The Death Exam

When I was a medical student, I followed a woman who died under my care. She was in her 70's, required dialysis every other day, and was admitted because of a massive stroke.
The stroke had made her completely incapacitated, unable to speak, move, or even control her bladder. Her eyes were permanently gazed to the left when she opened them.

Ultimately her family felt that she had no hope of meaningful recovery and decided to "let her go". We stopped giving her the dialysis that she required to stay alive and one week later, she passed.

While I wasn't present the moment she died, my resident told me afterwards, and I went along with him to pronounce her. It wasn't the first time I had seen a dead body, but it was the first time I had seen the dead body of someone that I had just seen alive. Her body still had some warmth to it, but you could tell that her muscles were starting to stiffen up. You wouldn't know she were dead if you just walked into the room. She just lay there peacefully in bed with her eyes shut.

But then you put your stethoscope on her chest and nothing. As medical students, we are always working hard to refine our physical exam skills. So we listen very carefully for every detail in the heart and lung sounds. You get used to hearing strange sounds that you've never heard before, but you accept them because you're just a medical student. But to examine someone's chest and not hear anything except emptiness is completely foreign even for a medical student.

I didn't actually perform a death exam myself until I was an intern. The basics of it include listening for heart and lung sounds, and checking for reflexes which test basic brain stem function.

There are a few different reflexes that you can check. One is the corneal reflex where you take a wisp of a cotton swab and touch it to the surface of the patient's eye. If the reflex is intact, they should blink. Another is called the occulomotor or "doll's eye" reflex. This involves holding the patient's eyes open and rotating their head from side to side (as if they were gesturing "no"). If the brain stem is intact, the eyes should rotate the opposite direction of their head so that their pupils actually stay centered as if they were looking at a single point straight ahead.

Another thing to check for is response to pain. The sternum (breast bone) does not have much fat or muscle overlying it. So when you rub it (usually with your knuckles) it is pretty painful. I prefer doing this, while others do a nipple pinch, which is exactly what it sounds like. Kind of cruel and obscene if you ask me.

And that's really all there is to pronouncing somebody dead. I'm not quite sure why it takes an MD to pronounce death. It's not all that complicated to perform. But it can be incredibly difficult for other reasons.

I was on call one night in the cardiac care unit. The nurse called me because one of other interns' patients had died and they needed me to pronounce him. So I walked over to the room with my cotton swab and stethoscope. When I entered, there were about 10 family members in there sobbing, hugging the patient and hugging each other. The room was dead silent except for the sobbing. It took me by surprise, but I had to do the exam so I broke the silence by introducing myself, giving my condolences, and explained what I needed to do. I gave them the option of leaving the room while I did the exam, but they wanted to stay to be with him. Just great. They stepped aside, eyes still fixed on their loved one, and I stepped forward. I don't like audiences to begin with, and now I had to do this in front of the poor family. I proceeded in as gentle a manner as I could. I listened to the chest, jammed his eyes open, stuck the cue tip into his eyes, rocked his head back and forth, and then crushed my fist into chest. He was dead. "Time of death, 13:43." The room burst into tears as everybody broke down at my words. I once again said how sorry I was and ran out of the room, mortified.

To this day, I'm still not sure if you actually have to say the time of death out loud.
I mean, they always do it on TV. But after that first experience, now I always ask the family to leave the room when I perform the exam. It's just not right to watch your loved one being manipulated like that.