This morning was formal rounds, with the attendings. One by one they left for clinic, till the remaining team members were down in the ICU. The chief’s pager went off. After answering the phone, she started running up the hall, calling over her shoulder, “Mr. Abbott is arresting!”
The junior resident and the medical student and I ran off after her, tearing through the crowded back hallways around the ICU till we got to the elevator, to go up several floors. Of course this would be the moment when the elevators absolutely refused to come to the floor we wanted, and when we finally got one, it was crowded, and already
punched to stop at every single floor on the way up. Part way there, the chief left with everyone else, and we saw her running towards the stairs, muttering, “Medicine residents coding my patient. . .” (Apologies, medicine folks; yesterday one of the medicine seniors wrote in the chart that our patient had rebound tenderness and peritonitis, when of course he didn’t have anything of the sort. . .)
Finally, we all arrived in the room at the same time, and found that another surgery resident had been on the floor, and things were fairly organized, but not looking good. As we struggled through the ACLS algorithms, all I could think of was, This was the first patient I met, at 4am yesterday, on this service, and he smiled, and didn’t complain about being woken up early. The first patient, and after only one day I felt like I knew him pretty well; and now . . .
During pauses in the code, while one person was doing compressions, the anesthesiologists were bagging, and everyone else was waiting to see if the most recent drug would help, we asked the nurses what had happened. Most of us had been in before attending rounds started; we had talked to him, more or less (the med student most, of course). He had seemed fine. And now all of a sudden, he was “found down.”
After a long time, it became obvious that his body was becoming colder and grayer under our hands, and nothing we were doing was making the slightest difference, or getting the tiniest response from him. (I hate dressing up for surgery work. It’s very awkward to work a code wearing a skirt and a necklace.) The attending and the chief agreed that they couldn’t think of anything else to do, and called the code. We filed out of the room, fiddling with our coats, or the pieces of paper and plastic scattered around the room, suddenly all ignoring the man who a moment before had been the center of attention.
We called the family members, who had not been in the hospital, and had to break the news over the phone – what an awful way to announce someone’s death. (I admire the way the attending didn’t push this job off on to the chief, but did the talking himself, in a straightforward and honest way.) They consented to an autopsy, and this afternoon we trooped down to the path lab to see what would happen. Which was fairly awful. You would think it would be hard for blood and dissected body parts to bother surgeons, but seeing our patient’s body spread out in the morgue was very disturbing. I think it was his face, which was quite still, and rather sad, not quite accusing. Usually surgeons are very careful to cover people’s faces before getting down to business. It didn’t make things any better that the pathologist discovered a problem quite the opposite of what we were expecting, which there had been no clinical warning of, and which ought not to have caused sudden death.
I feel horrible for the chief. She’ll be presenting yet again at M&M. She takes these deaths very personally (as she should). To me, even though I was starting to feel a connection to this man and the others on our service, they’re still not quite mine. They’re the attending’s patient, or the chief’s patient, and I’m taking care of things on their behalf. But for the chief, this was her patient. She had operated on him, had watched him carefully for several days post-op, had been looking forward to sending him home soon. . . and he’s dead. And yet, in a way, there’s a good side to the story. They had been unable to completely remove his cancer, which had turned out to be very invasive. Even if he had survived this admission, he would be dead within a year, probably quite miserably. But instead, he died quickly, and in fact without ever having to hear that he had metastatic cancer. That’s perhaps not the worst possible outcome; but it wasn’t our plan.
August 2, 2007 at 7:43 pm
“It didn’t make things any better that the pathologist discovered a problem quite the opposite of what we were expecting, which there had been no clinical warning of, and which ought not to have caused sudden death.”
So how do we know what the patient died of? Can an autopsy reveal the actual cause of death? Did this fellow really not know he had metastatic cancer?
Learn as much as you can, but don’t think that surgeons or doctors can have all the answers.
