I looked over at Crystal, the nurse who was recording for the code, and asked her to please advise me at two-minute intervals so we could keep track of our pulse and rhythm checks as well as when medication administration would be due. Over that time, I completed my physical exam: Good air entry in both lungs, and the patient’s oxygen saturations were in the high nineties, with the respiratory therapist’s continuous bagging, both signs pointing to the endotracheal tube being in good position. The patient’s fine salt-and-pepper hair bounced with each chest compression. Her plump olive skin was segmented by deep laugh lines, giving her face a wise and honest cast. Her heavy lids were coated with shimmery peach eye shadow and charcoal eyeliner; I lifted them to reveal large black pupils that were fixed and dilated. Her body showed no signs of trauma and no signs of movement save for the give-and-take of CPR. Her belly was soft.

“Four minutes. It’s time for epi this time,” Crystal announced.

No pulse at the neck. No pulse at the groin. The same fine line slithered across the screen, but this time it was almost entirely flat.

“Another epi, please, and let’s resume. Can someone go get the ultrasound for the next check? She’s down at least nineteen minutes, with no return of circulation and no meaningful rhythm. If people don’t disagree, I think we should call it at the next check unless there’s a change.”

“Definitely,” Crystal said. Heads nodded all around.

“Is anyone here with her?” I asked.

Tina, the tech, responded. “No. EMS said the family stayed behind because they had to make some phone calls. They should be arriving soon.”

“Okay,” I said.

We heard a clanking, crunching sound.

“There goes a rib!” said Jared, the nurse who was performing compressions.

“Yeah, but what’s the clanking?” Crystal asked.

We looked around the room. The bed was locked, and no equipment had fallen. Tina, the tech on the left side of the bed, lifted Ms. Giannetta’s left arm, raising her hand. Her nails were painted with frosted pearl polish. On her ring finger: a two-toned wedding band of yellow and white gold curled around three tiny antique diamonds whose settings resembled a row of gilded baby’s breath buds. Her fingers curled limply over Tina’s palm.

Tina looked up at us. “Her ring. Her wedding band is hitting the bars.” She then lowered Ms. Giannetta’s arm gently to the bed and positioned it closer to her body. No more rattle.

“Time!” Crystal said again.

No pulse. No heart sounds. No breath sounds. An increasingly fine and slow slither across the monitor that was now arguably flat by all measurements.

“Nuthin’, guys,” I said and pulled over the ultrasound machine. “Let me just check her heart for any beating.” I squirted a quick blob of jelly over the center of her chest and then placed the probe on her anterior chest wall, over the region of her heart. Turning my gaze to the screen of the ultrasound machine, I saw the thick gray chambers of the heart lying flat, with stagnant black holes for blood. The only movement was my hand swiping back and forth as I viewed the still, silent organ.

I removed the probe and replaced it in its holster. Looking up at the clock, I announced, “Time of death, four twenty-nine p.m.” I continued: “Okay, I’ll get to the documentation and calls to the medical examiner and organ donation. Can y’all please tell me if and when the family arrives.”

“Sure thing,” Crystal replied.

I sat at my desk, asked the clerk to get the medical examiner on the phone, and opened my chart to document the code.

“Doc . . . Doc?” A voice called out in hesitant upspeak.

I turned to see Crystal with one foot in Ms. Giannetta’s room and another pointed toward me.

“Yeah?” I said.

She was looking at me quizzically, her mouth open, but instead of words, she let out a sigh.

“Ummmm.” She narrowed her eyes and pursed her lips. “You know, I think you should just come back here and see.”

I felt a kind of instant dread. You never want to hear one of your colleagues say, “I think you should take another look at this.” Just as you never want to look down to see that the ultrasound-guided peripheral IV it took you four attempts and twenty minutes to place has red blood pulsing up into the IV tubing.

After two deep breaths, I followed Crystal back into the room.

Tina looked up at me with wide eyes as Crystal closed the curtain behind me. “Doc, she’s breathing!”

“What are you talking about?” I asked.

Tina pointed. “Doc, look.”

Condensation and slow swooshes of air rose and fell in the endotracheal tube. I listened at the patient’s chest to confirm. The monitor still showed a flatline. No pulses at the carotid. No pulsation at the femoral.

