I admitted a patient from the ER one night over the holidays. The ER called with a CT scan showing diffuse pneumatosis, and the most obvious portal venous air I’ve seen so far. The patient himself looked far better than the scan, and was amazingly comfortable, considering that he had a heart rate of 140 and was already in acute renal failure. He was so comfortable that it was very difficult to persuade either my attending, or the patient, that he needed emergency surgery. (“Pain out of proportion to exam, Alice. You can’t tell me he has ischemic bowel and no pain.” I insisted, so we didn’t really lose any time, but it was a little disconcerting.)
As for the patient, that was the worst conversation I have ever had to have. Telling a family that someone died is easier. Telling a man who’s chatting happily that he’s almost certainly going to be dead within 24 hours is nearly impossible, either to find the words, or to convince the patient. I had to not only convince him that matters were this serious, but also discuss the option of surgery – his only chance of survival, but a very slim one, with a significant chance of a long ICU stay and major morbidities, if he did survive. (Some might say that with that CT scan, we shouldn’t operate. 1) You can see pneumatosis and portal venous air from a bad bowel obstruction, which can be salvageable. 2) He was relatively young, and with few comorbidities. We never did figure out what caused his ischemia.)
In between talking to him, I was calling the chief and the attending and the OR and the ICU, getting iv fluids and antibiotics running, and moving him to preop holding. Not much time. No sooner had I settled him in preop, with a nurse to watch, and the attending about to walk in, than the trauma pager started going off with multiple gunshot wounds, so I had to leave him. Three hours and several traumas later, I found him and the chief resident in the ICU. The operation had been completely unsuccessful; there was absolutely nothing to be done. His body was shutting down, and there was barely time to have the family at the bedside before he died.
I felt awful afterwards. Not just because it was the holidays, and we had lost a previously healthy man suddenly, but because I had spent half an hour talking to him about his death, and had never talked about what would happen to him after death. I had watched somebody dying, and had never even mentioned God or heaven or hell. Which meant that I did him exactly no good at all. He died, as I knew he would, and had to face eternity, and I hadn’t even mentioned it.
Yesterday one of the PACU nurses came up to me. (At night PACU and preop are staffed by the same nurses.) “Remember that man with the ischemic bowel who died? I went to the funeral home. I had to tell his family something he told me that night. He said, ‘I’m not worried about this, because I’m putting it in God’s hands. He took care of me when I had surgery 30 years ago, and he’s taking care of me now. If he wants me to live, I will; and if not, it’s all right. If I don’t make it through surgery, tell my family I’ll see them in heaven.’ ” I started crying in the middle of PACU. He’s safe, after all. I didn’t do anything I should have, but he knew better than me. Next time, I won’t make the same mistake.
(As for the nurse, I have a whole new respect for her, going out of her way to comfort not only the family, but also the other caregivers.)
Cut On The Dotted Line 
January 7, 2010 at 11:54 am
Thank you for sharing this! God bless you.
January 7, 2010 at 2:29 pm
Isn’t He amazing? The God of second chances. I’ve had many similar experiences.
I recently transported a woman with a new diagnosis of leukemia from a small ER to a University hospital. I let her sleep most of the way. 10 minutes before arriving I asked her how she felt about her diagnosis. She went on and on about how many times God had taken care of her. We prayed together for the remainder of the trip. She’s back to work now, doing well.
A nurse who had taken care of her in the ER had written a note and stuffed it in her clothing bag. It fell out during the transport. I found it the next day. I gave it back to the nurse with apologies. She was pretty sad it wasn’t delivered. The note said, “I can do all things through Christ who strengthens me”.
She didn’t have time to pray with the patient or talk about God or her beliefs, so the note was her only hope. When I told her what transpired during the trip she burst into tears.
God usually finds someone. You learned a lesson you won’t soon forget, I can tell. Thanks for sharing this story, you’re an inspiration!
The story I shared can be found here:
http://mobileintensiveprayerunit.blogspot.com/2009/10/my-friend-katie_25.html
January 9, 2010 at 4:18 am
Alice: What is it you think you should have said to him? I can see where it would be comforting for a person with religious beliefs to talk about them in such a situation, but, as an atheist, I would find it inappropriate and offensive if somebody started trying to tell me about their religion in such a circumstance.
January 9, 2010 at 9:03 am
Sarah – I should at least have asked him if he had any religious beliefs, and if he wanted me or a chaplain to pray with him. Asking about religious beliefs is an accepted part of taking a history, and certainly appropriate in this setting. Particularly considering that I know full well that in my area, even more than the national average of people consider themselves Christian/religious.
As I am afraid you will discover, people’s views on this can also change when they find themselves finally about to meet the truth. Again, considering that the alternatives are accepting God’s gift of forgiveness, or spending eternity in hell, I think the stakes are high enough that I should at least take the chance of bringing up the subject.
