take care of that filial duty.

Mχ asked me if I was going to bring anyone to Mχs and L’s baby shower. (That kid is going to be super-lucky to have them as parents, I swear.) When I told him no, he used the term “terminal bachelorhood” and I had to laugh out loud. It’s odd, that. That where I am now is where I’m going to be when I die.

Part of it is that I’m on a geriatrics rotation right now, and prior to that, I was on an elective ICU rotation. Either way you slice it, the people I’ve been interacting with are all pretty much on death’s doorstep. So certain songs have taken on some rather dark, deep, depressing, and morbid interpretations.

(see also: [Radiohead’s live performances][a]) [a]: http://fabiocchi.altervista.org/ “Radiohead’s live performances”

I thought of some really morbid, macabre imagery to go along with this song. I imagine someone in the ICU, intubated and on a ventilator, with multiple lines going in and out of him. Someone like the soldier in white from Catch-22, almost entirely covered by bandages, so much so that you can’t even tell if there’s anyone in there.

That there.
That’s not me.

The main drive of the short narrative is the decision to withdraw care. So they go through the process of terminal extubation.

In a little while
I’ll be gone.
The moments already passed
Yeah, it’s gone

As the patient goes into agonal respirations, scenes from his life/my life are interspersed. Going out with his girlfriend. Talking to his parents and siblings. Living life, being happy and healthy.

The other song I think about is “What Sarah Said” by Death Cab for Cutie (who is apparently currently having a concert at the Greek Theater in Berkeley.)

Christian Sinclair, M.D. deconstructs the song expertly, bringing to mind exactly all the things that I think of whenever I hear this song, and I seriously always cry at least silent tears whenever I hear this song, and if I’m in a really bad or vulnerable mood, it will leave me bawling.

But I sort of have a different take on the instruments in the final passage, relegating them strictly to ICU noises, and leaving the emotional aspect more muted

• single guitar strum: inhalation/forced ventilator breath
• cymbals: oximeter alarm > agonal respirations
• organ: cardiac monitoring > asystole alarm
• continuous guitar strumming: tachyarrhythmia/vtach/vfib alarm
• snare drum: CPR/stop watch/clock ticking > death march rhythm > S1, 4/6 harsh sounding systolic murmur then S2
• bass drum: heart beat (on auscultation)
• descending piano: ventilator alarm (circuit disconnected)
• ascending piano: blood pressure alarm (A-line pressure tracing non-pulsatile)
• random instruments: all the alarms going off dyssynchronously
• doorbell: the elevator as they wheel the body away to the morgue

The cymbals are the first thing you hear, as your patient desats. The slowest rhythm is the single guitar strum, signifying a ventilator breath. The snare drum keeps time as code blue is called, but it also has the flavor of a march. It also happens to sound like critical aortic stenosis. The insistent continuous guitar strum reminds me of a tachyarrhythmia alarm, with the heart rate racing into the 200s, and then 300s-400s in v. flutter. The organ keeps the actual rhythm of cardiac electrical activity, which doesn’t match the bass drum because despite the flurry of electric impulses, the heart really isn’t pumping very effectively. As the code blue progresses, you start hearing the descending piano melody, as ventilation becomes compromised. One of the last thing you hear is the ascending piano melody as blood pressure tanks precipitously and irrevocably. Eventually, all you hear is the organ, now playing whole notes, reminding me of the asystole alarm. The cymbals start fading out, too, and they start sounding like unassisted breaths, or ineffective ventilator breaths. And then silence, and a quiet cacophony (is that even possible?) of dyssynchronous instruments as you take all the monitors off the body, letting the alarms go off willy-nilly.

Sinclair interprets the last sound as a doorbell, which may signify the arrival of the elevator car that leads to the morgue, but to me, it sounds like an old-school end-of-tape signal, both on cassettes and video cassettes.