August 3, 2007 at 1:11 am
Found your through tags on WP. I enjoyed your article. I’m a nurse of 17 years now (wow, I’m aging…) and feel some of your pain. Thanks for sharing your viewpoint. I wrote some about death tonight, as we face it more than any of us who wanted to “help people” ever really wanted to. Visit anytime.
Good luck with your journey!
August 3, 2007 at 6:12 am
Thanks, houkhouse. Enjoyed your post.
Robert – Well, we don’t currently know what the patient died of. Maybe the microscopic part of the autopsy will show more, but what we saw didn’t explain his death. Not sure what your second question is getting at. If you see an aortic rupture, a saddle embolism, a completely blocked LAD, a massive cerebral hemorrhage, that would tell pretty clearly what a person died of.
August 3, 2007 at 11:02 am
Since I’m guessing he had metastatic pancreatic cancer (just by your description of the service you are on) this death was probably preferrable.
It’s sad his family wasn’t there but it seems that the people who were with him did care and did grieve for the loss of his life in their own way. He was Mr. ‘Abbott’ to y’all, not Bed 3.
Don’t ever lose your attachment to the humanity of your patients Alice and you will be a great surgeon. I’ve dealt with the ‘soulless’ surgeon and dealt with the caring ones. I understand how much it takes out of someone to not distance themselves from their patients, but as patients it makes all the difference in the world.
My grandfather died in a similar fashion. Up talking to the doctor during morning rounds, eating his breakfast, telling the doc he was going to get up and shower and shave when he was done eating. 30 minutes later the aide went in and he was dead. Blessedly, he was a DNR, so they just pulled the curtain, straightened him up, called my family. No drama.
Take care
August 3, 2007 at 7:44 pm
It’s funny, the fact that Mr. Abbott could be annoying as well as endearing somehow just made our relationship with him even more dynamic. He was a real personality, and today the whole unit was still dealing with his death.
I’m sorry for the loss of your father, but it sounds like a good way to go.
August 7, 2007 at 5:43 pm
Dr. Alice,
Sorry I was so terse. It is a curse.
Since you have been on my blog, you might have noticed that this idea that we know what our patients die of bothers me. In the case of your patient, you did not see anything as dramatic as you mention. But even if you had, that is not necessarily the actual cause of death. The PE, the LAD blockage, the aortic rupture, the cerebral hemorrhage may have been present at death, caused by the same process as the cause of death, or been irrelevant. (I realize that the last sounds unlikely, but consider some of the great MI studies that are coming out now.) And they may be proximate causes but not the more important cause.
A fellow left lying in a hospital bed while someone tries to figure out obscure symptoms develops a clot, thrown to his lung when he gets up to shower. What caused his death? A fellow who knows he is dying because he just knows, then has sudden cardiac arrest. What caused his death?
A fellow who is blood thinners to prevent the aforesaid while he lies in bed in the hospital for a reason less than happy to him, has a cerebral hemorrhage. What caused his death?
A fellow who has lived a long life ruptures his aorta lying in a hospital bed for vague symptoms. Maybe he had syphilis when he was younger but had repented and was faithful for decades. What caused his death?
A fellow who is old and full of years lies down and takes his last breath. What cuased his death?
A fellow who silver cord is loosed, whose golden bowl is broken, whose pitcher is shattered at the fountain, whose wheel is broken at the fountain. What caused his death? Vapor of vapors. All is vapor.
August 7, 2007 at 6:10 pm
Robert – In a metaphysical sense you are right. But practically speaking, our entire system of science is built around the presupposition that since God is faithful, natural laws will remain in effect barring a miracle, and causes will have reliable effects. We do not, like David Hume, refuse to believe that because a thing falls to the earth a thousand times, the thousand and first time it will necessarily fall as well. So, if someone dies suddenly and has a saddle PE, one can assume the death is related to that. If someone has a ruptured aorta, it’s reasonable to conclude that that is the immediate, physical cause of death. Moral causes are indeed beyond our reckoning and in God’s hands.