death


Christos anesti! Elithos anesti!

Alleluia.
Jesus Christ, the King of Glory, has risen from the dead.
By death he trampled on death,
And gave life to those who were in the graves.

Christ is risen! Truly he is risen!

It’s a bad day. I discharged my poor fellow with terminal cancer – again. We ended up crying and holding each other’s hands, and it was all I could do not to hug him, because if I had he would never have let go, and I would have dissolved, and it would have been too hard to go on to the next patient. The fact that he’s a little demented and doesn’t remember the details of our conversations doesn’t make it any easier to say goodbye to him.

Another patient, a good ways out from a big surgery, had a major setback today. We were all crushed. We thought he was good, he was flying, he was going to be a success, almost ready for discharge – and now this. So utterly disappointing.

I keep doing stupid little things; nothing major, I just can’t seem to get the details right. I feel like an idiot, and like everyone else thinks I’m an idiot. It helps a little when the OR nurses say things like, “Oh, here’s Dr. Alice! So nice to have you today!” But really, it doesn’t matter if people like me, if I can’t do my job as well as I ought to. Being friendly isn’t a substitute for getting things right, because people’s lives depend on me – and will do so even more next year.

And tomorrow, I’m assigned to a case which has an 85% chance of turning into a real mess. The other interns and I have been playing hot-potato with this scenario, and I lost. Hopefully we’re overestimating the potential for all-around trouble; but with our luck so far, we’re only underestimating.

And I have a beautiful controversy on my blog, and I don’t have time to write as much as I want to.  :S

But I am still thrilled to be doing surgery. I’m just getting to realize what fun it is to have spent an entire year (mostly) on surgery, not rotating through other things like medicine and peds and neuro. So nice to be out of medical school and able to throw all my energy into one area. (And seeing how little all that has accomplished, it’s a good thing I haven’t had any more to work on!)

The other day I saw my first ED thoracotomy. For those of you who aren’t medically fluent, that means splitting someone’s chest open in the trauma bay of the ER in a usually doomed attempt to save their life by cross-clamping the aorta to prevent bleeding, and dealing with fatal holes in lungs and heart. The success rate if this is performed for penetrating trauma (gunshot, stab wound) is commonly reported as somewhere near 5%. Perhaps not that much, although we did recently have a guy be discharged less than a week later. The indications are few and far between: for blunt trauma (which means that the attempt will probably be worthless, since if the person is dying of a blunt chest trauma it implies a massive disruption of the aorta, or something else impossible to fix) it’s only strictly indicated the patient codes while being wheeled into the trauma bay, or shortly thereafter. For penetrating trauma, the rules are a little broader, involving loss of pulses anytime after the medics get there.

The trauma team was short-staffed. It was the kind of day where all the junior residents know they’re supposed to come and help if things get hairy and they can manage it. When the page went out, “trauma code, gunshot wound to chest, unknown male, intubating, eta 5 min,” we knew it was finally real. Our trauma center tends to do a lot of fake penetrating trauma: gsw to chest, really through the flesh of the shoulder; gsw to abdomen, a glancing blow across the flank; stab wound to chest, a 1cm flesh laceration; and so on; which are all billed as trauma codes, because they’re quote penetrating. But if this guy was getting intubated – that’s real. I was in the ER anyway seeing a flow of consults, and now I was just waiting for CTs to get done. I knew they wouldn’t happen while there was a trauma in the vicinity, so I had time to go see.

The trauma chief and intern always put on gowns, face shields, and shoe covers for these things, because you never know how much blood there will be. This time we all, including the attending, who rarely has to get his hands dirty, covered ourselves from head to toe in paper and plastic. The trauma bay looked more like an operating room than a space in the ER by the time the ambulance rolled up. The trama chief, who’s done this a couple times before and doesn’t really need instructions from the attending any more, was very organized, determined to avoid the kind of chaos that sometimes ensues when a trauma is halfway between nonsensical and deadly serious. He handed out orders: I’ve got the thoracotomy tray, you put in the left-sided chest tube, you do a cut-down and get access, you look for an ABG, you’ve got the airway, you help with the airway, keep xray out of here there’s no time for them.

One of the techs looked out the door as the ambulance rolled to a stop. “They’re doing chest compressions, guys,” he reported; and the chief broke the final seals on the sterile thoracotomy tray.

The medics wheeled in, transferring the patient onto our gurney, giving their meager report: gunshot wound, down for maybe twenty or thirty minutes by now, maybe more, pulses in the field, lost in transport, finally intubated a few minutes ago. Then there was a perfect storm of activity, but all in dead silence, because no one needed instructions, and we could all tell by the skin’s gradual transition from pink to grey that this story was not likely to have a good ending.

