Monday, November 15, 2010

The Pit Stop

I walked up to the closed door and paused , exhaling a deep breath weighted with disappointment, trying to clear my thoughts for the conversation about to come. My clenched fist was briefly suspended, mid-air, ready to knock. Beyond the door, I could hear muffled conversation and movement.

A calm, pretty woman stood beside me. An emergency department case manager. She held a notebook and pen, ready to jot down any useful information that might be shared with us by the room's occupants.

I turned to the case manager. "Are you ready, Cindy?" I asked, making sure she was prepared for the gravity of this unfortunate situation. She nodded "yes," confident in her skills during such adversity.

I turned back to face the beige, chipped door of the family room and knocked lightly. The noises of conversation and movement suddenly ceased, and I could easily imagine the stillness and anticipation that pervaded the room.

I rotated the door handle, gently pushing the door forward before stepping into the room. The air and energy of the room were stale and suffocating, especially after leaving the hallway atmosphere of chaos. My eyes darted quickly, taking in the whole of the room. On the couch, two elderly people, a man and a woman, sat on either side of a middle-aged woman, their hands linked in unity. The two corner chairs were filled with a middle-aged man in one, a college-aged boy in the other. All five people focused intensely on our arrival, their dilated eyes wary for the news I was about to bring them.

Before sharing my news, I briefly introduced both myself and Cindy and learned that this room contained the patient's wife, his in-laws, his brother, and his son. After shaking hands, I deliberately continued to hold on to the wife's hand while her father rubbed her back.

"It's not good, is it?" the wife asked me. I shook my head "no" to her question before saying the word out loud. "No," I reiterated, "it's not good. Despite all of our attempts, we can't seem to get your husband's heart beating again."

I had left Room 17 for the family room with a dismal feeling. The woman's husband, in his late 50's, had collapsed at work and, despite being intubated, having immediate CPR and being given all the appropriate life-saving medications by our prehospital team, still had not responded to any medical interventions. He had arrived at our facility ten minutes earlier, thirty minutes after his collapse. After several attempts of high-Joule defibrillations and multiple escalating doses of medications, our team remained unsuccessful in our resuscitation attempts. I had left his room with the patient in asystole, a malignant situation where the heart was not making any electrical signals to stimulate itself to beat. It was not looking good.

For the next several minutes, I explained to the family, with earnest, what our medical team was doing in attempts to resuscitate their loved one. After I finished, the wife stood from the couch and dropped to her knees, half in prayer and half in disbelief. "Please, Gary," she wailed in a desperate voice, "don't leave me yet. I want to talk to you one last time."

After helping her back to her feet, I offered her to come to Gary's room with me to be with him during our resuscitation efforts. She accepted.

The patient's wife, Cindy and I walked back to Room 17. As we neared it, I explained the focused commotion she would witness when we walked into the room--three nurses, several techs, a senior resident physician, a pharmacist, a respiratory therapist, and several others all scurrying in their efforts to help her husband, who would be lying on his cot in the middle of all of this activity.

I pulled back the curtain to the room and walked in, surprised to see that CPR was not currently in progress. I introduced Gary's wife to the team and guided her to Gary's side before seeking out my chief resident as to what transpired in the last few minutes. It seemed that right before we had entered the room, Gary 's heart rhythm had switched from asystole to ventricular tachycardia, another life-threatening rhythm. However, this rhythm responded to our team's electrical shock and Gary, still unresponsive, now had a faint pulse accompanied by a normal sinus rhythm. After being down for forty plus minutes, this was nothing short of a miracle. A well-timed miracle corresponding to his wife, on her knees in the family room, pleading with him to hold on.

We encouraged her to talk as much as she wanted to her husband.

And so she did. With tears brimming her reddened eyes, she remained near her husband's left ear, continuously whispering her hushed encouragements and pleas while stroking his hair. Soon after, her son and the patient's brother also were escorted in to be with the patient. Their expressions of disbelief as they walked into the room were heart-breaking.

We called the cardiology team who, after arriving at this patient's bedside in minutes, prepared to take him to the cath lab. Unfortunately, his outlook was tenuous. I was skeptical, after 45 minutes of resuscitation, if Gary would have a positive outcome. Even if he survived, there was no predicting how mentally capable he would be after such a long time in cardiac arrest. If not to survive, why else would he be hanging on?

