January Elegy #5
I have not written much since he died. I should have forced my way through it, even if it sounded mechanical to me. Because I have now passed the rawest months I can’t recreate.
Grief is, for me, I think, all about tiny events. And even Bruce’s dying was a series of tiny events in succession that added up to that one final moment when his last heart beat was not followed by another and his last exhalation was not followed up by the reaction of an inhalation. We looked at the monitors then, in those last minutes as his heart slowed. I felt myself pulled to watch the screens even as I wanted to watch him. I listened to the machine noises, the pulses and pitches, to tell me when he was gone, even as I wanted to discern it sensuously from the series of cessations those sounds described. The machines are so authoritative, telling us things that are inscrutable – blood/oxygen values. It’s easy to think our sensory perception of the indicators of life are beyond us. I wish I had had my head on his chest. I wish I had been alone in the room. But I am the one who made sure he was surrounded by everyone I knew enough to know he loved.
He came to the doorway. He had been scanning the polaroids he just took. There were a few spots of blood on his upper lip and he had a tissue. He said – Call 911.
I get here and I start to cry. I’m sitting in the same kitchen writing, the sink in front of me at the end of the counter I’m sitting at. And I see Bruce in my mind, fiddling with the syringe to inflate the cuff inside the trache tube. I tried to help him and he pushed me away and blood was coming out of him into the sink. I wish I could remember it better. It was happening so fast. I was on the phone by then, talking to the emergency response operator. But I don’t remember much about it. He needed more gauze. Blood was wicking out of him on the gauze he had stuffed in his mouth and he had to do too much at once – inflate the cuff, pack the gauze. I ran upstairs to get more, on the phone the whole time telling the dispatcher what was happening. By the time I got back downstairs he was on the floor unconscious, a strand of bloody gauze strung between the kitchen sink and his mouth in a wet arc and the blood kept coming out and his eyes were a cloudy grey/blue and he wasn’t breathing. I started screaming, frantic.
I checked the cuff and then tried to get him on his side so the blood would come out of his mouth instead of going into his lungs but his body was so heavy and awkward. The emergency person told me to calm down every time I screamed and instructed me to get him on his back to prepare to do CPR, which was possibly wrong because I think he was drowning. And in a flash of recognition I remembered what the respiratory tech told us in the hospital before we left; he couldn’t breathe because he was wearing the speaking valve while the cuff was inflated. Everyone warned about the combination. But the tech had told us why. He couldn’t exhale through the valve. So he couldn’t inhale. That’s why he fainted. I pulled the valve off the trache tube and could hear the breath come out of him, feel his chest deflate. That’s when the emergency response team arrived and I called Nora and crouched in the corner of the living room while they suctioned the blood out of his lungs. When I called out and asked one of the team if he was alive he answered – I think so.
If you had been alone you would have died. If you had been alone you wouldn’t have died because you wouldn’t have been wearing the speaking valve; you only wore it because you were talking to me. If you had been alone you could have died because you couldn’t talk to call 911 if the cuff was inflated. I don’t think you would have died. You didn’t bleed enough, fast enough, for your brain to starve and your body to empty out before the bleeding stopped.
I meant for this to focus on the blood. I wanted to think about blood at the cellular level, not as a liquid, but as a collection of cells that hold together and follow one another. I wanted to think about your blood relating to your shredding arteries, slipping through tiny holes, cell by cell, propelled by the pressure of your heart’s beats, pushed along and then pushed out, the system failing catastrophically.
Here is what happens:
When a blood vessel is injured, the damaged cells in the vessel wall send out chemical signals. These signals cause clots that slow or stop bleeding.
A blood clot forms through several steps:
- The blood vessel narrows. First, chemical signals cause the injured vessels to narrow to prevent more blood from leaking out.
- Platelets travel to the site of the injury. The chemical signals travel through your blood to the spleen, where many platelets are stored. The signals tell your spleen to release the platelets into your blood. Back at the injury site, the vessel walls become sticky and capture the platelets as they float past.
- A platelet plug forms. The platelets change shape and become stickier. This allows them to attach to the vessel wall and clump together into a plug.
- The blood clot forms. Clotting factors in your blood are normally turned off so that you do not form abnormal blood clots. When there is an injury, platelets release molecules into the blood that help turn on clotting factors. One important clotting factor is fibrin, a long, thin, and sticky protein. When it is turned on, it forms a mesh to hold the platelet plug in place. This is called a fibrin clot. The mesh also traps red blood cells to form a blood clot. The platelets contract to pull the two sides of the damaged vessel closer together, so it is easier to repair.
When there is an injury that causes bleeding, the nearby blood vessels constrict (narrow) to help prevent blood loss. Platelets arrive and plug the leak. The platelets also create a reaction with clotting factors that react to form a fibrin clot. Medical Animation Copyright ©️ 2022 Nucleus Medical Media, All rights reserved.
Once the blood clot is formed, your body’s immune system repairs the injury. At this point in the process, factors in your blood start to break down the blood clot.
Is there another chemical process that took over after your blood became sticky and clotted up – long enough for you to write down (when I asked) that you wanted cremation and your ashes scattered on the upper ridge trail, to send a text to Anthony, who was driving down from New York, that you wouldn’t make it, to text Julian, as he stood next to you watching your thumbs grow clumsy with morphine, that I would need his support and you were sorry your end would involve so much blood?
Did there come a point when you had lost enough blood for long enough that your body sent a different chemical signal of surrender and told the spleen to rest? Or was your platelet reserve simply exhausted? Were your arteries so compromised that no amount of narrowing or cellular contortion could compensate? I imagine them coming apart like gauze, the vestigial, necrotic arterial walls eroding like loose soil, your blood pooling in your open mouth as you breathed through the trache. The nurse placed a suction in the left corner of your mouth to siphon off the blood before it could spill over. Even so it soaked the bed.
Does the body realize when the damage is just too much and it can no longer patch the holes? Is there an intelligence of cells that calculates catastrophic failure and stops trying? Or does the body work to fix itself even as it passes the tipping point? Does the body persist and strive to live until we decide to die?
As your heart slowed on the monitor and your breathing changed, I said – Bruce, there are so many other forms you can take.
You stopped struggling and stopped.