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"How Much Longer Will It Be?"

Thomasrobey72x721Thomas Robey -- The third year of medical school is full of firsts. With new experiences, sensory collection mechanisms kick into overdrive and the brain says, “Hey, I should record this.” These first experiences and emotions stay with you forever. Some firsts that I remember as clearly as if they were yesterday are my first delivery, first terminal diagnosis, first surgical scrub, first admission, and first code.

I remember another first as though it was yesterday. It was yesterday. I was doing chest compressions an hour after a patient came in to the ER. I heard, “strong femoral pulse with CPR,” and focused on locking my arms, lifting my fingertips off the chest wall and maintaining a fast rhythm. In my mind: “four and five and six and...” I did not realize how fast she had deteriorated. When the attending ER doc told me I should stop compressions, I stepped away from the body only to notice her family watching from the hall. They had asked to observe. By the time I had gathered my thoughts, the tubes and wires had been removed from her body and she was covered to her neck in a clean white blanket. Her lifeless face looked at peace. No longer scared. No more strain. The family slowly filed in. How I wish I could transplant her last squeeze from my hand into her granddaughter’s palm.

She was 89 and had been discharged only days before following treatment for a pulmonary embolus. Lung function was compromised. Her anti-coagulation was therapeutic. Even so, we think a clot found its way into a renal vein. Her kidneys failed. She became toxic on the digoxin she took for her arrythmias and heart failure. This is all to say that she was very sick. Her family knew this. They had spoken with her about resuscitation. She wanted it, but not with an endotracheal tube.

Thirty minutes previous, she told me through her oxygen mask that she had not eaten in days: the nursing home food was terrible. Could we bring her some food? Yes, we could. No, she’s not in any pain, she says. She is very tired. I explain that we’ll need to admit her to the ICU tonight.

Later: “How much longer will it be?” I say “not long,” thinking she’s asking about the bed or the food. Was she asking me something else?

Note: This patient’s daughter-in-law told me I could write about this without using the family’s name.

February 17, 2008 in Thomas Robey | Permalink

Comments

In your heart of hearts, I think you already know the answer. You gave it your all. 89 is a great life span. But, thank you for the provocation. I hope I listen more closely for a while.

Posted by: Rick Ash | Feb 19, 2008 3:48:33 PM

i'm doing my emergency rotation at the moment. lots of people coming in dangerously ill; many brought in flat-lined; life on the brink. sometimes i look at them during resuscitation, and i imagine if it were a loved one, or if it were myself, and it's difficult to imagine how we would want to be treated under these circumstances.

Posted by: neo | Feb 21, 2008 8:40:28 AM

Neo,

I feel the same as you. What made this case special for me is that the family had talked about the patient's interest and commitment to resuscitation. That they wanted to watch the attempts could be unnerving to some, but for our team (including the ER doc, the patient’s primary care doc, myself and the other mass of care providers present in a code), I think it was different. Everyone knew how close to death she was, and I think we were all on the same page. Simply because the family had the discussion.

Would I want to go through resuscitation? I have to consider the outcome. Chances are good you would not remember CPR, given the dire situation. If you made it through resuscitation, I think you would be okay with a few broken ribs.

Posted by: Thomas Robey | Feb 21, 2008 1:05:51 PM

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