“I think we have a dead patient.”
That was the unit clerk talking to me. We were standing outside in the bright sun, both squinting a little bit at each other because we had so recently come from the hospital’s disorienting, windowless emergency department. It was about noon. I had left the ER maybe 30 seconds earlier, an extremely rare departure, because I had needed to get a text out to a specialist consultant in a different state, and the concrete-and-metal aesthetic of our ward made us a no-reception zone.
“They just told me someone might be dead. They brought them back to a room.”
The clerk was completely calm. That’s not an unusual trait for someone who is good at their ER job and who has done it for a long time; yelling and otherwise-appropriate emotion can be dangerous, can lead to mistakes and delays, irrational responses. The gravity of a situation often has to be distilled from the actual words that somebody has said, and these were as clear as they were unexpected. The department was busy when I stepped out, but nobody was “sick” in the way that we mean when we say “sick” in the ER. This was not a message I was ready for.
I put my phone away and walked quickly back in, straight to the resuscitation bays that we keep empty for true emergencies.
There was a nurse briskly attaching cardiac-monitoring electrodes to a frail elderly woman who hadn’t been there when I left. This must be her.
“What’s going on?”
A major part of being a doctor is asking the dumbest question you can think of until you totally understand the answer.
“A paramedic saw her looking bad in the waiting room, and he couldn’t find a pulse.”
I looked at the monitoring screen: an absolute flatline, no heart activity at all. I shook the patient and tried to rouse her. Nothing. I couldn’t feel a pulse anywhere on her; I couldn’t hear a heartbeat.
There was a woman at the bedside, her daughter. I asked questions as fast as I could, trying to determine whether my new patient really was dead and, if so, for how long she had been. I didn’t want to crush an elderly body with futile CPR, but I didn’t want to let important seconds slip away, either, if there was something that could be done.
She had been hospitalized a week ago but had improved and was discharged. They thought maybe it was a urinary tract infection, and she was finishing up some new antibiotics. She had been dwindling for two days, eating less and interacting less. Her last words were hours ago, and her last signs of life were a cough and maybe an arm movement while she was being loaded into the car to reach us.
Loaded into the car to reach us. That had to have been at least 10 or 15 minutes ago.
A nurse reported the core temperature: 91.5F. That’s low. You can go low from infections, especially in the elderly, but that’s really low. You can get that low from being trapped in a cold environment, but she had been in a room-temperature home.
She had been dead for some time, and her body was naturally losing heat.
A nurse pulled over the ultrasound machine. I found our patient’s heart as fast as I could, and we watched it sit perfectly still. The heart is actually strangely hard to locate definitively on ultrasound when somebody is dead because you only ever see it in motion. Once that stops, it begins to look more like the surrounding tissue and less like itself. The blood in the heart also changes, forming into sludge and clots that make the whole thing look less heart-like. But this was clearly the heart, and it wasn’t moving.
The cardiac monitor was also still a flatline. It’s a popular misconception that you can “shock” (electrically cardiovert) people when they flatline, but you can’t. Squiggly lines, jagged lines: that’s what we shock. Flatlines, those are the far end-state, a level of heart activity so low that it can’t be coaxed back with electricity.
The nurses were shifting about. Nobody wanted to start CPR. This woman had clearly been dead for some time.
It had only been maybe a minute, and I had been narrating our team’s findings to the patient’s daughter, trying to explain our process as we blew through it. I looked over and saw her waiting for the next bit. There wasn’t a next bit; this was it. I realized that we had ended up far too technical, a collection of medical data that hadn’t communicated truth. When that happens, nothing is more important than fixing it immediately. Everybody has to be on the same page, so you have to go direct.
“I’m so sorry to tell you this, but your mother is dead.”
“What? We came here to get her treated! Can’t you do something?”
“Everything we’re seeing suggests that she’s been dead for 10 minutes or likely much longer, and the brain doesn’t typically survive more than 3 to 5 minutes without blood flow. CPR would be ineffective and could damage her body without any benefit.”