I think my mind did something funny, because I somehow didn’t even look until the chest was wide open and the chief had his hands deep inside, probing for the aorta to cross-clamp. Ok, so I had been assigned something else to do, but you would think I would look at the first time I’ve ever been present for this legendary maneuver.

It didn’t matter, in the end. The bullet had torn straight through the apex of the heart, shredding the muscle. A liter of blood and clots poured out when the chief had the chest open, and then the heart was loose and floppy in his hands. The hole was too big and ragged to do anything about, and there was no blood left inside to try to keep in, anyway. (Which makes me question the theory of his having had pulses until just before he arrived; I don’t see how he could have lived twenty minutes with that big a hole in his heart. Tamponade, maybe.) Somebody had good aim; unusually good aim; fatally good aim.

(The cops are kind of funny at these scenes. They hang around at the edge of the trauma bay, fascinating to us because maybe they know what happened, and we don’t, and most likely they’re going to arrest someone based on what our attending tells them. Then one of them steps forward as the assembled techs, nurses, and ER residents fade away, and asks, “Is he deceased, then?” And we all shrug, and I’m left to answer. “Yes sir, he’s dead.” His chest is gaping open and most of his blood is on the floor, there’s a tube in his throat that’s not connected to anything. Yes, he’s dead.)

Everyone else is gone now, and it’s just handful of surgery residents left standing in the blood and litter of papers on the floor. The man’s face is completely grey, a strange contrast to the blood scattered so liberally over the rest of his body, and indeed over us as well. Without a whole lot of conversation, the attending grimly motions us all over to the right side of the chest, determined to make sure that we all know what the aorta feels like when you’re hunting for it blind, arm reaching in past the elbow, the view obscured by the lungs being inflated by the ventilator, and no time to think. Based purely on feel, the chief had somehow separated the aorta from the heart above it, the esophagus beside it, and the spinal muscles behind it, and clamped it just above the diaphraghm. It felt strangely limp, unnaturally empty. For this guy it’s too late; but we’re not going to waste the opportunity, since nothing can hurt him any more, to learn things that could save someone else’s life in the future.

It was somehow not as dramatic as I’d expected, the actual event. Perhaps because the conclusion was so clear from the moment the medics walked in. Perhaps it would have been different if we’d really though there was a chance.

But it raised the same old questions for me: the chief tore this man’s chest open and plunged both arms in, recklessly dissecting down to the aorta. Will I ever be able to do this? Do I want to be the kind of person who can do this?

The chief said almost nothing, before, during, or after the incident. He’s grown a silent, protective face over the last year. I remember in July, his face used to give things away, and he would get hurt by it, when confronted by an attending in the OR or in M&M conference. Now his face is almost always the same, no matter what’s happening – years older and locked like a bank. He’s got two months to go on trauma; and that’s the only thing pulling him through; that, and his wife. So I think inside, things like this disturb him, too; but he doesn’t talk to us much about it anymore. Maybe his wife hears, but no one else.

They sent me on a donor run today. A donor run is when a transplant surgeon travels to an outlying hospital to harvest organs. As far as I can tell, there’s a call schedule shared between the transplant surgeons in a large area, but going out usually implies that you plan on using at least one of the organs at your own institution. Usually this is the liver, since this is the trickiest to harvest correctly, and the surgeon likes to know that no useful pieces were accidentally left behind, and no unrecognized variant arteries were damaged.

“They” sent me, as in the senior residents universally declined to go (bad time of day, weekend, weather, etc), and were secure in the knowledge that I would jump all over the opportunity if they let me. When I told the attending I was being sent, his response was: “You? !! Oh, really. I guess so.” Later on: “Why on earth did they send you? Where are the other guys? They’re a bunch of lazy slackers . . . I’m going to be grouchy about this for an hour. Go to sleep.” Five minutes later: “Do you tie well?” Me (afraid to claim something I won’t be able to live up to): “I wouldn’t want to say that.” Surgeon: “You should be able to tie well. If not, you should be practicing. If you can’t tie well, no attending will let you do anything. . . So, Alice, can you tie?” Me: “Oh yes, very well!”

This surgeon is young, dedicated, ambitious – aggressive, even. He makes himself available at all hours, ready to go on donor runs at any time, and then come back and spend the next eight to twelve hours transplanting what he harvested. I called him once at night to say I felt uncertain about a patient. He reassured me over the phone, and then fifteen minutes later turned up in the patient’s room, sitting down to chat with him, and then to explain the lab results to me in detail.

