Puella cum Cultello

girl with a knife – the tired ramblings of a female surgeon-in-training

Tag: death

Outside hospital – ain’t so funny in real life

The Outside Hospital video is great satire – and like all good satire, it shines a very bright light on some uncomfortable truths.  In this case, we’re given some examples of medical hot potato: the patients who do poorly in some God-forsaken outpost before being transferred, with very little useful documentation, to a tertiary care hospital in the Big City.  Sadly, most of us in the trenches of these hospitals have our own memories of being handed a trainwreck with very little back story to help us out.

Mr B was my hot potato.  I was the surgical ICU nights/consults resident, and I got a quick phonecall from the chief resident a couple of hours into my Friday night shift.

“We’ve got a transfer coming in from Outside Hospital, it’s a 78 year old guy who had surgery 3 days ago for gallstones.  Sounds like there might have been some kind of intra-op injury, he’s had a rising white blood cell count and hasn’t gotten better despite antibiotics.  I don’t really know too much else, Dr J [our attending] accepted him and said they sounded like they just gave up.  We’ve requested their scans and notes, but do a history and physical and get some labs when he arrives and give me a call, he should be there around 10pm.”

Phew.  So a potentially very sick old man, and it seemed like we were didn’t have the full story yet.  I’d have to wait it out and piece it together once he arrived.

Sure enough, around 10:30pm, my pager went off. “Mr B is in room 525.”  *groan*  Great.  I had no idea how sick he might be, but he’d scored a bed on a floor that wasn’t used to taking care of anything but the most stable of patients.  I trudged up the stairs, complaining under my breath about this case already.  And that was the last peace I had that night.

I walked into the room, and introduced myself to Mr B’s daughter and wife before turning to say hello to the patient himself.  One look told me all I needed to know at this point.  He was sick, really, really sick, and he didn’t belong on a regular floor – certainly not a floor with no cardiac monitoring.  After saying hello to Mr B and his family, I excused myself and marched right over to the telephone to wrangle with the admissions people.

Me:  Mr B needs to be in a bed with cardiac monitoring.

Admissions:  We only have one regular monitored bed left, and that has to be saved for ER admissions.

Me:  Well, I don’t care where you put him physically, he just needs to be on a cardiac monitor, he’s too sick to be left on level 5.

It went back and forth like this for a few moments, until they agreed to let him have an ICU bed with basic monitoring status.  This was a decision that would serve me well later on.

I went back to the room and finally performed my full history and physical.  I began to have sympathy for vets and pediatricians.  The patient and his family were vague about the details.

Mr B had abdominal pain a few days ago, they went to Outside Hospital and the surgeons told them he needed emergency surgery.  He woke up feeling a little better after the surgery but still had fevers, jaundice, nausea and vomiting 3 days later and then the doctors at Outside Hospital said he needed to come here.  Oh, and his incision was still hurting a little bit.

That was it.  They had no idea which surgery he’d had, no idea why he had it, no idea why the other surgeons thought he wasn’t getting better.  Nada.

I took a deep breath before telling them my plan.  Get labs, start antibiotics, transfer to the ICU, ASAP.  Then I can figure out what the hell’s going on, I thought to myself as walked back to the nurses’ station.  I hoped the notes that came from Outside Hospital would help me.

Ha!  Wishful thinking.  Two hours later in the ICU, I was still sifting through them.  From the reams they’d sent, I had managed to pull out a handful of potentially useful pieces of paper:  two pages of labs (one pre-op and one from that day – stratospheric white count and liver function tests on both); a short typed up history and physical from the ER visit; a barely legible post-op note, from which I could just about tell their diagnosis and operation; and scrawled, completely un-readable notes from the day after surgery.

No operative note to tell us what they’d found or their operative technique, no interval labs or other tests, no discharge summary.  Just a big stack of nursing notes.

At this point, I texted the chief resident with our lab results (high white blood cell count, elevated liver enzymes), and my antibiotic plan, just to keep her in the confused loop.

A couple of hours later, in between taking care of other patients, Mr B’s story was finally beginning to make sense to me.  Then his nurse came over to tell me that he was having some respiratory trouble.  We got some x-rays to make sure he didn’t have a raging pneumonia or heart failure and he perked up for a little while after breathing treatments.  My note was almost done (finally!) when she asked me to take another look.

This time, Mr B had taken a definite turn for the worse, and even from the doorway, I began wondering whether we should intubate him.  After telling the nurse to begin another breathing treatment immediately, I left to ask for a quick second opinion from the medical intensive care attending on call.  Less than 30 seconds later, Mr B went into cardiac arrest.

The usual chaos ensued, and in the midst of the code blue, my mind was racing.  Had I missed something in his history?  Given how little I had to work with, it was possible, but there wasn’t much more I could have done differently that night.  Did I under-treat his respiratory issues?  No, my treatment when he first had breathing trouble had been appropriate.

Did I delay intubation too long?  Well, less than a minute had elapsed between the time I learned of his new breathing trouble and his cardiac arrest.  There was no way that we could have called anesthesia and had him intubated in that time.  But there’s a saying in medicine: if you’re thinking about intubating, you probably should.

By now, I could hear his family wailing in the hallway outside his room.  And in between her sobs, I heard his daughter say something that made me want to punch a wall.

This didn’t happen at the other hospital!

I don’t think I’d ever been that angry with a patient’s family before.

No, no it didn’t.  Of course not.  Because Outside Hospital passed the buck before it could happen.

The three hapless amigos

Friday nights are perfect for hanging out with your buddies and partying, maybe going a little nuts.  It’s just innocent goofing off, all fun and games… until someone wraps a car around a lamp post and the three amigos are pulled from the wreckage.