“Please. Please try it.”
So I did the CPR. The daughter and I perched on the edge of the gurney, my locked arms pushing into her mother’s chest forcefully, pumping out the strangely quick speed of modern chest compressions. An artificial rhythm appeared on the monitor, but it tailed off into blankness between rounds.
This was not a fixable situation. The unit clerk had been right; we had a dead patient.
When the original patient is gone, everybody else in the room becomes your new patient. “To cure sometimes, to relieve often, to comfort always.” I believe in that aphorism that describes the purpose of a doctor, and no situation so clearly demands that a doctor provide comfort as when the patient has died.
I looked over to the daughter and stopped to see her clearly for the first time.
Her mother had been in her 90s, and she appeared to be somewhere in her 60s. She was composed and holding her mother’s hand.
She was black.
Of course I had noticed her and her mother’s skin earlier, but I had only taken it in as one fact among many: I wouldn’t be able to see red rashes as easily, or notice bruising that could indicate a recent fall. I hadn’t yet processed any other reality of the situation, and now I needed to.
My new patient was black, female, and from a different generation. I was white, male, quite a bit younger, and telling her that her beloved mother was dead. We had known each other less than 10 minutes.
Med school tries to teach “cultural competency,” tries to make you aware that your care and your message has to take into account who you are and who your patient is. The same words can work for one pairing while failing in another, and good doctors must learn to predict and navigate that reality.
So we were looking at each other, an oblivious monitor beeping away in the background, she likely wondering if this was truly reality, if her mother was really gone so suddenly, and me wondering how to be a white man.
It’s rare to receive important life advice that also comes with a title so plain that its purpose and utility cannot be mistaken. Imagine being in a sinking boat, frantically bailing out water, only to accidentally pull out a book titled “So You’re in a Sinking Boat, Frantically Bailing out Water.” Ridiculous, right?
But I swear that happened to me.
Three months before the universe sent me an elderly, black, female, dead patient, I was sitting in a darkened theater at PianoFight, watching a play by Luna Malbroux and Jennifer Lewis, titled “How to Be a White Man.”
I didn’t know what to expect going into it, but I can tell you what I got: a much gentler exploration of intersectionality in our society than any white man in this country deserves.
For those of you who aren’t going to win the woke olympics, intersectionality is an elegant theory that posits that our identities and life experiences are shaped by “intersecting” axes of social identity. That is, rather than being defined by just our race or ethnicity, we are each the product of a complex set of attributes, such as gender, skin color, and wealth. Have you ever thought something uncharitable about somebody because of their race, sexual orientation, disability, gender identity, education level, socioeconomic status, or really anything else at all? Congratulations, you’re an intersectional hater, just like all of us (apologies if I’m projecting).
It’s a brilliant theory, and the evidence supports it. One of my favorite types of sociologic research study is the “audit study,” and I feel like it has been used to prove that intersectionality exists. Basically, audit researchers submit two profiles (often résumés) for a job or apartment rental ad or whatever other type of common listing. The profiles are the same except for one or two carefully controlled variables; maybe one has a name that sounds more “black,” or possibly extracurricular activities that appear more low-class. Then they see how many callbacks they get.
Changing the name on a résumé shouldn’t matter, right? Wrong: “white” applicants get more attention. Well what about two “white” people who just have a different gender or social class? They also get treated differently. And if you’ll look at that second study, you can see that the really messed up thing is that our intersectional characteristics interact with each other. Being perceived as “high class” added points to white males but actually harmed white females.
If you look at enough audit studies, you’ll notice that the one unifying thing in America is that being a white guy is great. It’s a built-in advantage, some might even say a (white dudes: trigger warning) PRIVILEGE. It’s a privilege. Your cruddy résumé will get more calls. I’m not sure how else to frame that. Intersectionality lets us know that poor white guys have it worse than rich white guys, yes. Gay white guys, white guys who didn’t go to college, white guys from certain states: you all have some relative disadvantage, too. But we’re all white dudes. It is THE club in this country. The evidence is in.
