She rolled in to Resuscitation Bay One an ashen grey, the tired paramedic straddling the stretcher doing chest compressions. Sweat poured down his brow and arms. They had been at this for an hour en route to our hospital on dark, twisty back roads. She was just shy of 90 years old.
She died for the first time at home while washing the dishes; her husband heard a plate shatter and found her dead on the floor. He started CPR while calling 911 and valiantly kept doing chest compressions until the medics arrived. They jump-started her heart with a defibrillator, but she died for the second and third times on the way to us.
There is a hue about truly dead people - an aura, almost. Extremities pale and mottled, lips colorless. When she arrived the other physician and I shared a knowing glance. This would not end well for her. She was long gone already, but her wishes were to "have everything done". So, we started doing everything.
It is a peculiar feeling, cracking someone's ribs while doing CPR. The heart is simply a series of one-way valves; by doing chest compressions blood is forced out of the heart to the rest of the body. Unfortunately generating that much pressure is often too much for osteoporotic, elderly bones to handle. The result is a *snap* as ribs break from the force. It feels like torture.
Broken ribs are unbelievably sharp. Chest compressions generate inward force, and so the bones rip and tear the lungs, causing air to leak out. With nowhere to go, eventually the air pressure deflates the lungs. The solution is to "decompress" the pulmonary cavity with large bore needles stabbed directly though the chest wall.
As her heart began to fibrillate we began to shock it with 200 joules of electricity, over and over, in an attempt to regain a normal rhythm. Caustic medications were pushed through her IV's to try to stabilize and restart the heart muscle. None of it worked, of course, but she wanted everything done.
In ACLS training this is referred to as a Megacode - a code situation where every therapy and every algorithm is used. It's purely for training purposes; you never survive these extensive measures.
She briefly regained a pulse and then died for the fourth and final time, with a tube in her trachea and esophagus, every rib broken, a needle in each side of her chest, IVs in each arm, special intravascular devices to each groin, and a catheter up her urethra.
I wish I could bestow my entire medical knowledge on patients and families before they ask to have "everything done". They cannot possibly understand what they ask me to do to the ones they love.
Last week a man was rolled in to the ER, although I hesitate to call him a man. He looked more like a mummy; lips shriveled, eyes sunken, arms and legs even wrapped in gauze to cover his numerous decubitus ulcers. He had suffered complete and total anoxic brain injury months earlier; there was nothing left of him but a physical husk. Every single physician and nurse dropped what they were doing to stare incredulously as he was wheeled by. He was death incarnate.
The medics, with a wry smile, handed me his chart from the nursing home. Handwritten, on a single blank sheet on top of the chart was a family member's scrawl, underlined three times and followed by a plethora of exclamations.
It became quickly apparent that he was much sicker than his chronic state of nearly-dead. Heart rate was up, blood pressure was down. We sat around for a moment, twiddling our thumbs. He was clearly going to die no matter what we did. The "right" thing to do from a legal standpoint was to rush him up to the ICU, flood his system with antibiotics, take him to the operating room to slice out all of the decaying flesh, and pound him with fluids.
The "right" thing to do from a medical and humane perspective, however, was to let him go. I would add "peacefully", but that opportunity was lost months before when we stabbed a breathing tube through his neck, shoved a foley up his urethra, a catheter up his rectum, and a feeding tube through his stomach in the name of Good Medicine. So, instead, I pulled the family aside to talk about end-of-life care. I wish I could say it went well.
"I'm sorry to tell you this, but there are two ways he can die tonight," I said quietly, "peacefully, with morphine to make it painless and comfortable, or with the ICU physicians cracking ribs during CPR, pushing painful medications through his veins, and shoving you out of the way during his last moments so he can't be with his family."
The daughter looked at me with a distasteful look. "Well, we goin' home, so it's between him and God now," she scoffed, "so y'all better do everything for him. I got faith he'll pull through. Here's my phone number in case anything happens. If it's busy jest call back later."