He holds himself to very high standards, and he demands the same from the residents. When he called to tell me to go on this run, one of the senior residents remarked, “He’s an old school surgeon. If things aren’t exactly right, he’ll get upset. Don’t take it personally.” I’m still not sure what he was talking about. I take this attending’s remarks personally to the extent that I’m pleased he recognizes me now, even if he’s not exactly thrilled to have me with him. I’ve made mistakes around him, and he knows that. On the other hand, after a few hours of sleep, he was much more cheerful, and by the end of the trip kept repeating how much I’d learned today, and how I would learn even more, and get to do more of the procedure, on future runs. I know that I don’t know enough – anatomy, surgical technique, transplant lore – and the best way for me to learn more is to have him firmly unhappy when I don’t work hard enough.

As for the procedure itself, what can I say? Regard for current news prevents me from going into much detail, except to say that the patient had sustained clearly unsurvivable injuries, and was pronounced brain dead before we were even called. The entire proceeding was marked by respect for the family’s wishes (allowed to take this, not allowed to take that, make things look good for the family), and some (limited) sorrow over a young person’s tragic death. Not too much of that, however, because frankly this is a brutal procedure, and the only way to do it is to completely block consideration of the donor as once-living (he’s dead now, completely dead now) and to concentrate on the patients whose lives will be saved by what we did. I did my best to do exactly what the attending wanted, and although my skills still leave a great deal to be desired, I did tie well enough not to tear blood vessels or leave them leaking, and at least I answered all the anatomy questions correctly.

Some people question the ethics of transplantation, denying the existence of “brain death.” I’ve thought about this a fair amount, since this would be absolutely impossible to do if there were any question of the donor being in any sense alive. (Remember that one of my reasons for staying out of ob/gyn, in the end, was concern about the abortifacient nature of contraceptives, since almost every single one acts in some aspect by preventing implantation of a conceived child.) I concluded in the end that brain death, when rigidly defined (absence of every single brainstem reflex, no confounding circumstances, after extensive testing) and properly diagnosed (by two doctors from separate services, apart from the transplant surgeons) is a real entity. This patient, for example, still had oxygenated blood flowing to his organs, but only because of aggressive ventilatory support and several iv pressors. In fact, our work was made more difficult by the fact that he was becoming very difficult to oxygenate, or to maintain a pressure on. He was indeed dead, and his body was on the edge of shutting down despite all our technology. We hastened nothing. I think some of the lay objections stem from a confusion between brain death (the concept that the brain is as vital an organ as the heart or lungs, and once it stops working, the rest of the body will follow shortly) and “permanent vegetative state” (which is a vague and difficult to diagnose condition in which the person breathes on their own, but doesn’t seem to respond to stimuli; this is what people recover from on very rare occasions). People cannot recover from brain death.

The other night I wandered into the ICU just to look around. Our vascular surgeons seem to be going through another AAA phase, with record numbers hitting the door in the last few weeks, and I wanted to see how things were going in the ICU.

I found one of the junior residents, Joe, just getting into a difficult discussion with a patient’s family. He was an old man, with a lot of problems, and this time around they had all caught up with him at once. He was in respiratory failure, on a ventilator; his kidneys were failing, and he had already had one round of dialysis; his blood was filled with a raging infection, which didn’t seem fazed by all the antibiotics he was receiving; his liver was starting to look bad; and the monitors were showing more and more abnormal beats, indicating that his heart didn’t have far to go either. The resident explained to me, behind the nurses’ station, that he had received a very frustrated signout on this patient: “He’s in multi-system organ failure. There is nothing we can do for him surgically, or medically either. He shouldn’t even be in the surgical ICU, since he hasn’t had surgery recently. Just make the hospitalists take him, or something. It’s hopeless.”

Joe was not one to take a passive approach. He decided that since no one else had managed to get very far in talking with the family, and since he didn’t want to be the one running multiple hopeless codes on this old man through the night, until finally he didn’t respond to ACLS protocol any more, he would tackle the job of getting DNR status from the family.

I was frankly curious. Much as I hate to think about it, in four months I’ll be the one left over night with four or five ICUs full of patients, and I’m sure it won’t be long before I run into this problem. I wanted to hear what he said. It helps that Joe is about six foot four, with a quarterback’s build. I don’t think I’ll ever make as impressive and authoritative a figure as he does. He told the son and daughter quite bluntly that their father was in bad shape. He explained how all his organs were failing at once, and went through the list of heroic interventions which were necessary just to maintain the status quo. Then he got down to it. “Your father is not going to survive this. I’m sorry to say this, but he is going to die, soon. The question is, how much more do you want him to go through before he dies? Right now, if his heart stops, we’ll do everything we can, giving him drugs and pushing on his chest. It might work for a little while, but it’s not going to reverse what’s going on here.” Within an hour, they signed DNR papers, and the old man died that night.

