death


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.

(the cedar waxwing expired not long after we last observed it, without any interference from the cat; an accidental poison ingestion is suspected; no autopsy will be performed)

The speaker at graduation was rather humanistic in his ideas, with great hopes for perfection through technology. However, he had an entertaining way of talking, for which virtue a great deal may be forgiven to a commencement speaker. One point he made, which was echoed by all the doctors in the family when we got home and started dissecting the evening. He talked about being at the deathbed of a patient who died joyfully, and going to the wake of a patient, at which he was the only guest, because there was no one (besides a very few family members) to mourn them.

My relatives, the doctors, told several similar stories from their experience, emphasizing the importance of doctors accepting the fact that patients will die, and then helping them with it, rather than remaining in denial. (Which reminds me of how upset the attending last month got with some of the heme/onc consultants, who would come see a patient who was obviously fast on the way downhill, with metastatic disease and many medical issues, and talk about some aggressive chemo or surgery; the attending would then come behind them and have what he saw as a more honest conversation about the seriousness of the patient’s condition (some of these people we saw clearly didn’t have more than a month left, and yet had not been told that they had a terminal condition), the very poor prospect of any benefit from treatment, and the possibilities for hospice and comfort care.)

I should have realized it before, I guess, but it only clicked the night of graduation: Doctors need to go to patients’ funerals(/wake/viewing/whatever). That’s as much part of the job as anything else. They didn’t tell me that when I applied, but I can see that it will be very important.

Saturday was a great call day. Most of the day was quiet, and I curled up in the residents’ lounge with my cross-stitch, alternating between a spy story and Advanced Surgical Recall. Beautiful. Since the lounge is provided with oversized leather recliners, it was even more comfortable than being at home.

Then, just as the intern prepared to join me and enjoy the baseball game on TV, the ER started calling. We had finished the first admit (a serious chest pain, no cocaine – we were delighted, especially since the patient wasn’t dangerously ill) and had just walked into the next patient’s room (another patient with an actual problem, for a change) when a nurse announced overhead: “Code Blue, ICU, Code Blue, ICU. . .” We hastily excused ourselves from the patient’s room and ran upstairs while blaming the intern for having lamented not having a code all month so far.

We arrived in the far corner of the ICU to find several nurses, the code cart, and a surgery resident who’d been in the ICU at the time it happened. I stood against the wall and tried to match events with what I remembered of the ACLS book. The patient was an elderly lady who’d been conversing with her family, then all of a sudden became unresponsive. Some of the family members were now standing in the hallway, while we desperately tried to figure out -what her electrolytes were -who her primary doctor was -what her code status was -what to make of the rhythm on the monitor.

I won’t go into every detail, because for those of you who know, the specifics don’t matter, and those of you who don’t know don’t really want to hear. But, it went on for more than an hour, getting her intubated, then her pulse dropping in and out, various arrhythmias showing up on the monitor, all disappearing into asystole or sinus before defibrillation was called for. I helped with CPR; I know I broke some ribs, and it doesn’t bother me, because that means I was for sure doing it right, unlike the last time I tried to help. I stayed with the residents as the extra nurses one by one filtered back to their main jobs, and the patient’s pulse continued to play hide-and-seek with us. I proved to myself that I could accurately tell when there was a pulse and when there wasn’t (not so easy – even the ICU nurses were sometimes puzzled; she had such severe vascular disease that one femoral pulse wasn’t palpable even when everything else was ok).

Things I learned: running a code isn’t impossible. In spite of the chaos, as people duplicated the same job, shouted back and forth, missed instructions, and so on, I could tell what was happening, I could see the outline of how it followed what I studied in the book, and I could almost tell what the resident was going to ask for next. There was a lot of adrenaline at first, after running through the hospital, and arriving in a room crowded with other equally excited people; but by the time we were well into the proceedings, I stopped being scared and could think about what was happening. I can imagine being the one running the code; it’s no longer out of the realm of possibility for me.

Also: I would rather be a surgeon than an internist. The surgery resident, although he’s one of the weakest in this program, knew what needed to be done, and was ready to give directions firmly enough to make some order out of the inefficiency that always prevails at the beginning of a code. He didn’t, though, because in this hospital it’s the medicine resident’s job to run codes (except on surgery patients), so he had to hold back and let my resident do things. She was obviously more flustered than he was, not quite sure what to do next, not able to take control of the roomful of willing assistants. She did the right things, got the patient intubated appropriately, and did succeed in getting a strong pulse back in the end; but she wasn’t comfortable, and the nurses knew that she wasn’t really in control. The surgeon definitely stepped on her toes, and she didn’t appreciate his forceful assistance; but it is always hard to let someone else make a bad job of something you can do well.