Well, first, there’s the dead one.  He never had a chance.  The impact tossed him around for a few seconds, until he was ejected.  He landed 30 feet from the car.  There was no life left in him to salvage when the cops arrived.

Then there’s the organ donor.  He was driving.  By the time the medics got him out, his body and brain were already giving up.  They kept his body alive long enough to get him to the ER.  Then we were able to keep him alive long enough to gather the family.  Mom, dad, and little brother look shell shocked this morning.  Grandma’s still crying.  There’s about thirty friends with tear-streaked faces loitering about in the hallways.  People are asking each other, “How could this happen?”

Easy peasy, I want to reply,  Take three young men who believe that they’re special immortal snowflakes, add a case of beer, and the keys to dad’s sports car.  Voilà.  Instant wreckage.

Instead, I walk past, head down, in respectful silence.

Finally, there’s the spoilt brat.  There’s always one.  He has a couple of extremity fractures and the delightful attitude of Verruca Salt.   He appears to be doing his best to antagonize the nurses. Periodically, you’ll hear him bellow from across the ward, “Nurse!  I want some water!  Nurse! Where’s my food, I’m hungry!  Nurse!  Gimme my pain meds!”

I wonder if he’s confused and believes that he’s at Burger King.  You don’t get to have it your way in the hospital, buddy.

Perhaps, for now, he thinks he’s the special-est snowflake of them all.  But eventually,  even he will melt into nothingness.

I know…

I know I don’t want to die this way

I don’t want to die in any kind of accident or attack.

I don’t want to die surrounded by strangers.

I don’t want to die with a tube in my throat.

I don’t want to die in a hospital.

I don’t want to die in pain.

I don’t want to die with doctors giving me CPR.

I don’t want to die with my skin poked full of holes from IVs.

I want to die in peace, in a familiar place, with people who love me.

But first, I want to live.

Code Blue

Because I could not stop for Death,
He kindly stopped for me;
The carriage held but just ourselves
And Immortality.
-Emily Dickinson

In medicine, we confront death on a daily basis.  It’s been 8 years since I started medical school, but for me, it remains sad, terrifying, poignant, brutal.

The first code I participated in was all of these and more.  I was on call on a Saturday evening with another 3rd year medical student, W. It had been a slow day, and we were just hanging around, studying, chatting, and waiting for 6pm.  W had taken a short break while I continued reading, but she’d been gone for a while.  I decided to give her a call.

While we’d been separated, she had been drawn into a “code blue” on the fifth floor.  This was was where ventilator-dependent patients, among our sickest, were placed – never a good sign.  I raced up the stairs before W could tell me the room number.  I knew that when I reached the ward, the crowd that assembles at every code would lead me to the correct place.

I no longer remember the patient’s name, or even what she looked like.  But I do remember that she was a young woman, diagnosed with an aggressive cancer while her children were still in need of mothering.  Even though her condition was terminal, her husband had insisted that everything possible be done for her.  Death had been looming for weeks, but he wanted their children to have their mother for every possible second, no matter how incapacitated she might be.  She’d spent the last few days alive but unable to interact with them in any meaningful way.  On this quiet weekend afternoon, with none of her family nearby, her body was finally giving up.

She was one of my first lessons in clinical detachment.  During this code, she wasn’t a wife or a mother anymore, she was just another patient, one we were trying to keep alive at her family’s behest.  We knew that we were fighting a losing battle, even if her husband had refused to accept the limits of our abilities.

A couple of residents were taking turns pumping her veins full of medication and pounding on her chest, the respiratory therapist was trying to keep pushing air through her tracheostomy, and W was standing in a corner, holding up an IV bag and looking as though she hadn’t yet decided whether to cry or vomit.

I caught our resident’s attention and asked what I could do.  I became the designated equipment runner, a task complicated by the fact that I was unfamiliar with this floor and couldn’t get into any of the locked supply rooms.  I proved far more adept at relieving W from her imitation of an IV pole.

The code went from bad to worse.  The patient’s heart wasn’t responding to medications, chest compressions, or electrical shocks.  The pumping of the ambu-bag was frequently interrupted by attempts to clear the secretions which were plugging up her trachea.  Blood-tinged froth bubbled from her mouth and nose.  Her pulse was thready despite the fluid and medications we were giving, and her blood pressure was too low for our monitors to detect.

Finally, after 40 minutes of this, the attending running the code allowed us to admit that we had lost this round: “I’m going to call this one. Everyone agree?”  She named the major team members one-by-one, making sure that there was consensus, that we had done all we could.

As the techs, nurses, and residents filed out, W and I stayed.  The attending taught us the steps of confirming brain death: the patient was totally unresponsive; she didn’t have any brainstem reflexes; there were no breath sounds.  We were instructed to ignore the slight fluttering of eyelids before her dull eyes were hidden – it was merely a sign of residual electrical activity in her peripheral nervous system, not an attempt to show us she was still clinging to this world.

Neither W nor I were sure to say or do next.  We’d seen dead people before, from the cadavers in anatomy lab to the autopsies in pathology.  We’d met hundreds of patients already.  But today, for the first time, we had watched someone die.

No lecture, no group project, no role-playing session prepares you for that moment.

So, we reverted to helpful medical student mode and tried to assist with the clean up, using damp towels to wash the body of a woman we had never known while she was alive.  The nurses would then tidy the rest of the room to allow her family to say their final goodbyes.

After wiping the last of the blood from her face, we covered her limp, broken body with a clean sheet, as though concealing our collective defeat.

She was finally at peace.  We were not.