Friday, April 9, 2010

The Witness

The patient arrived in cardiac arrest. He had been brought to our emergency department in the middle of the night. Although he had a significant cardiac history, he was only in his late-forties. His transport from his house to our department had been less than ten minutes and, along the way, the pre-hospital team had done an excellent job of intubating this patient and establishing an IV.

His wife was with him. Less than fifteen short minutes before their arrival, her life had been altered forever when her husband had woken her, from a deep sleep, to complain that he had intense chest pain. Seconds after, she witnessed him become unresponsive.

On arrival to our ER, we found this patient to be in pulseless ventricular tachycardia, a malignant, life-threatening electrical rhythm of the heart. Following ACLS protocol, we shocked this patient several times while performing CPR and administering multiple doses of medications to combat this rhythm.

After several very intense minutes, we were able to regain a sinus rhythm and a pulse on this patient. Despite this, he remained unresponsive and his blood pressure was minimal. We continued our efforts to stabilize this patient as we awaited cardiology's arrival.

Despite our aggressive medications and interventions, this patient returned to a pulseless ventricular tachycardia. More shocks followed. More medications were given. And, once again, we were able to break the bad rhythm. But, not for long.

Cardiology arrived and together, we continued to fight for this man's life. His rhythms were very fragile, and it seemed that he alternated between a normal rhythm and these continued life-threatening ones, now including asystole (a flat-line, so to speak). Asystole is bad, very bad, and is rarely survivable.

We were running out of options. If we were going to be able to intervene any further, we needed this patient to remain in a more stable rhythm. Getting him into a sinus rhythm had been hard enough, but nothing we seemed to do would keep him there. His heart, from previous infarctions and damage, was resistant and stubborn to our best efforts.

As the cardiologist and our ER team continued with resuscitation efforts, I went to the family room to speak to his wife. She was obviously upset, and I explained her husband's dire situation. Our reality was that time was not our friend, that the longer he continued in asystole and ventricular tachycardia, the less chance of his survival. She understood my words. "I always knew it would end this way," she said, her honest words reflecting her inherent sense of the situation.

I invited her back to be with her husband, to witness the momentous efforts we were all giving him. She wholeheartedly agreed, embracing my invitation.

Returning to the oversized room, filled with people and shiny medical equipment, I looked at the resuscitation through her eyes. Three nurses, each scurrying with a focused determination, documenting our efforts and pushing IV medications. Two techs, one actively performing CPR while the other was readjusting the patient's blood pressure cuff. Two respiratory therapists, standing at the head of the bed, one using an oxygenated bag to ventilate this patient via his airway tube while the other prepared a mechanical ventilator, ready to be used in the event of our resuscitation succeeding. The cardiologist, standing at the patient's open side, dictating the next course of medications. The pharmacist, standing with the crash cart outside of the patient's door, repeatedly handing in the next dose of ordered medication. The patient's wife. Me.

And the patient. Lying on the hospital cot. Unresponsive. In asystole. Again.

I guided her to his side, where she grabbed his hand.

Despite this many people in our big resuscitation room, the air seemed open, the frantic energy palpable. The team moved purposefully and in sync. Their caring, their vigor, their sadness, their intensity was obvious, witnessed by the patient's wife.

Unfortunately, the patient's heart became refractory to all of our best efforts and our medications no longer had any effect. I had the tech hold CPR and we confirmed asystole on several cardiac monitor leads. The portable ultrasound was brought to this patient's bedside. It confirmed our worst fears, that his heart had no squeeze, no motion, no life. His wife saw the stillness of his heart on our black-and-white screen.

Forty or so minutes had passed since the patient arrived and, as I had explained to the wife in the family room, time was not our friend. We had no other options of treatment to save this patient.

"Please, stop," the wife said. "Please, just let him go in peace."

A powerful moment.

With no objections, we ceased resuscitation efforts. Time of death was proclaimed. I thanked my team. I crossed myself. I conveyed my sympathies to the wife. The crowd of people slowly withdrew from the room. The lights were dimmed. The patient was covered in nice, clean blankets. The patient's wife was brought a chair, along bedside, where she sat, continuing to hold her husband's lifeless hand within her trembling own. A box of Kleenex somehow found her lap.

The family doctor was called. The coroner was notified. I dictated my note.

All methodical parts of my job. When I was done dictating, I went back into the room. As I expected, his wife was still there.

"I'm so sorry for your loss," I repeated.

She nodded. "I know you tried your best." She paused, taking a deep breath, before continuing. "Thank you for letting me be with him in the end. I needed to be here."

I walked back out of the room, thinking about how much medicine has changed. Not only with newer drugs and newer procedures, but newer thinking. A few short years prior to this patient's arrest, it would have been unthinkable to invite a family member to bear witness to resuscitation efforts. Some literature has evolved since, strongly in favor of presenting this as an option. Clearly, this wife was empowered, her view clarified, by being with her husband at the end. It was necessary for her closure, to witness our heroic attempts.