January 9, 2010 at 4:26 pm
I too find this a particularly difficult thing to do. How do you approach discussing eternity with a patient right before operating on him? What does it say about my skill / confidence as a surgeon? Is he thinking “What hope do I have if my surgeon thinks I’m going to die in surgery?”.
I think it’s difficult to do because it entails the possibility of admitting defeat before even attempting the surgery, and what surgeon does that? It is a very humbling thing to do, but is necessary because ultimately it is all in God’s hands, not ours.
January 9, 2010 at 5:12 pm
I have a lot of experience in asking patients about their beliefs in an emergent situation. Here’s what it looks like and my rationale behind it.
As a former atheist, I sympathize with Sarah. ‘Preaching’ as we usually think of it, is in my opinion, inappropriate in such settings. It smacks of unethical behavior and doesn’t go over too well. It probably doesn’t benefit much, anyway.
But nearly every hospital that is modern in it’s approach to assessment of patient needs recognizes the validity of ‘spiritual needs’. At some point in the chain of care – someone needs to ask the question if the patient has any spiritual needs that need to be addressed. There isn’t always time for a chaplain to handle that task.
Anyone can do it; some are better than others. Practice helps. You don’t need to be a pastor or chaplain. What you need is a heart of concern for the best interest of the patient. All one need do is ask in whatever way you find that works for you, if the patient has any spiritual needs at this time. Open ended questions work well in bringing up the topic. How the patient answers will dictate the direction of the interview from there. I always respect the wishes of the patient.
If one is a Christian, they should be able to follow the lead of the Holy Spirit in these matters. God has often told me not to pray for people I wanted to, and encouraged me to pray for others I didn’t want to. He has never led me incorrectly.
Once in a while I ask if I can pray for someone and I get the reaction – “Am I in that bad of shape?” I explain that it’s my habit to pray with everyone I transport who desires it, hangnails, headaches or heart attacks. It takes the fear factor away.
I’ve prayed with over 500 patients in my ambulance in the last 18 months. I’ve only had 2 or 3 people decline. They all thanked me for asking, even those who declined. I’ve had several atheists who wanted me to pray for them, even though they didn’t believe in God.
If we are professional, respectful and demonstrate a high level of caring toward the patient, there’s little to lose and much to gain.
January 10, 2010 at 4:24 am
Alice (and Dave): Oh, I see. Yes, I’d consider that quite OK. From what you were saying, I was concerned that you wanted to try converting people on their deathbeds.
January 12, 2010 at 4:06 am
Undead Doc: Oh, yes, just wanted to add a word about what you said.
I agree that I wouldn’t want a surgeon bringing up the subject of my possible death just because they were doing a routine operation on me (I mean, I understand that they may need to mention it as part of the informed consent, but that’s a bit different from the emphasis involved in a “Since you may be about to face death, would you like me to pray for you?” message). But, in the sort of scenario Alice described, where there *is* a high and serious chance of dying that needs to be taken into account, I would prefer it if the surgeon’s words suggested that (s)he *did* take that possibility seriously. I would much prefer a surgeon who accepts the risks and takes them seriously to a surgeon who appears to want to be in denial about the possibility of any risk and tells me breezily that I’ll be fine even in the case of statistics that suggest that this may well not be so. If I am ever in such a position, honour my possible death by accepting and acknowledging it.
January 27, 2010 at 5:21 pm
A related post:
http://mobileintensiveprayerunit.blogspot.com/2010/01/second-chance.html
April 20, 2010 at 5:31 pm
“I had watched somebody dying, and had never even mentioned God or heaven or hell. Which meant that I did him exactly no good at all. He died, as I knew he would, and had to face eternity, and I hadn’t even mentioned it.”
Just be glad you don’t work in the UK or you would be given a warning if not dismissed from your job (or “sacked” as we say here) for daring to infringe on a patient’s ‘rights’ etc. Our Government has taken civil liberties to excessive lengths and is now actively discriminating against Christians in much of its legislation. Read the story of what happened to one nurse who got reported for caring in this way here – http://www.christian.org.uk/news/prayer-nurse-returns-to-work-after-suspension/
Sadly I think the US Government is leaning heavily in this direction too, so maybe make the most of your freedom of opportunity while you have it :(.
April 20, 2010 at 6:53 pm
I read the above article about the nurse who was suspended and admit this kind of action surprised me. I think you’re right that faith in the workplace will become more volatile in the future.
We have an organization in the states that provides legal defense for people whose religious freedoms are being questioned or abused; the American Center for Law and Justice (ACLJ) They have won many legal cases of religious discrimination in school and workplace settings, getting their clients placed back in good standing. Their services are free.
Thanks for the reference, I’m re-posting the article to my blog on May 1, 2010.
July 5, 2013 at 11:11 pm
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