Suddenly, I thought back to Gary's wife dropping to her knees, begging for a last chance to talk with her husband. I thought of Gary and how, out-of-the-blue, he suddenly regained a faint pulse after multiple failed previous aggressive attempts to jump-start his heart. I looked at his wife, his brother and his son currently holding Gary's hands and whispering their loving words into his ear.

Was this the reason?

I was searching for some sense in this nonsensical situation. Possibly, I realized, I might have been over-analyzing the whole situation, trying to understand how Gary could possibly still be alive. Quite frankly, though, after 45 minutes without a pulse, Gary should not have been successfully resuscitated. Was the whole reason of Gary's lingering due to something beyond our control--the fates cooperating to let his wife and family have several more minutes with him? For proper goodbyes? Or was it because his body really was responding to all of our heroic measures and would heal itself with our modern interventions?

I was eager to know how our efforts would be interpreted by fate. Watching Gary being wheeled down the hallway, from Room 17 to the cardiac cath lab, with his family by his side, I was hopeful that there might be just a sliver of a chance at his full recovery. If not, though, just seeing his family have the opportunity to be with him, to speak to him, to accompany him so he wouldn't be alone during his passage, was enough of an explanation for me.

I got my answer when I returned for my scheduled shift the next day.

Although Gary had still been alive at the end of my previous shift, he never regained consciousness. Per Cindy, he peacefully passed soon after, in the evening, surrounded by his loving family.

He had hung on for all the right reasons...

As always, big thanks for reading. I wish much peace for Gary's family. I also hope this finds you all well. See you again later this week...


Sucheta said...

This was a very good post. You're my favourite doc blogger!
How many years have you been in practice? It is very awe-inspiring to see someone 'connect' with patients so well. You inspire me in many ways!
-from India

Anonymous said...

After a decade in hospice, I am only mildly surprized by this post. I had a terminal patient waiting to say goodbye to his dear grandson, who was in the Middle East in combat. It took almost a week for the Red Cross to get him home to say goodbye to Grandpa. During that WEEK, the patient had consistent VS of (roughly) 96.2~30~5-6, 50-60/palp. He had about an hour with his grandson (still in combat uniform, fresh off the plane) before he finally allowed himself to die. Ask anyone in hospice and you will hear story after story just like this. The human spirit and divine assistance is awe-inspiring.

Pattie, RN

rnraquel said...

Thank you so much for your writing. You always remind us to look at the whole picture of our patients and their families. You are a blessing to others.

rlbates said...

Thankful for the family's last hours with him. Peace to you all.

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

what a beautiful and beautifully told story today doc. i don't think i'll ever be ready to lose my hubby. i always (selfishly) wanted to go first. i may not get that chance...

smiles, bee

SeaSpray said...

With all my heart, I believe that was a gift from God for a last goodbye. Why it happens for some and not others? I don't know.

But you all witnessed something special.

Beautiful writing Jim. I walked in the room with you when you twisted the doorknob open.

Tiff said...

Jim, this brought tears to my eyes. Such a touching a post. You have such a talent of making the reader feel like they are right there with you in the ER dept, expierencing the emotions first hand. Thanks again for sharing your expierences through your talent of storyetelling. Keep up the good work Jim, both in the ER and in the blogger world! Hope you have a great week!!

Katie said...

What a wonderful story! I have no doubt God heard the woman's plea, granting her the opportunity to say goodbye. I believe in miracles.

<>< Katie

"Doctor" Matt said...

I haven't been "on the wards" very long myself, and even I have seen a time or two like this already. It makes you really appreciate the unique experiences we have in the healthcare profession. What an honor to be involved in such an event. Thank you for sharing; as many have said, you're truly gifted.

Cal said...

I am glad they all got a chance for a final goodbye. How heartbreaking!

Winking Doll said...

Beautiful. I believe that the dying tries to hold on for the loved ones to say their closing goodbyes. I have seen it too.

coulrophobic agnostic said...

I never really stopped to notice how long people attempt to resuscitate until after my dad...they told us they tried for twelve minutes. I remember thinking "That doesn't seem very long. What, do you have something better to do?" I would've given anything for what this woman had with her husband. Though I suppose we would have given anything twice over to have them back.

Karen said...

I worked with a man who, although was only 61 years old, he looked 81. He'd had his first heart attack in his early 40's and several after that. At the end of his life, he had CHF and knew the end was near. Family was his everything and one daughter lived in Hawaii. He called her one night saying that he wanted her to come home. She flew home, they visited for 4 hours and only then did he die. If she were not to arrive until the next day, I'm convinced he would have lived another day just to see her.