Dvořák Symphony No. 9 in E minor (“From the New World”) – Movement II ‘Largo’: a soundscape like floating beside the clouds in a perfect blue sky. The brass chords flood your ears. The underlying orchestra adds harmonic depth and richness. The English horn solo tugs at heartstrings, sighing at the end of each phrase.
After years spent in numerous youth symphonic orchestras, this performance stands out to me among an extensive repertoire. With my cello nestled comfortably into my body, the smell of wood, dust and rosin filling my nose, and stage lights as hot as the summer sun, I had watched our elderly conductor delicately paint that sky with each stroke of his baton.
Five minutes in, a darker theme takes over with only hints of the previous melody, like overcast weather obscuring all but a few piercing rays of sunlight. This “B” theme has musical significance. The first movement is retold in these middle five minutes, a recurring character in the symphony’s melodic story. Its presence is also a contrast, so when the movement’s first theme is repeated, bitter elements mix with the sweet “A” theme, producing a more complex emotional response. That complexity is one that I may have known intellectually but had yet to experience until, one month into my first clerkship rotation, a 50-year-old cyclist lay in the trauma bay 30 minutes after being struck by an SUV.
The room isn’t big enough for all the attendings, residents, nurses, and pharmacists trying to get twenty things done at once. When the primary and secondary surveys were completed, his condition balanced precariously. He is stable enough for a CT. We catch our breaths. Just a few seconds pass and a single push over to the transport bed sends his blood pressure plummeting. His heart tracing goes flat. “Starting compressions!” the trauma resident yells, and the organized chaos from before multiplies three-fold. “Students, get ready to cycle for CPR!” My turn arrives. I start sweating from the exertion, the feedback device imprinting onto my hand: It’s a storm all around me, and I am standing in the eye, single-mindedly pushing.
We cycle again and again, and on my third cycle, out of the corner of my eye, I see a woman enter the room, speaking briefly to someone. “Stop compressions!” Everyone in the room freezes. I vaguely hear some words (“wife,” “past nurse,” “want to stop”), but the message is clear: she wanted us to stop. He didn’t survive. It was my first experience with death.
The room screeches to a halt, voices quiet, and alarms are silenced. From the emptiness, a single nurse’s voice speaks up.
“Could we take a moment to pause and honor this person? This was someone alive who has now passed away. They were someone who loved and was loved. They were someone’s friend and family member.”
In the moment of silence that follows, I bow my head and hear my own heartbeat pounding in my ears, a painful contrast to the stillness of the man lying in front of us.
I wash my hands, a reminder that I can still breathe and feel and stare at the red curved imprint from the feedback device that is already starting to fade, knowing the memory imprinted in my mind and heart is permanent.
New fears begin to invade: the realization of human fragility, the abruptness of death, and the prospect of one day growing numb to death. “Did I do everything I could?” I think as I leave the bathroom. As I return to my team, there is not a single dry eye in sight: the trauma attending, with years of experience, is crying the most. Yet, hints of hope poke through. “It never gets easier,” she says, “but it motivates you to do better and help everybody possible.” I glance around the ED as people are trashing gowns, typing notes, reorganizing medications and checking pages, all amidst tears, their fierce determination reflecting this idea. The wife is sitting beside her husband’s bed: she too has a soft smile, as if remembering the times they shared. The words that were spoken moments after his death return to mind: “They were someone who loved and was loved.”
These instances of contradictory emotion recurred again and again throughout the year. On my second night on overnight call, a young boy’s passing brought sorrow but also thankfulness as he had offered his organs for donation. A woman with liver cirrhosis, soon to be discharged on hospice having been denied transplant candidacy, proudly told me every morning about her two adult children. A man with high stage undifferentiated lymphoma spoke at length about his love for history and how much he had enjoyed teaching high school. The family of a woman with spontaneous tumor lysis syndrome smiled through their tears as they told us about her life as a hospice nurse and at the relief that she could be home with them for the end. Hope, joy, relief, thankfulness — these feelings continued to surface.
Sorrow and joy, fear and courage, regret and hope — the same Dvořák is now tuned differently to my ear. The last bitter-sweet theme encapsulates the complexity of moments at the end of life. Emotions clash — the encroaching inevitability of death makes a celebration of their life much more powerful, which also accentuates the reality of their current suffering. It is not just an “A” versus “B theme,” a coin of emotional states spinning on its side before resting on one face at a given time. These moments are instead like a watercolor painting of our inner state.
Individual colors bleed into one another at their interfaces until a picture with hazy borders is created. As the movement’s final chords shimmer, gray clouds run from the whistling wind, reflecting a blend of red, orange, and purple thrown by a setting sun against an ever-shifting sky.
Daniel Song is a medical student.
Image credit: Shutterstock.com