If I’m going to be a doctor at all (which seems to be pretty well settled by now), I want to be one who can handle serious emergencies. In my imagination, a real doctor is someone who can start any line, do intubations easily, handle procedures without getting nervous, and take control of an ICU code or a trauma resuscitation, and then some. I didn’t realize, when I first imagined it, that that really only describes surgeons (ok, and ER doctors); but whatever the price turns out to be, it will be worth it to be that competent. If you can handle codes and surgical emergencies, then it should be easy to wing through a hypertensive emergency, or DKA, or whatever else. I don’t think that I’m actually any less shy than the medicine resident; but I want to learn how be in charge so that things can run better for the patient, when being in charge is needed.

The patient coded again early this morning, and by this time her family were willing to agree to DNR, so that was that. But that was the first semi-successful code I’ve seen (as in, we didn’t have to stop the code that first time).

I was with one of the other doctors today. He starts earlier in the morning, and finishes earlier in the afternoon. For some reason, a quarter of his patients didn’t show up today, so he finished even earlier than he’d planned. He was rather puzzled, and not very pleased with this. As he wondered what had happened, I didn’t suggest that the power of my positive thinking about an earlier finish to the day had anything to do with it. . . Now if only I can make this work for trauma patients, too, that will be a real service to humanity.

One of the new patients was an elegantly dressed lady, actually what I would consider elderly, but very well-kept and spritely. Her hair was perfect, and her nails and makeup matched her crisp spring outfit. She had recently remarried, many years after her first husband’s death, and kept referring to her new husband fondly.

She has Parkinson’s. She was complaining of a tremor, but at first we could hardly see it, because she masked it so well by arranging her hands. The doctor had to ask her several times to relax and let her hands go so he could see what she had come to ask him about. When she stopped holding onto it, the tremor was very clear and fairly typical.

My grandfather had Parkinson’s. I hate diagnosing people with that. I think that was part of my problem yesterday morning: I just didn’t want to have to tell those nice ladies that they had it. (Tsk, Alice, that’s not how medicine works; wishing doesn’t fix things.)

The patient today did all of the undignified tests we wanted of her, and listened calmly as the doctor explained the diagnosis (much more bluntly than my usual preceptor would have) and the treatment options. She didn’t turn a hair while we were talking, but I could tell that she was probably going to have a good cry when she got out to her car. I wished I could say anything, but there was nothing that would help.

This rotation is probably the one out of all of medical school which has made me think the most about aging and mortality. These elderly patients come in, stooped over, hard of hearing, having difficulty finding words to explain their problems, accompanied by a sheltering son or daughter. Not that long ago, they were tall and proud and independent, soldiers, executives, craftsmen, teachers, socialites. I can’t really fathom how they manage the transition.

And then the way that a husband or wife will take care of their spouse. They come and explain the whole history, while the sick spouse sits still, mute, detached from the world. The stronger spouse can tell us all about the other, literally as if it were their own body they’re talking about. Both of them have long ago lost all resemblance to their wedding pictures, and often their personality is disappearing too, sliding away into the morass of dementia. And yet they remain loyal and dedicated to each other. Such impressive commitment, something that younger generations mostly have no concept of. Or does it come with age? I wonder what will become, in old age, of people who in youth make and break one relationship after another. What happens at the end? Do they change, or do they die even more miserably?

Last night I met the patient who’s probably going to be the first to die while I’m actually taking care of them.

Mrs. Buckley is in her 80s. She and her husband are still living in their home. Yesterday morning she suddenly collapsed, in the middle of a sentence. CT scan at the ER didn’t show anything remarkable, although by this time she was intubated and barely responsive to painful stimuli. An emergency MRI was arranged, and I caught up with her in the radiology suite, as Dr. Isakson had sent me to see her right away. The main thing to be seen were her eye movements, constantly rolling back and forth, back and forth, unfocused, unaware of surroundings. The nurses and I were very puzzled by this, but Dr. Isakson later dismissed them as “roving eye movements,” indicating brainstem function without cortical input.