What would you do?

Me? I'm not so sure. I don't know if I would want to bear witness to such an event of a loved one. I probably would. I have to wonder, though, if my indecision or hesitation is, in part, from doing this job for a living or just my inherent spiritual make-up. Obviously, witnessing such a dreadful event may not be for everyone.

Let's just hope that we never have to make this decision.

As always, big thanks for reading. Next post will be Monday, April 12. I hope your weekend is a good one...


Marie said...

Both the patient and his wife were fortunate to have ended up in your ER.

The patient because you all fought so hard for him and his wife because you were so respectful in giving her the option of being with her husband at the end.

My husband died of a massive MI when he was 40. He had been playing pool with friends, he didn't feel well, he went outside for some air and collapsed.

He was transported with CPR in progress, but was never revived. He died all alone. I have always regretted that.

Maybe it's not for everyone, but I believe it can be an important life passage to be with a loved one when they die. My husband was surrounded by strangers. No one said farewell, I love you, you are going home.

No one knew how funny he could be or what a good father he was, how he read to the kids every night and was never too busy or too tired to shoot hoops or play a board game.

Although I find I have to have tissues handy every time I read your blog, lol, thank you once again for a moving and thought provoking piece. :)

Sharp Incisions said...

As someone who's waited in the 'family room' in a similar situation, thank you for giving your patient's wife this option. Although some may not have chosen it, I would have. It can be very comforting to know that 'you did everything you could', even though as a family member, often all that can be is to be there for those last few moments holding your loved one's hand. It is something I will try to keep in mind for my own patients someday.

coulrophobic agnostic said...

She's a brave woman. I couldn't bring myself to see my father in that state - I also refused to enter the room during the open casket portion of the wake - and I don't regret those things. I've always felt strongly that I didn't want the last images I have of people to be like that.

Hey, wait a minute, they only worked on him for 12 minutes...why did this guy get 40?! ;) I kid, I kid.

rlbates said...

So sorry for her loss, but glad she could hold his hand one last time.

Heather said...

Please, hire me. ;)

I have often been the one in the room alone with a patient who's been DNR while they take their last breath. Alone. Because the family can't take it. And that breaks my heart. Death is not ugly. It's not scary. It's actually quite peaceful.

I am so sorry for the woman who lost her husband so tragically. But I am thankful that she got to make the decision and rest in that peace.

Happy weekend, friend!

Winking Doll said...

I am impressed.

The patient's wife's courage and love.

The large team of specialists giving their best to the ER patient. I don't think we get that number of specialists attending to 1 patient for 40 minutes in Singapore. In fact, once brain-death is pronounced in "government" hospitals and the patient is eligible for organ harvesting by law, a team of organ harvesters would swoop in. Sadly, that's how things work by law in Singapore... I suspect it is traumatising even to the staff.

Tanya said...

I would want to be there in the room with my husband. It would be hard and scary, but I would want to be there, to have one last chance to hold his hand. I'm glad that you allowed this unfortunate woman that last moment with her husband.

Katie said...

Awhile back (some undetermined amount of time but since I've been in college) my dad found himself in the ER in the middle of the night with chest pain. Eventually not ruled to be a heart attack, he was released and the family went home. Months (years?) later it came up at dinner. Kind of a "remember that time?" note. No, I didn't remember that time. I was away at school and on one bothered to tell me about their mid-night adventure. Naturally, I was irked. They tried to justify themselves saying he was fine there was no reason to worry me. The fact that they felt the need to hide it actually worried me more. I fear the "come home NOW" phone call that seemed feasible with my four living grandparents, but recently it's dawned on me that my frantic 15-hour drive home might not be because of my grandparents. Please keep fighting for lives! But thank you for letting the family be there to witness the organized chaos.

I hope things are well with you and your family,
<>< Katie

Anonymous said...

Knowing that Doctors have to do their best job to save lives, if I was in her shoes, I would also want to see it for myself, to feel like I was there helping as well.

Leslie said...

I definately would have wanted to be there. I'm glad you gave her the opportunity. ---Gotta run, if the kids see me crying at the computer they are going to worry...

AtYourCervix said...

I would have wanted to be present while a loved one was resuscitated. Just being there when they pass is comforting. I was present when my own mother passed on, but she was at home (hospice).

terri c said...

While of course each person's needs are different I think many would choose to be present if invited. When I work hospital shifts as chaplain and get called to the ED, I aways feel the pressure to get the family away; I keep them "out of the way," but not an inch farther away from their family member than they want to be. My fave ED docs are the ones who do what you did, allow the family to be present and involved. One doc had to secure consent from the family to stop the resuscitation and then invited all of them in, encouraged them to take places touching the patient, and then directed the team to cease. If there was any sensation even on an unseen level, that patient died with loving hands all over and around him, and the family gave him the sendoff they wanted.