So who is Luna Malbroux and what does she know about it?
Simply put, Luna is one of two authors of the play “How to Be a White Man,” and she was also its lead actor in the FaultLine Theater staging that I saw a few months ago, directed by the talented Nikki Meñez. In more detail, Luna describes herself as a “queer Black woman,” a phrase which includes a capital letter that sent me down a rabbit hole of semantics and copyeditor arguments after reading it.
The fact that the word “Black” (or is it “black”?) can be an immediate minefield in itself partly explains why it took me three months to be able to write this; there’s just so much that I don’t know about the topic, despite the name of the play, which implies that I should be an expert. It kind of feels like being asked to describe your own face, even though you’re probably the one who’s seen it the least, ironic as that may be.
Luna has worn many hats over time, from social worker to stand-up comedian to app developer, and before writing White Man, she took a trip across the United States to interview people for a project about identity and perspective called “Mapping Privilege.” She then took the accumulated experiences and melded them into an intersectional, theatrical bouillabaisse that will appropriately needle anybody who takes a seat in front of it.
Malbroux spreads her barbs out, however, and her chastising is prone to turn inward just as keenly and quickly as it looks outward. White men may be the lens for the play, but they are not its enemy. Black parents who don’t fully accept their queer daughter feature on stage prominently and contiguously with the internal drama of a lesbian relationship, which in turn abuts the racial realities of different women interacting. You may not be a white man, but you still can’t touch my hair, lady; I don’t know you. Even topics like substance abuse, laziness, and egotism get a mean-eyed shake, and more often than not, Malbroux is bending around to look at herself.
Structurally, the work is built around 10 “steps” that the viewer can take to realize life as white men live it. To complete the role-play, everybody’s seat has a coupon under it that “entitles the bearer to White Male Privilege” for the remainder of the 90-minute play, and the whole audience is encouraged to suspend disbelief and live the dream. Each step is then enumerated on stage, with illustrative skits and asides that build out a cohesive narrative arc.
Some steps are straightforward (“Step 2: Embrace your inner asshole”), and others read more like a zen koan (“Step 5: Be the subject, not the object”). They all ring true, though, and even in writing this I’ve already checked the boxes for, at a minimum, “Step 3: Did you know you’re an expert?,” “Step 6: If it’s not about you, make it about you,” and “Step 8: The key to a real non-apology.” I mean, I opened the piece with a 1,200-word first-person story and it’s nominally supposed to be a theater review. That’s some serious white-man garbage, right there. And I encourage all of you to adopt the same strategy; coupon’s under your seat.
Just before the play started, the FaultLine team announced that they had intentionally minimized the set design, lighting, music, and other theater effects, so that the gravity of the play’s topic could stand on its own, unadorned in its transmission.
That’s a noble sentiment, but the talent of the crew shone through despite the stated goal. It would then be irresponsible not to mention the subtle but compelling contributions from Sophia Craven (lighting), Kitty Tores (costumes), Sara Witsch (sound), Cole Ferraiuolo (set design), Beth Hall (stage manager), and Maxx Kurzunski (projection designer). The set was indeed minimal, but it was dynamic, with projected images and their overlying soundscapes regularly creating entirely new spaces out of physically static objects.
Key props and settings at times evoked a dank, brick-backed comedy rathskeller, with Luna retreading her stand-up persona, mic stand in front of her.
“Y’all look at me like, ‘Is everything racist?’ Well…yes.” A coy, conspiratorial smile afterward. The delivery perfect and the audience laughter organic, with Malbroux deftly shooting arrow after arrow through the timeless double bullseye of what is both sickly true and yet somehow funny.
Then a chair papered in fake money while a scene supposedly based on race occurs around it. The intersectionality in the play constantly occurs on various sensory dimensions, so the words may take you in one direction while the visuals pull in another. There’s a lot to take in, and just as no character in the play is defined by one singular trait, no scene is defined by any one dimension, either.