I went to talk to her family and try to get some more history. They were all sitting in a small “family room” in the ER (why are the family rooms always dark brown and green, with low lighting? I wonder whether this color scheme helps, or not). In spite of myself, it was a rather dramatic entrance, because they all thought I would have something new to say. . . And all I could do was ask her poor husband to relive his last moments with his wife again.

Dr. Isakson broke his rule, and looked at the MRI pictures as soon as they were done, before seeing Mrs. Buckley. Now, when an elderly person drops down and doesn’t regain consciousness within a few minutes, it’s never a good deal. For Mrs. Buckley, it was a very bad deal. The entire front half of her brain was dark: no blood flow, totally ischemic. The MRA (angiogram) confirmed the unbelievable: both internal carotids were completely invisible. Only the vertebral arteries were visible, joining into the basilar artery that lies at the base of the brain and feeds the brainstem. The only possible explanation was that one carotid had become chronically occluded, and then that day a clot from somewhere suddenly occluded the other side. The end. (It would be too improbable for two such huge clots to enter both carotids at once.) Once she was settled in the ICU, we found that her neuro exam matched pretty closely: absolutely no cerebral function, and already a few brainstem reflexes disappearing.

Then Dr. Isakson had to talk to the family. As a neurologist, he must have to do this very often, deliver bad news with a bad prognosis and very little possibility of recovery. That’s why I’m puzzled by how diffident and uncomfortable he still seems. I mean, I don’t suppose you should ever become happy with telling such bad news; but he seems unusually ill at ease and uncertain.

Mr. Buckley was sitting on one side of the room, and hardly spoke at all during the whole meeting. His daughter seemed to take over for him, asking questions. After Dr. Isakson had repeated for about the third time, in simpler words, that Mrs. Buckley had had a massive stroke and was unlikely to recover very well at all, her husband suddenly covered his face with his hands and started crying quietly. Seeing this strong old man so broken, I felt like crying too. (Alice, what do you think you’re going to do in a surgical/trauma ICU if you start crying every time someone’s family does?) Dr. Isakson broached the subject of DNR, and the family briefly decided not to come to a conclusion until the other children’s flights came in. Then the daughter stood up and announced flatly, “I want to see my mother,” and walked out. End of meeting.

This morning, the brainstem reflexes that were present yesterday are becoming fainter. Sometime this afternoon the family will probably understand and accept the message of finality that the nurses and doctors are silently communicating, and decide to withdraw care.

I don’t know what to think. On one hand, watching the family’s pain, I’m wondering how I can stand this, for the rest of my career, reliving my grandparents’ deaths in imagination with every episode in the ICU. On the other hand, as one of my friends said when I showed her the MRA, “It’s a pretty good way to go.” Suddenly, no pain. I think her family will agree, when they’ve thought about it for a little while.

One morning recently somebody decided it was time for an introspective discussion group during morning conference, instead of the usual case presentation and mini-lecture. The subject was a short article by a military doctor about a patient in Iraq, who was receiving a great deal of scarce resources and fairly futile care, but had become very closely connected to the doctors and very important to them as an individual. I was afraid the discussion was going to turn into bemoaning our presence in Iraq, but fortunately not. The main discussion was, what constitutes futile care, and how (or should) we even try to determine that, since at the beginning of a series of risky interventions you can never tell whether this particular patient is going to improve, or not.

Thinking about war casualties in Iraq, and seriously ill patients in general, I realized that I have a problem. I’m three months away from graduating from medical school, and I still retain that adolescent delusion of immortality. Not only can I not picture myself or my family becoming seriously ill, I can’t really picture my patients not recovering, at least to some extent. I still expect everyone to get better and go home from the hospital, or even stop needing to come into clinic to have their meds readjusted on a monthly basis. I have not grasped what seriously bad shape people can get into, whether from accidents or cancer or diabetes or. . .

After two years of clinical medicine, I have had three patients die. One doesn’t even really count, because I had never even heard of the man until the nurses paged the resident to say that the patient had died (since he was DNR, we weren’t notified earlier), and would we come and pronounce him? And the resident made me listen to his chest for two minutes (or was it five, or ten? forever, anyway) to demonstrate that there were no heart or breath sounds. Which you might not call nice of the resident, but it was good for me.