I believe that what Joe did was good. He helped the son and daughter understand what was happening, probably better than anyone had before. He helped them come to some kind of terms with their father’s impending death, before it happened. He decreased the patient’s suffering, by not forcing him to go through futile codes, and letting him go a little more peacefully. He helped the surgical team, by solving a problem for them.

I’m sure that within a year, I will do the same thing. But right now, I can’t picture it. I tried to imagine the words in my mind, but somehow, despite how much my understanding of “end-of-life issues” has changed in the last eight months, I still can’t make those pessimistic words come out. I still try to think of what might happen well, how things might turn around. I tried to imagine a discussion about “do not intubate” status, which is an oxymoron and a disaster (how can you code somebody, or even try to do pressor support, if you can’t maintain an airway? it’s useless). Some recent tragedies have demonstrated that DNI status simply ties the doctors’ hands. The patient should be either DNR, if everyone is ready to let go, or full code, if it seems like a survivable illness. But whenever I try to put words to that, I find myself arguing for full code. Maybe things will get better; we shouldn’t give up yet.

I think Joe had it on his list for the night: “Check CBC on Mrs. Adams. Serial abdominal exams on Mr. Jones. DNR status, likely death, of Mr. Smith. . . ” Maybe after I run a few hopeless ICU codes, it will be easier to go hunting for DNR status, just another item on a list.

I hate walking past the ICU waiting room at 5am. Usually the people there look burdened by sadness, eyes wet and red, but at that time of the morning – or even worse, at midnight – you know they can only be there because a family member is close to death. The grief and tension are palpable in the air, radiating from their tense postures. I can’t bear to look at their faces. The surgery ICU is especially bad, because I wonder which one of us is failing to help them. It feels as though all the residents and attendings are one group, sharing coverage responsibilities, and it touches all of us when we end up with families sitting in the waiting room at 5am.

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Sunday night is usually bad. The nurses are disgruntled about working the last shift of the weekend, the residents who were on during the day don’t clean up as neatly as on a weekday, and the patients who were trying to wait out the weekend finally give up and come in to the ER.

I spent the first four hours handling situations that had been developing all day. The patient had been short of breath, and finally somebody noticed that they were desatting as well. The patient had been tachycardic, and the nurses decided it was high enough to be worth calling me about. The patient had been febrile all day, and now high enough to need some investigation. And the ICU patients were apparently falling apart just the same, only more so, so Brad was too busy to help me at all. Amazingly enough, everyone turned out ok.

Sometime in the wee hours of the morning, the code pager went off. I had just dozed off, and was so startled I didn’t even go to the correct floor at first. It didn’t really matter, because it was one of those “patient found down, we just noticed” kind of codes, where the patient was clearly -dead- from the beginning. No lines were called for, so Brad and I stood in the corner and watched. (Or rather, I watched, and Brad critiqued the medicine residents running the code.)

Two hours later, the pager went off again, for a room just down the hallway (yes, you’re correct, this is one of the floors the surgeons hate). It felt like deja vu, but at least I managed to get the right floor. I had the line kit opened by the time Brad arrived, but I figured he would want to do it himself, since this was a witnessed arrest and thus rather more urgent. I should have known better. Brad can be quite arrogant and abrasive (for this whole code, he was telling me things like, “What do you think you’re doing? Don’t you know how to do that? Come on, you know better than that. What are you thinking?”); but he does want me to learn. He made me put the femoral line in, and completely to my surprise, it actually went where it was supposed to go, and fast enough to be useful for fluids and drugs.

So now I feel bad, because I was just thrilled to have gotten the line in, and couldn’t even particularly consider the patient, who is no doubt dead by now. Which is really awful of me to be happy on such an occasion. But now that I know how, I should be able to manage much more easily at future emergencies. So I’m grateful, in a very weird way, to this patient for teaching me this, and to Brad for making me do the line.

I got a page from the nurse: “Dr. Alice, do you think you could come see Mrs. X? She’s very anxious, driving herself and us up the walls. She and her family are demanding to talk to a doctor about her condition.” “Her condition” being metastatic cancer. Sure, I would love to come talk to her.

I took a brief detour past the computer to review what I thought I knew about her cancer. Yes, very short life expectancy. Yes, very unsuccessful treatments. Yes, only a few experimental trials. Great.

