Puella cum Cultello

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

Tag: grief

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.

Advertisements

Heartbreak Hotel

Residency can be lonely, with long hours that make isolation from friends and family inevitable.  Often, during that separation from our own social supports, we’re left to care for people in terrible situations.  This piece was written several years ago, while I was working nights in the ICU, right around Thanksgiving.  Reading it again has brought back a flood of emotions.

……………………………………………………………………………..

Over the last few weeks, I’ve been taking care of a very sick woman, D.  She had 2 prior bouts of cancer, and then developed a third, more malignant form in her upper esophagus this year.  Her tumor grew so large, so rapidly, that she could no longer swallow her saliva.  Our attending agreed to remove the cancer and reconnect her esophagus, with the understanding that this would be a palliative procedure, not a curative one.

She underwent a technically challenging but successful procedure involving two surgeons, and several residents.  Unfortunately, when D woke up, she couldn’t move one side of her body – she’d suffered a stroke during the operation.  We couldn’t treat the stroke because it was caused by a blood clot deep in her brain – using a clot busting drug would turn it into a bleeding stroke, one that we’d be unable to control.

By the following day, D had another blood clot, this time in her leg.  Because we couldn’t use any clot busting medications, she went back to the operating room to remove this blockage.  Most of the blood clot was removed, but the smaller blood vessels below her knee remained closed off.  She was left with considerable pain from both surgeries and her mottled leg.  Further testing showed that she had a disorder of excess clotting, one that was quite rare and not routinely tested for.

During all of this, the blood supply to D’s new esophageal connection was also compromised, damaging the delicate tissue that had been so painstakingly re-attached.  We had no way of knowing this until foul smelling liquid began to ooze from her incision.  Upon further investigation, we found a gangrenous esophagus.  From a medical perspective, this was essentially irreparable.  There was nothing we could do to significantly prolong her life.  Her underlying condition was incurable, and in her current state she wouldn’t survive long.

Our attending tried, in the best way he knew how, to convey that to D’s twin sister, the only family member still alive.  He repeated it over and over… D had a clotting disorder that no one could have known about before the operation.  The same process that happened in her head and in her leg had happened in her neck and damaged the esophagus.

To our medical minds, this meant that the graft was dead, well beyond repair, just like her brain and leg.  To her twin, it meant that there was still hope.  After all, she also had clots to the brain and leg – those were damaged but still alive.  She could survive this too, right?

Everyday, the attending would repeat the same phrases.  And everyday, the well twin would nod and smile bravely and tell us that D was a fighter.  We soon began to wonder when she’d finally put her sister in hospice, end this futility.  As the time dragged on, I slowly realized that it wasn’t false hope – this woman wasn’t in denial, she simply didn’t understand what we were trying to tell her.

Finally, the night before Thanksgiving, the well twin approached me in the hall.  I was in the middle of transfusing blood for another patient who was bleeding it out almost as quickly as I was putting it in.

Doctor, that graft… is it ever going to work?

Oh no, I cringed internally.  Not this question, not now.  But as I looked at her, I couldn’t just walk away.  She needed to know, to understand.

So, I answered her truthfully.  As I spoke, I could see the hope in her eyes fading.  The esophageal tissue was dead.  In the best of circumstances, we might have been able to perform an even more complex salvage operation.  In this case, with D’s body already so badly compromised, the salvage operation would likely kill her faster.  I tried to be as plain as possible and as gentle as I could be.  The words sunk in and her tears welled up.  All I could do was put my arm around her shoulders and wait for her questions.

But I just didn’t have time to comfort her.  I had to leave, my pager calling me to other tasks, other patients, other disasters.  I spent the next couple of hours distracted as I worked, hoping I hadn’t just destroyed the well twin too.  When I finally saw her again, she thanked me, for telling the whole truth, helping her understand.  But it didn’t feel like I had done much, certainly not enough to deserve thanks.  Then she told me her plan for D.

They would spend Thanksgiving, the next day, together – just as they had for over 60 years, as a family, as they only family they each had left.  The decisions would come after that.  I think we both knew the decision had already been made.  And all I could do was hug her again.

Later that night, a photograph on the bulletin board caught my eye.  It was part of a display explaining the benefits of an “open” ICU.  The well twin was shown asleep, in a chair beside her sister’s bed.  All you could see of D was a hand, extended over the side of the bed.  Even in the middle of the night, sleeping in an ICU room hundreds of miles from home, the twins were inseparable, hand in hand.  Yesterday, they went home together, to allow D to die at home.

And I stood there again tonight, alone, staring at that picture.