“Crystal, can you come over here and check, too?” I asked.

Crystal walked slowly to the left of the bed and placed the pads of her index and middle fingers to the neck. “Nothing,” she reported. Then she shifted to the left groin. “Wow . . . nothing.” She shook her head in disbelief.

We looked at each other.

I frowned and crossed my arms. “I’ve never seen anything like this.”

“Doc, I’m a heck of a lot older than you, and I’ve never, ever seen this happen. I mean, what the heck?!”

“Jackie!” I called out to the clerk. “Please tell the medical examiner never mind.” I looked back at Crystal. “I guess we have to cancel that time of death stuff and continue the code. While the ACLS algorithm doesn’t specify a case like this, I’m pretty positive I can’t pronounce someone dead who is still breathing. How she’s all of a sudden breathing while still having no cardiac activity, I have no idea.”

Crystal went back to the code sheet to document this new turn of events and called the crew back in.

“Jackie, please call Dr. DeLaurentis, since he’s covering the ICU. Luckily, he also happens to be her cardiologist. I’ll have to run this by him, I guess, for the sake of completeness. Can you also please call Respiratory to hook her up to a ventilator and page for portable chest X-Ray to confirm the endotracheal tube placement while we sort all this out? Crystal, she has two good peripheral IVs, so let’s start dopamine in one, since there’s clearly no blood pressure. Peripheral access is good enough for now, since I don’t know how far we can go with this.”

“Sure. Uh, I guess we kinda have to, don’t we?” Crystal said.

My medical training was little help in explaining what Ms. Giannetta was experiencing. Not only was this not the stuff of medical science, but it demonstrated its limitations in comprehending life on this plane.

“Dr. Harper, Dr. DeLaurentis on the phone,” Jackie called out.

I picked up my phone and relayed the whole fantastic story to him. He was a kind, gentle doctor, and I imagined that was why he received the story much better than I would have if someone had called me out of the blue to assume care of a patient who was, technically, not really alive.

I hung up and told the team: “Dr. DeLaurentis will be right down, and he’s gonna call the family, too. He knows them well.”

Within moments, Dr. DeLaurentis appeared in the ER. One never recalls exactly the details of an exchange with Dr. DeLaurentis because he swoops in mesmerizing. After the interaction with DeLaurentis, you know you’ve seen a man approaching in a smart Italian suit with coordinating classic leather dress shoes and belt, there’s the black hair combed back with a slight wave, and then the smile that illuminates the whole ER with its sincerity. But then the details of the conversation become hazy; you simply recall that he was there, and that made everything better. He approached me with outstretched arms.

“I don’t know what to say. I mean, when you called, I believed you, but I didn’t really believe you. I just examined her, and what?”

“I know!”

“Well, let me have a talk with the family, since I know them and I’d be the one to admit her. I’ll take it from here and let you know how it goes.”

“Please let me know if you need anything.”

It was always a lovefest with the debonair Dr. DeLaurentis. Later, after the family had arrived and he’d spoken to them, I had just finished repairing a leg laceration in Room 6 when he pulled up a chair next to mine.

“I had a long talk with the family. I was honest with them. I told them that given how long she’s been down with her heart not beating, there’s no way she’d have any meaningful brain function if, on the slim chance, she were to survive. They all said this is not what she would have wanted; she wanted to go peacefully and with dignity when it was her time. We turned off the vent and the dopamine. They’re sitting with her now. They’re just waiting for one of the daughters-in-law to arrive. Do you mind if we use your room for a little while longer? If this goes on too long, I promise we’ll move upstairs.”

“Not a problem. Please keep me posted.”

“Will do,” he responded before returning to the room with Ms. Giannetta’s family.

I saw a woman in tears being escorted by the triage nurse to the room only several steps behind Dr. DeLaurentis. This must be the family member they had been waiting for. I saw Dr. DeLaurentis open the curtain for her and then close it. After a moment, the beeps of the monitor stopped. Soon after, Dr. DeLaurentis returned.

“She passed away. Stopped breathing.”

“Just like that?” I asked.