The DO Book Club, December 2023: ‘Code Gray: Death, Life and Uncertainty in the ER’

Welcome back to The DO Book Club!

Very rarely, I come across a book that captures the essence of my professional experience as an emergency physician. As an avid reader and reviewer, I have read several medical memoirs that came close. They tend to be compilations of the most moving (and awful) experiences in the lives of the physicians and staff of the emergency department.

I am pleased to say that in this book, “Code Gray: Death, Life and Uncertainty in the ER,” author Farzon Nahvi, MD, has absolutely captured the essence of the great privilege, joy, despair and uncertainty of working in a modern urban emergency department. As an emergency physician in New York City during the early months of 2020 through the first wave of the deadly COVID-19 pandemic, Dr. Nahvi draws back the opaque curtain on what was really happening and how frontline medical staff were sharing information and trying to figure out how to treat the novel coronavirus.

The first COVID wave

Dr. Nahvi’s book is really two in one. The first part, entitled “Prologue,” was what the young doctor never expected to become part of his publication. When the epidemic of COVID-19 began, we knew hardly anything about the virus. The traditional timelines for testing evidence-based medical treatments were far too slow to be of use to the physicians, nurses and respiratory therapists faced with the first wave of afflicted patients. The author includes redacted text messages between himself and his colleagues working in the emergency departments of other cities.

In these messages, Dr. Nahvi and his colleagues describe running out of medications used to sedate before intubation, as well as shortages of personal protective equipment, IV pumps, antibiotics and ventilators. They describe the sheer ferocity and rapidity of disease progression. They discuss cases when COVID took patients before they even arrived at the hospital or intensive care unit. The author was particularly distressed over how he could accurately tell patients or their families about the terrible course and prognosis of COVID-19 that medical professionals knew so little about and were not substantially able to change.

The rapid spread of COVID-19 stressed a health care system that was already strained.

“COVID-19 was not a wrecking ball, then, but a magnifying glass,” wrote Dr. Nahvi. “It did not break American medicine but reveal it for what it has always been—long before the pandemic had ever hit, our experiences were challenging, strange and discomfiting. Our routine was to encounter impossible situations for which there exists no answers, and to answer them.” (p. 47)

Relaying bad news

The majority of “Code Gray” focuses on an intense examination of one particular afternoon in the emergency department that Dr. Nahvi calls “simultaneously routine and exceptional.” Although he focuses on the treatment of one critically ill patient and interactions with her husband, he loops in several other patient care experiences and the difficult lessons he learned during his years of training.

One point that Dr. Nahvi explores is the universal experience that physicians have when they must deliver bad news to their patients. In painful detail, he brings in several examples from his own career and others’ of how physicians routinely fail in this endeavor. He notes that the softening of bad news with euphemistic language like “mass” instead of cancer or “not doing well” instead of dying only harms the patient or the family.

“Ultimately, using anything but honest and frank language is not something that we do for our patients, but for ourselves,” wrote Dr. Nahvi. “We may believe we are softening our blows for our audience, but we know that in the end, doing so does not actually help them … we do this to avoid our own discomfort.” (p. 153)

Tied back to the central patient case narration, Dr. Nahvi faces the uncertainty of how to deliver the devastating news of the patient’s cause of death to her husband. Even exposing that one fact opens a gray area of questions and conundrums. The author presents many of the dilemmas faced by compassionate physicians and health care professionals: What can we do when the rules of the system deny treatment to some or offer no realistic care for unhoused or uninsured people in our care? How can we be honest with our patients without blaming them for their illness or injury?

“When I was a medical student, many of the professors spoke about the sense of pride we would one day feel upon appreciating the awesome responsibilities that our profession entrusted us with,” said Dr. Nahvi. “They never once mentioned the inverse. They never mentioned the deep sense of shame we routinely feel in knowing that our profession lets so many of our patients down.” (p. 175)

Connecting with physicians

The professors did not know yet about the prevalence of moral injury and burnout. Dr. Nahvi knows and shares thoughtful explorations of the gray areas with his readers, not just in the abstract, but with real and relatable patient case histories from his years training in residency and as a young attending physician. For the public, much of what they read in “Code Gray” may be new and shocking in nature.  Physicians reading the book will find themselves nodding in agreement and remembering many similar situations that they lived and worked through.

Dr. Nahvi artfully presents the trials and tribulations of the emergency department, not just the exciting narrative, but as a metaphor for life in general.

“Life sometimes contains no perfect solutions and no correct courses of action,” said Dr. Nahvi. “We are often surrounded by unknowns, and yet we must take action. We are routinely presented with the impossible situation where there exists no right thing to do.” (p. 139)

Readers will come to understand, through Dr. Nahvi’s detailed and lyrical prose, how uncertain the art and science of medicine actually is.

Related reading:

Fewer physicians are pursuing emergency medicine

Breaking down the concerns about the future of emergency medicine