We found an empty room to sit down in, and talked. Fortunately, a lot of it was her just wanting to talk about how miserable she’d felt, and how we’d neglected some of her needs. Which we had, so I apologized, and straightened things out with the nurses. But finally, she and her family started asking about what treatments were available, and how soon they could start. I got through it somehow, mostly by promising to go get a more definite answer from the attending; that was one question I wasn’t too afraid to ask him, since he’s very gentle and careful about his cancer patients.

At one point they did ask something about prognosis, and I made some kind of statement involving the phrase “metastatic cancer.” I knew the attending had talked to her family right after surgery, and to her the day after. I assumed he’d used those words, since everyone on the team had known it from the moment the incision entered the peritoneum. Nope. There was a blank look on their faces, and I backtracked hastily. Fortunately (this time) I tend to speak really fast under stress, and sometimes pretty softly. I think most people in the room missed what I said, except for one son who looked far more enlightened than I could wish. . . I asked what the attending had told them, and then stuck to his phraseology: “a little too large to remove with surgery.” I should just play dumb more often. Just because for once I did know the answer, doesn’t mean I have to show off by giving the answer.

I hate being the intern, totally ignorant about prognosis and treatment, being the one available to discuss all this with the family at the time that they’re all visiting on the floor. I hate being in the dark about what the attending said and what his plans are, and being left to trip through minefields, damaging the patient’s morale and their rapport with the attending. I hate cancer; and I really hate metastatic cancer.

Mrs. X is a Christian, I believe. I have prayed with her, just about recovering from surgery. I think it would count as undermining the attending’s plan if I tried to say anything comforting about death itself, since he doesn’t want to go there with her yet.

From rounds:
Med student: “. . . Besides which, her white count is up today from 16 to 18,000.”
Attending: “What’s the difference between 16,000 and 18,000?”
Med student (obviously thinking he’s got an easy question this time): “Um, 2,000?”
Attending: “No, zero, because it’s within the range of lab error.”
After which the chief ordered cultures anyway.

From the OR:
After we’d moved the patient from the OR table to the bed:
Anesthesia resident: “He’s desaturating. . . ambu-bag, please. . . this isn’t working, I’m going to have to intubate him again.”
Surgery resident, to the ceiling: “Interesting, that’s exactly what happened last time.”
Anesthesia resident, curious: “You mean this happened before?”
Surgery resident: “Yes, when we did the first surgery four days ago, he had to be reintubated after moving off the table. Good thing he’s got an easy airway.”
Moral, not to assume that people know things. You’d think that such a significant event occurring only a few days ago in this very hospital would be mentioned between members of the anesthesia team caring for this guy; but I guess not. It’s our fault, anyway, for assuming that the anesthesia resident knew what had happened. We should have told him. Better to remind your colleagues of something they already know, than for everyone to overlook an important fact. (The patient is doing fine.)

From the floor:
Nurse: “You’d better come see this patient. Something’s going to happen.”
Me: “Why, what are his vital signs?”
Nurse: “Pressure’s ok, but he says he’s got to go see the Blessed Mother, that she’s in the room calling to him.”
Me: “See who?” (I’m not used to the Catholic phrases that are so common around here.)
Nurse: “Mary and Jesus. He says they’re talking to him. You’d better come. The last three patients who told me that died within an hour.”
Fortunately, this patient didn’t. We had a long and rather wild delirious theological conversation with him, attempting to persuade him that Jesus and Mary could wait for a while (good thing at least one of the nurses was devoutly Catholic too, since my Protestant tendencies are too strong to allow me to discuss visions of the Blessed Mother with a straight face). The next day the anesthesia drugs finally wore off, and he became quite lucid; still devout, but not as frightening.

Other than that, this service is starting to get to me. Too many cancer patients. I guess I didn’t realize how much cancer showed up in general surgery; I thought you had to go into surgical oncology to get this involved. We sent yet another patient home to hospice today, we added on an emergency case for which the final diagnosis is probably going to be cancer, and we shortened the OR schedule considerably by opening one of my favorite patients, taking a quick look and a few biopsies, and sewing up again because the cancer was so widespread. Then there’s the poor little lady with advanced cancer who looks like a skeleton, literally. She’s scaring the nurses, because you have to watch for a couple minutes to be sure she’s breathing. They keep moving her closer and closer to the nurses’ station because she makes them so nervous. For some reason, the attending hasn’t talked to her and her family about DNR status yet, or at least hasn’t signed the papers, which makes signout pretty uncomfortable: “And then there’s Mrs. Smith, whom you know; she’s still a full code, I’m sorry, I’m really hoping it doesn’t happen tonight.”

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