Indeterminate. That’s the word we use when we’re unsure whether a patient will be able to survive without mechanical ventilation. We can’t say for certain that they have a good prognosis, but we can’t say they have a bad one either. A chaplain once said that those teetering between life and death can sense two things: sounds and smells. They also shared a story about a patient who woke up from a comatose state and recognized the chaplain’s voice. This was shocking to her because she had never met him while he was awake. The only time she spoke to him prior to this was while he was unconscious. It was the first time she had encountered something like this.

This story has been playing repeatedly in my mind this past week as I began my neurology inpatient service as a 3rd-year medical student. Every day on this service, I’ve seen a man who has been comatose since I arrived. Unfortunately, he experienced a cardiac arrest for roughly 15 minutes, which meant no oxygen reached his brain during that period. Since then, he has been unresponsive, intubated, poked, and prodded. Team after team has come to check on him and determine a prognosis. Indeterminate. That is still all we can say after 9 days in the hospital. I arrived on day four and watched as residents, attendings, nurses, and students continued to poke and prod. Our team was tasked with figuring out what he could respond to, and part of this included pinching his skin to see if he responded to pain. The first time I saw this, I flinched. He lay there, unable to say anything, and no one told him this was happening. They just did it. Could he hear us talking about him? Could he sense the pain but not move his body to respond? What does he know? If the chaplain was right, he could hear us talking about his prognosis. Indeterminate.

On day 8, he lay still, barely moving his mouth around the tubing that connects to his airway. This time, his wife was with him. The team knocked, opened the curtain to his room, and I saw her praying at the patient’s bedside. She had a rosary on the bed near his head. She lifted her head and looked at us. I could see the worry and fatigue on her face. We updated her on his prognosis. Indeterminate.

Then, we let her know we would do a short physical exam on him momentarily. The chief resident looked at me and my classmate to ask if we wanted to conduct the physical exam ourselves. I immediately said yes because I wanted to learn and practice. But as I put on gloves, I looked over at the patient’s wife. “Oh no,” I thought. She had to watch us pinch him, force him to gag, lift his eyelids up, and try to get him to respond to pain. No one said anything to her, but we began anyway.

I asked the patient, “Señor, ¿puedes oírme? (Sir, can you hear me?)” I repeated. Still nothing. Indeterminate. Next, I raised his eyelids to visualize his pupils. I used my penlight and checked his pupillary responses. Intact. Next, we put saline droplets in his eyes and checked his corneal response, intact in one eye. Next, the gag reflex. I turned the valve so I could put the tube down his throat. It went further, further, and further down his throat until I couldn’t push it anymore. I brought it out as I suctioned, and he coughed.

Then, the part I dreaded. I had to intentionally hurt him. Still, no one said anything to the family member. I looked up to let her know what was about to happen so she would be aware of what this test was for and could feel involved in the visit. Then, I squeezed the skin on his shoulders at the base of his neck. He didn’t withdraw from the pain. But did he feel it? Next was to squeeze and pinch the skin on his upper extremities. No response, but did he feel it? As we moved to the lower extremities, I worried if I was hurting him. Sometimes people leave bruises on patients when they do these types of exams. I didn’t want that, so I squeezed his leg over his gown. Still no withdrawal to the pain. Our attending and resident said to pinch harder to see if we could get a response. Another resident said to twist as we pinched. Finally, we got a withdrawal response to pain on both extremities at that point. It was over. That was it.

Still indeterminate. But could he feel it? Could he hear us talking about inflicting pain on him? The team started to walk toward the family member to discuss what this exam meant. I took off my gloves and went to the head of the bed where the patient lay. “Gracias, señor, por su paciencia con todo y lo siento por el dolor. (Thank you, sir, for your patience with everything, and I’m sorry for the pain.)” I told him as I placed my hand on his shoulder. No one else said anything to him. Was I crazy? Would he even hear me? Would it even matter? I’d like to think it would. I’d like to think he did hear me. I’d like to think that others would speak to him too. He’s not my family member, but he is a human being. Regardless of the word “indeterminate,” this still holds true. If he did hear, I hope it brought him peace to know that someone is still thinking of him as a person and involving him in this process. Because at the end of the day, he was the center of it all in that moment. Because at the end of the day, our patients are at the center of all medicine.

Elizabeth Rodriguez is a medical student.