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I CAME TO HATE THE telephone. I used to spend hours conniving a way to keep nurses' home phones ringing all night after they woke me repeatedly to request sleeping pills for insomniac patients. When it rang for a bona fide emergency, there was no time to think as you threw yourself into hospital clothes and ran the short distance across the grounds to the emergency room.
   Jesse Stuart lay quietly on the ER bed clutching his chest. His wide eyes spoke the fear that his tongue could not express. His vital signs were stable and the injected morphine produced almost instant relief from his chest pain. His eyelids relaxed and covered soft brown eyes. After blood was drawn for analysis, the intravenous fluid ran through the needle keeping a patent pathway; oxygen flowed via a nasal catheter. We moved him on his bed to a small private room to do an electrocardiogram. There were no monitoring screens, no elaborate electrical connections, no rush of nurses or other staff members. Just the patient, doctor, one nurse, intravenous tube, nasal oxygen, and morphine. This was 1959. This was an isolated hospital in the hills of depressed Appalachia. The electrocardiogram confirmed a myocardial infarction and heparin was added to the treatment.
   Jesse's wife had the same lack of expression that was typical of miners' wives. She did, however, appear to be relieved when I told her Jesse was resting comfortably, and that everything we could do was being done. Mrs. Stuart returned to the waiting room, and I settled down to a long night of observation. I kept seeing Jesse's anxious eyes; their sense of fear and danger was contagious.
   The stillness of the room was interrupted by a groan. The whites of Jesse's eyes rolled to prominence as his breath stopped. The stethoscope registered only my own heart thumping in my ears. There were no peripheral pulses. Pupils high in their sockets dilated. His face and hair were slick with sweat. Thwack! My fist hit his chest -- once -- twice. Nothing. My mouth girded his as I blew hot, nervous breath into his lungs. Thwack! -- again. Nothing. As I screamed for the nurse I found the vial of adrenaline on the emergency cart and drew up 1cc into a syringe fitted with a four-inch cardiac needle. My fingers slid over the left fifth anterior rib on to the soft intercostal space above. With the needle poised I entered the skin and muscle, and pushed into more resistant cardiac musculature. When blood swirled up into the syringe I plunged the fluid into the left ventricle, withdrew the needle, and released my breath. My hand resting on his chest felt his heart and mine beating as one. The nurse was there in an instant and we both were encouraged by the return of a few heart beats. It did not last. The quivering fibrillation of a dying heart refused to reverse. It was 1959: there was no electric cardioversion. There was nothing more I could do; Jesse died.
   The sense of hopelessness and despondency over the loss of a patient never changes, even after 40 years of practicing medicine. Feelings of inadequacy and anger plague you. Could something else have been done? Could the death have been prevented? With a mind twisted by doubts, the body somehow finds the courage to inform the family and give needed support. Death is the single most difficult problem a physician must face, and it never gets easier.
   I walked the hospital floors while the body traveled to the morgue. The quiet of the night was roughened by an occasional distant snore, and the sound of nurses' heels receding along shining linoleum corridors. As I passed Jesse's room a small light reflected over the crumpled sheets on his empty bed. I stared, haunted by the memory of fear in his eyes. I realized then that he knew he was going to die. Tomorrow I would complain to my colleagues about losing sleep and spending an unsuccessful night on call. We frequently joked and made accusations to hide the hurt felt after losing a patient. Tonight, however, I walked to the bed, lay on the sheets still moist from Jesse's sweat, and wept.

Dr. Rita Mariotti, CW'52, is working on a book about her early experiences as a doctor in Kentucky. This article was excerpted from the first three chapters.
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