As a boy growing up in a small town in Pennsylvania, I never gave much thought to the concept of a kiss. My family gave and received kisses without hesitation. I continue to give and receive kisses from my wife and kids in the same nonchalant manner.

Until one night — on shift.

I work in the ER of a medium-sized town in southern Oregon. It was late into my shift. The call came in: “Helicopter en route, 32-year-old male, gunshot wound to the head, self-inflicted, airway is a nightmare, ETA 3 minutes.”

The usual prep ensues. Respiratory therapists arrive to help set up. Nurses pull the trauma packet and prep IVs and monitors. And then, we wait.

I’ve always found in these moments, when all physical preparation is complete, that there is an opportunity. The unknown can make even the best medical staff feel angst. I use these opportunities to remind the staff of a few key points. First, we can’t control everything. Second, the staff is skilled and need to remain confident of those skills. Third, speak only when necessary. And, most importantly, I tell the staff that I believe in them. And I do.

The patient rolls in. He looks horrible. His head has an entry wound on the right temple area and an exit on the opposite side. Blood caked his head and hair. His mouth was full of blood. The primary survey is straightforward. Airway, breathing, and circulation followed by neuro assessment and exposure. The airway stops us. He has an endotracheal tube in place, but it’s not functioning and needs to be replaced with a tube that will stay secure. While trying to visualize the vocal cords and suctioning blood, I removed the defunct endotracheal tube. The coagulated blood was sticky, and the ET tube wouldn’t initially pass. I used the largest one available. I passed it blindly, hoping I was still in the appropriate location.

Next, I was anxious to get the patient to CT. However, his vital signs deteriorated. First, his blood pressure rose to a very high level, and his heart rate decreased — known as the “Cushing response.” There are steps you can take to treat this phenomenon, but its presence signifies imminent death.

I ordered the usual treatment. It didn’t matter. His heart began to slow further, and we lost his pulse. Ultimately, we got his heart rhythm back to a sinus rhythm, but despite this, his pulse didn’t return. He received a lot of medicine but didn’t experience a perfusing pulse.

Just then, nursing staff told me that the family had arrived. I froze. A wave of nausea came over me as I envisioned the drama that might occur. In 2000, the American Heart Association recommended the option of Family Presence During Resuscitation (FPDR). Although the studies showed that families want to be present, it has been only slowly adopted in the medical community.

I decided to talk to the family just outside the curtain of the trauma bay. The wife was in her early 30s, brown hair, combed in a straight style. Despite her tears, she appeared determined. The parents were in their mid 50’s and dressed in business attire. After a short interaction, it was clear that the wife may be able to enter the trauma bay, but the parents may do better outside the room.

I opened the curtain to the trauma bay and led her in. She was trying to remain strong, and I noticed that she was holding on to stationary objects as she passed them. She went to the head of the bed and was visibly searching for a way to touch her husband. He was underneath a tangle of IVs, cardiac telemetry wires, ventilator tubing and pacemaker pads. It was apparent that she didn’t quite know how to connect with her husband — but needed to — in a concrete, physical way. Her eyes scanned his body looking for a way to interact, but, finding none, had a perplexed, sad appearance. She leaned over her husband’s face and whispered, “I’m here, I love you.”

As time went on, it became clear that it was futile. The patient had been without a pulse for some time now and had undergone extensive treatment without success. I asked my usual, preparatory inquiry: “Does anyone object to terminating the resuscitative efforts?” At this moment the patient’s wife turned to me. She realized that the moment was imminent. She knew that this would be the last time on this earth that her husband would be officially alive. She turned to her husband and positioned her head nose to nose with him. She whispered, “I’m here. I love you.” Then, with blood caking his face and lips, she leaned in and kissed him on the lips. It was genuine, affectionate and not burdened by what others thought. She made that connection with him that she had been attempting since she entered the trauma bay. She did it on her terms despite the insanity of the circumstances. This was a genuine sign of affection that was unencumbered by societal norms. The room was silent with the exception of the ventilator hum. No one dared speak. We were all sanctified by the same spirit. It was a holy moment. You could tell that she wanted it to last forever, and in some small way — we did too, but she realized the impracticality of that unverbalized request. She finished her kiss and turned toward me. She looked at me and nodded her head slightly — acknowledging the inevitable.

I called the code at 0131 hours. I thanked everyone for their efforts.

I’ll never know what events led this man to take his life. What I do know is that he was loved on this earth by at least one person. And now, as I kiss my wife or kids “goodnight” or “just because,” I do it with a slightly different tenor. I understand, with a little more depth, what a kiss can signify.

Lee David Milligan is an emergency physician.

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