Amy said...

Great story! (Though sad.) I think if I had been the wife, I would want to be there.

Anonymous said...

This was a fantastic post. Well written, brisk, and as stark as the situation it describes was.

I believe it's important to give the surviving family member or spouse the option of being with their loved one at the end. As harrowing as such a thing would be, I can see how this might help some people move on, as they need to be able to.

I was in the hospital room when my father died. I'm grateful that I was able to be there.

You're very kind, Dr. Jim. If I ever need emergency medical care, I hope it's from a doctor as expert and compassionate as you. Have a lovely weekend.

Ms2Mrs said...

Dr. Jim --

beautifully written and told. Words truly can not express what the patient's wife had/is going to experience. I applaud you in your innovative method of allowing the patient's wife back.

I working on a PhD in biomedical ethics with my focus on end-of-life ethics, palliative medicine and death with dignity. I state this because what you did for this family was just that. You allowed this man to pass with dignity (In my opinion). You allowed his wife to be present to see what the situation was. To make the best, most informed decisions she could. Both you and she should be applauded for that.

While the outcome was not what your team, and the patients wife was hoping for, I truly am impressed with the sensitive way you addressed this very difficult situation.

Kelly said...

When my father had a sudden, massive MI, I had the option of being there when they stopped compressions. I chose to be there because I couldn't stand the thought of him being alone at that moment. I can't say how glad I am that this is becoming more common in medicine, because knowing that he wasn't alone was one of the few comforting things I was left with, at that time.

Also, nearly 8 years later, I've gone to nursing school and am now a cardiac nurse. That is, in no small part, thanks to the compassion and generosity of spirit of the nurses, MDs, RTs and techs that were around when my father died. I still hate seeing asystole on the monitor, though. Awful, awful feeling even if it's someone's time.

Bravo to the entire staff in your ED. Codes can be so chaotic that it's easy to forget the human factor in our hurry to preserve physiology. All of you managed to preserve both dignity and compassion.

Empress Bee (of the High Sea) said...

no matter what she did thank you for allowing her to choose. that's what i would want for sure.

smiles, bee

Anonymous said...

Thank you very much for your moving story.

One question, please: Forgive my ignorance, but why a pharmacist handing drugs from the crash cart as opposed to say, a pharm tech or a CC nurse?

Thanks again,
Hopalong Ginsberg

Anonymous said...

I was thankful to be with my dad as he took his last breath. My mom died alone and it haunts me still.

Hip, hip hop, hip hop Anonymous. said...

Thank you for all the stories. I found your blog a couple of weeks ago and have read from the beginning up to somewhere around mid-March. They're so well-written and really show what a great person you are. If I ever get the chance to become a doctor, I hope I'm half as compassionate as you are (wouldn't mind if I could write half as well, too). Thanks again! :)

Anonymous said...

I was with my mother as she passed away, and it was not frightening at all, rather, a privilege.

My daughter had no one with her when she died, and was crawling to the front door for help.

That is what gives me nightmares still.

Stephany said...

The gift of choice, let them have it, always.

Anonymous said...

How does organ donation play a role in the ER? Thanks for going well beyond your duty as a physician.

Rositta said...

Poignant post... I was with my Mom when she breathed her last. I was holding her in my arms. My father died alone, I had just left the hospital because I was assured he wouldn't die this night but they were wrong. As another commenter said, it too haunts me. I suffered from tachycardia for years not realizing it could be life threatening. Lucky for me, two years ago I had ablation and so far I'm okay. It never occurred to me that I should go to hospital when my heart was beating 200 bpm. I would want to be with my husband if something happened as I'm certain he'd want to be with me. With luck we won't have to worry about it for a while...ciao

Anonymous said...

Wow, what amazing and respectful writing. What a story. This really moved me. I've been following your blog for a few months, and admire your ability to be a caring, compassionate physician in the face of some wrenching facts. I would totally want to be with my husband at the end, and I know he'd want to be with me.

Louise said...

Powerful. These stories can't be easy to write. Thank you for finding the strength to do so.

Anonymous said...

It is so wonderful to see a compassionate ER doc. I'm sad to say, so many seem so jaded. Please stay just like you are.

My friend, an older lady like a mother to me died not too long ago (but not in the ER). They called the rapid response team to her regular room initially - and I was so grateful they did not try to get me to leave. When she was conscious, I held her hand. When she wasn't, I stepped back and just let them work.

When she really crashed, and they took her up to the unit, we were separated briefly. I told the nurse (in charge of the unit) that I don't care what I see, I want to be with her. And very quickly, when it got bad, they brought me in.

I was the one to tell them they could stop the code. I was so grateful, it was the last thing I could do for her - which I had promised I would do, if the time came.

Being separated from critically ill loved ones is the worst thing - I am so glad that medical personnel are becoming more aware of this.

Anonymous said...

It ?is healthy!