And so, he went to the ICU. Predictably, his heart stopped beating, ribs were broken during CPR, needles were stabbed into any remaining veins, and no loved ones were with him when he died. The phone was busy. They stopped by the hospital late the next morning with a bag of Dunkin Donuts to sign the paperwork.
Is there a moral here? I'm not really sure. I suppose I can only speak for myself when I say - vehemently - that I would never want to go that way.
I remember all my first deaths.
The very first was our cadaver in medical school. As first year medical students, we shuffled quietly into anatomy lab, nervous giggles escaping pockets among the crowd. Lying cold, still, aseptic, was our body. Charlie. It's an unsettling feeling, laying hands on a dead body. There is a quiet dignity about death, a final stillness that is unmistakeable. I remember stainless steel tables with stainless steel scalpels, and the subtle scent of formaldehyde barely masked by the cloying smell of wintergreen. My hands shook violently as I made the first incision.
The second was the first death I ever witnessed in person. Surprisingly, it took until my 4th year of medical school, on an ER rotation in Seattle. He was an elderly gentleman who had shot himself in the head after downing a 5th of vodka when his wife divorced him. His features were barely recognizable with all the damage. He was intubated, paralyzed, and barely had a pulse on arrival. CPR continued only for 5 minutes before he was pronounced dead; somewhat of an afterthought. The only thing keeping his heart beating until he reached the hospital were the massive doses of epinepherine circulating in his bloodstream. I remember being sorry for him, but not devastated - he was already DOA.
Last night, my patient died.
The page came: ADULT TRAUMA CODE ONE FIVE MINUTES OUT BY AIR
I sprinted downstairs and into the trauma room, a sea of faces greeting me. My favorite nurses, our best physicians, waiting. These are the most capable people I know. They were ready - I prepared myself for the survey. As the trauma intern, it's my job to perform the whole physical examination in front of everyone and call out significant findings. All we knew is that the patient was a 70-ish woman in a car accident.
The medics rolled the stretcher in, and instantly the mood changed; suddenly silent and tense as we saw how bad off she really was. For a second, the only sound was her quiet wailing, "Oh, Lord. Oh, Lordy, my arm hurts. Please, my arm hurts so badly..."
The moment ground to a halt. I remember utter quiet as the seconds ticked by, as long as minutes. Her forearm had three joints where it should only have two...
Silently, I took in the damage. Horrific, tenting fracture to the left forearm. Right wrist splayed off to the side, every bone in her hand likely shattered. Right ankle sideways. Left shin with shards of bone sticking out the front. Amazingly, she was still talking and protecting her airway, the first thing ever said in a trauma assessment.
So I spoke.
"Airway... is currently intact."
Time sped up, sounds and colors rushing in to fill the void. What once was silence and stillness was bedlam and cacophany. Everyone talking. Everything moving. I was lost in the exam, hoping against hope that if I could just find the one thing that was wrong, I could save her. But there was too much.
Broken bones were quickly realigned, blood lost was quickly replaced, but we were waging a war against death and we were losing. For every vein that we accessed, another collapsed. For every unit of blood given, she bled two more. I was struck for a moment by how beautiful it was, all of these people working in harmony to try to save one life. Grim faces and furrowed brows desperate to help this stranger. People at their best.
Blood pressure started dropping. I had my hand on her pulse and felt it ebbing away, slowly, surely, towards that final quiet stillness. I remember at one point looking up at the clock and realizing an hour and ten minutes had elapsed. There was the chill, certain realization that nothing would stop this woman from dying. My fingers felt her pulse getting weaker. Slower. Fading. A few minutes later, she was dead. Everyone shuffled out of the trauma bay until it was just me and her. I was struck by how cold she was. Like Charlie.
And then the page came: PEDIATRIC TRAUMA CODE ONE 6 MINUTES OUT BY AIR
Off to save a life, this time.
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