There were also a flurry of key supporting performances, with Jessica Jones and Jennifer Greene being particularly interesting as a two-headed, coral-clad Grecian chorus cum muse and shoulder angel, intermittently appearing and prodding Malbroux to her better graces through endless chiding and sermonizing. Jones and Greene were ethereal and seemed likely to be mostly beneficent figments of Luna’s guilt and worry, never letting her forget her legacy and ancestry, despite her immediate mortal desires. More inescapable than helpful, they appeared to personify a voice that Luna can’t get out of her head but doesn’t seem to mind.
It is tempting to reduce the other secondary roles to their shallow nuts and bolts (Ashley Gennarelli: perpetually misguided white fan, Derek Jones: all-purpose black guy, Akaina Ghosh: complex significant other, Kevin Glass: all-purpose white guy, and Linda Girón: female comedy counterpart with a Hispanic angle), but that would boil off all of the tiny intricacy that the play depends on.
In reality, Malbroux and Lewis go to lengths to sketch in intersectional dimensions for each character, so there aren’t any throwaway roles. This creates an interesting effect, with every character being at once a protagonist and a foil. There really aren’t heroes or villains, and the entire cast did a laudable job portraying this complexity.
Around the same time that I saw White Man, I also saw the SF touring production of Hamilton. It was an amazing show and performance, and it deserves the attention that it has gotten, but one thing rang hollow for me: our audience glaringly did not match the cast. Lin-Manuel Miranda’s opus famously features people of color in most leading roles, but when the house lights were up, I could see that our would-be shared reality was more like a peep show.
San Francisco has been becoming more male and less black and Hispanic in recent years, and that was seemingly on full display during my Hamilton night. I think there’s nothing inherently wrong with a demographic that looks like clones of me and my dad enjoying a reimagining of part of our country’s founding, but it bothered me that it was such a homogenous difference from the people on stage.
Then, when the story was over, the lights came on, and we all filed out while the actors were gone. There was no chance for public reflection, so it was entirely unclear what message people had taken from what had just transpired.
White Man, on the other hand, had a planned debrief at the end that I found useful. It’s a small touch but, I think, an important one for a production that wants to engage seriously with social issues. It forces everybody present to experience the message as actual rhetoric rather than just art, the latter of which we all have developed an ability to observe and then ignore, à la Hamilton from a distant but comfortable seat. Turn on the lights and face your skin; it’s healthy.
One part of White Man also stuck out to me in a unique way, and it’s still bouncing around in my head a few months later.
Sometime early in the play, the coral muses and Luna reflect on the need to be a “strong black woman,” how you could make it and thrive by being “strong.” There is inevitable discussion of Oprah. But then Luna muses, honestly, “Who wants to have to work that hard?”
I was thinking the same thing before she said it. Men, and especially white men, can skip shaving, put on lazy clothes, and still be included in the conversation. It doesn’t even matter what conversation I’m referring to there; we’re in it. When a dead black woman showed up at my ER, I hadn’t shaved (my shift started at 7am, come on now), and I was wearing scrubs and tennis shoes.
I wear that outfit all the time, actually, and when I walk up to an ambulance drop-off, the paramedics know that I’m the doctor. When I answer the phone, people say “doctor.” When I walk into a new patient’s room, I hear “doctor.” I know from experience that this is not the same for my female colleagues, and that’s before we even get to any issues of skin color.
There’s no way that black, female doctors get the same auto-respect that I’m used to, and if I had to be as put-together and perfect at all times as they do, I’d scream. That would be exhausting.
“They saw an old black woman, and they thought she wasn’t useful to society anymore, so they wanted us to let her die.”
My mind skipped a beat, and I replayed the line in my head to make sure that I had heard it right. This was my patient’s daughter. I had called her the day after the ER shift, wanting to debrief everything, to answer her questions and spend time. I wanted her to know that I really did care.
