This story has been fictionalized.

Dorothy Klein. MRN 508291987. DOB 12/22/1962. Patient A-. Unit A-. Unit number W038306745014-K.

OK. Next.

Dorothy Klein. MRN 508291987. DOB 12/22/1962. Patient A-. Unit A-. Unit number W038306928906-K.

We finish checking the emergency release blood and wait. We know that whatever was coming up isn’t going to be pretty. A lung transplant gone bad, uncontrolled hemorrhaging, 14 hours on the table. So much blood transfused, an exploratory laparotomy was necessary to relieve the abdominal compartment syndrome created by the sheer volume.

When the OR team brings Dorothy up, I barely have time to acknowledge how bad it is. Her face so edematous, I can’t pry open her eyes to check her pupils. Her tongue bulging out of her mouth. A nasogastric tube poking out of what might be the tiniest nose I’ve ever seen. In another life, it might have been adorable. Pulmonary edema gurgles from her breathing tube as the respiratory therapist puts her on the ventilator. Her lungs so badly injured that she receives a tablespoon of air per breath. The open incisions along her chest and abdomen, with blue surgical towels and loops of bowel visible through the transparent dressing. The ECMO cannula the size of my thumb draining crimson blood and two more returning it in scarlet.

There’s no time to appreciate the horror. Before handoff can begin, the ECMO suction alarm breaks the busy silence, signaling that she doesn’t have enough blood in her veins to maintain flow. Two more units each of packed cells and plasma. 250 mL of albumin. A gram of calcium chloride. Just to get through the OR report.

Truthfully, I don’t remember much from the next five hours. Hanging countless blood products, stripping chest tubes until my hands hurt (her body was simultaneously clotting and hemorrhaging as it entered disseminated intravascular coagulopathy), changing the chest tube containers as they filled with nearly half her blood volume per hour, troubleshooting the ECMO and IV pumps, and a never-ending stream of alarms. We give her over 40 liters—not units—of blood product. A revolving cast of nurses cycles through my room, until I feel like a failure, that it takes this many hands just to keep my patient alive.

Finally, it’s 6:45 a.m. and my relief is ready for report. I hardly know what to tell her. I go over the events of the surgery, review the major systems, vascular access, devices, medications, and blood products. I say goodbye to Dorothy, certain she won’t be alive when I return. I go home and sleep fitfully, with phantom alarms waking me more than once.

The next night as I walk into the unit, I hear a commotion down the hall, from the same room I’d left that morning. Report is brief.

They took her back to the OR. Still bleeding. They can’t control it. Surgeons and family are optimistic. We have blood transfusing continuously. She crashes if it stops. ECMO support is increased, but flow is decreasing due to the abdominal pressure. CRRT is running off the circuit. Good luck.

With that, I’m back in the fray of transfusing, hanging medications, and constantly stripping chest tubes. Blood bank tells us they are almost out of all the platelets in the hospital—a Level I in the height of trauma season. Her husband holds her hand and asks me with tears in his eyes when he should stop us from doing anything more to her.

By 10:00 p.m., we get word that after a multidisciplinary meeting, the team has decided that the situation is futile. The family comes in and takes turns kissing her swollen face, hugging her shattered, bloody body. By 10:45, they tell us they are ready to stop. With silent teamwork known only to ballerinas and fighter pilots, my respiratory therapist and I power down her life support simultaneously. She’s dead before we finish. 10:54 p.m.

One by one, her family leaves the room. Her husband—every bit a cornfed 6′ 4″—sobs on my 5′ 7″ shoulder. Her sons and daughters join. I choke, but I can’t cry. Not here, not now. Not when there are still people to care for. Maybe now, as I write. But not when Dorothy still lays in her bed. The same cast that helped me keep her body alive now helps me bathe her, as we remove what we can. Even still, Dorothy carries an endotracheal tube, three ECMO cannulas, a quadruple lumen CVC, and a Cordis—as well as the PICC that administered her treprostinil while she went on her walks to prepare for surgery—into the next life.

My coworkers filter out until it’s just me and a tech left. We place the body bag around her and zip it up. I hate the smell of body bags. It’s like a beachball, but more chemical. I wonder aloud if a surgeon has ever had to smell one. The tech shrugs.

That would mean being there till the end, she says. That’s our job.

Jonathan Friedman is a nurse.