And then the elderly man in the car accident, whom I’ve written about many times (first and second), and the elderly lady who got a simultaneous laparotomy, fem-fem bypass, and amputation and died a month later from ventilator-associated pneumonia on top of everything else. But I wasn’t there for either of those; the man we heard about the next morning in sign-out, and the lady died after I’d been off service for a couple weeks.

I’ve seen a few failed codes, too, but they don’t count. I didn’t know the patients before, and no one in the room ever expected them to survive, so it didn’t bother me a great deal.

Whereas I gather, from the books and articles and conversations around me, that a great many patients do die, sometimes because of things we do, sometimes because of things we fail to do, sometimes because we just can’t stop time. That objective fact doesn’t have any practical significance to me yet; and I suspect it’s not going to be a great deal of fun acquiring it.

My father’s mother went to be with the Lord Jesus yesterday morning. Most of us were there, as well as her daughter. It was very peaceful; indeed, we could hardly tell when she went. We had all been crying, but when she was gone, my aunt, with remarkable faith, began to rejoice. She had been suffering from severe dementia for many years, so indeed there is nothing to mourn for, only to rejoice that she has finished her race and entered into rest. She is now perfectly well, able to praise God and meet with her husband after these many years.

(Firmly persuaded that we ought to be happy; I’m not sure why I keep crying. I suppose partly a reflexive response to death, and partly longing, because we all wish to be where she is now.)

I was able to leave the hospital to be with them in the morning, then came back for a lap gastric bypass in the afternoon. More family members are coming this evening, and we will have the various arrangements on Thursday. The residents are being very nice, and letting me have Thursday off. I suppose I could have more if I asked, but it doesn’t seem really necessary. There’s another case on this afternoon, and I’m supposed to be on call Friday.

Ok, I just sent – and paid for – my ERAS applications. I can’t believe I’m applying for a residency. Time flies. This ought to be still a million years away.

Half the programs I applied to are plastic surgery residencies. What can I say, my father told me to. I am not into cosmetic surgery; that stuff is so fake. But he assures me, which I can see from the surgery schedule, that lots of it is really medically helpful. I suppose I can refuse to ever do any liposuction or tummy tucks once I finish residency.

—————
My grandmother is dying, we think. Half the time I’m thinking like a medical student: possible causes of decline, immediately helpful steps, ethics of starting ivs/feeding tubes/etc, following my father around as though he’s an attending while he talks to the nurses; and the rest of the time I’m just remembering how she used to be, and hugging my little sisters. . . How about if this just doesn’t happen, and we don’t have to think about it at all? How about if we stop time? How about if I knew how to do something really worthwhile, how to fix strokes and make them never happen and undo all of this. . .

. . . has received http://www.cnn.com/2005/WORLD/europe/03/31/pope1/index.html”>last rites.

And yesterday he had a feeding tube put in. As my mother said, I think this is God’s commentary on Terri Schiavo.

I’m not Catholic, and I don’t like everything this pope has done. But the closer he gets to the end of his life, the more I admire him. He seems to have been standing more and more for Biblical morality and contrary to political correctness.

Wittingshire has an http://wittingshire.blogspot.com/2005/03/schiavo-isnt-only-one.html”>excellent discussion of court cases in the past two decades which ended in judges ordering feeding tubes from people about whom there was significant controversy as to their level of consciousness. In fact, some of these people were capable of asking for food and water – and still didn’t receive it.

“Slippery slope” can be a logical fallacy, but this time it isn’t. The Dutch know where you can get too, and Hitler knew too. When a culture begins to accept the taking of active steps to end the life of a person, for any reason, they have turned down the road (with very few exits) to absolute eugenics and euthanasia of persons who do not wish to die.

I am ashamed of every single doctor and nurse in these stories, and every medical person at Terri’s hospice, that they could let these things happen, and do nothing. I don’t care what the consequences are. Lose your job. Get arrested. (And by the same token, very proud of those protestors who have gotten arrested for trying to help Terri. They have the courage of their convictions.) But God holds us responsible for those who are led off to death before our eyes; he will not accept excuses. I am hereby resolving not to keep silent, third and fourth year, when there’s a discussion about disconnecting life support – especially feeding tubes. Personal integrity, and advocacy for those who can’t speak, is more important than passing a clerkship, or getting a good letter of recommendation. . . I better write that down somewhere, to remember it. . .

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