The ER is so busy that your dead mom has to timeshare with a guy who cut his head and a child with a cough. The contrast is as gross as it is stark, and it often plays out across paper-thin drapes that don’t block sound. You can hear me asking pedestrian questions about cold symptoms from the next bay over, maybe 30 seconds after I updated you on when the morgue technician would be arriving for your parent. It’s heinous, so I made protected time the next day that I didn’t have to share with less important issues.
“She was tough. And obstinate. That doctor was trying to tell me we shouldn’t do anything, that we should ship her somewhere and she would die within a few months.”
My patient’s daughter was recounting her mother’s hospital stay from the week prior, when she had been admitted with decreased mental status. She called out the inpatient doctor by name, and I recognized him as another white male doctor. I listened, almost out of body, while she shared her experience of what we call a “goals of care discussion” in medicine.
Any conscientious doctor who admits a 90-something-year-old to the hospital with altered mental status will have a goals-of-care talk with the patient’s family members, and we use it to try to figure out if we’re really going to do full-bore CPR with shocks and compressions and breathing tubes and ICU stays, should the patient lose their pulse. There’s a burgeoning recognition, finally, that we are often torturing our older loved ones at the ends of their lives, keeping them in malodorous, beige hospital beds for their finals days, poking and prodding them for blood draws and infusing medicines with weird side effects while they drift in and out of painful consciousness.
As doctors, we’ve all seen this many times, and we hate it. I know the white male doctor whom my patient’s daughter was talking about, and he can be bullheaded and indelicate, but I’m fairly sure that his counsel in this case was not based on gender or skin color. I’ve heard him give the same advice for elderly white grandfathers, too; it’s an age-based talk.
But that’s not what my patient’s daughter heard. The rough math suggests that she was born before desegregation, and her mother was likely old enough to have lived through the entire Civil Rights Movement as a full-fledged adult. Their experience of this country involved white authority figures turning firehoses on peaceful marchers, lunch counters and water fountains that they could not use, and schools that they couldn’t attend. Our entire society was organized to ignore and disregard the existence of black women, at best, and to actively seek their death, at a disturbingly common worst. It seemingly hasn’t changed enough, either.
As my patient’s daughter continued, she kept complimenting my bedside manner and saying that I was bringing her peace. The CPR that I had been loath to perform turned out to be a hugely important point for her; she mentioned it several times. I felt like an imposter. Under other circumstances, I might have been the one having a goals-of-care discussion with her and recommending against CPR. On the phone, as a trusted healer, I was now hearing that this heartfelt advice would have read only as “your elderly black mother should be dead.”
While she talked about her hardworking mother, I felt shame at my prior callous feelings toward family members who had continued to advocate for a “full code” approach for their dying parents. I hadn’t understood why they would want to put their elderly mothers and fathers through suffering just before death.
I hadn’t been thinking about anything but age, but now I could see that the family members were thinking about race and wealth and class and probably a whole number of other factors.
“This was her time, but she wasn’t going to go before her time,” my patient’s daughter was saying, and now I was hearing the echoes of past decades of racism and sexism, clawing at her door daily like a wolf testing the locks. Would this be the day she failed to be “strong” and let the white men win, giving in to their passive but constant wish for her disappearance?
Being strong is exhausting.
Luna’s words banged around in my head deafeningly while we finished our call, and I thought about her question again: “Who wants to have to work that hard?”
I don’t. For sure I don’t, and I don’t want my patients or anybody else to have to work that hard unfairly, either, but intersectionality exists. Honestly, it is incomprehensible that the vast majority of black women wake up in this country and go to work and contribute to society, for less pay and less respect than anybody else, instead of just spending all day screaming.
It is incomprehensible, and it is incomprehensible that Luna Malbroux could live her life in this country and then still produce such a gentle examination of intersectionality as “How to Be a White Man.” Speaking as a white man, we don’t deserve something this fair.