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...

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...

My Spinning Head

My head is spinning. Seriously spinning.

Let me see. A combined twelve years of elementary school and high school. Four years of college. Four years of medical school. One year of internship. And three years of residency. Oh yeah, don't forget about the thirteen years of "life" I've had since all of this formal schooling and training has finished.

Yet, for all of this experience and hard work, I felt abandoned. Confused. Wayward. Standing in the middle of a store aisle. I ended up looking to my left, ready to plead for a stranger's help. I looked to my right, hopeful that some angelic vision enveloped in a bright, shining aura would proclaim the answer to my question. And I looked ahead of me, acutely aware of all of my options.

Which cough and cold medicine should I buy?

You might laugh but, seriously, how does the common person do this? Here I am, with all of this medical knowledge and ER experience in my back pocket, and even I can't make a decision to what I should buy in this endless cough and cold medicine aisle.

It started out simple enough. Traveling down the fourteen hours to Hilton Head these past few days, staying in a hotel room halfway through the trip, lots of car time with some lingering kid-coughs, closed continuous car circulating air, and, before I could blink, my wife has a runny nose, sinus congestion, and headache. And is feeling rundown. And is achy everywhere. And has a sore throat. And a fever, "well, maybe I don't have a fever but I feel warm." I'm sure it was brewing before we left but, unfortunately, presented itself at the start of our vacation.

The thing is, my wife never gets sick. Seriously. She takes her vitamins, she exercises, she eats her vegetables, and not from a can, mind you (that would be me and my love-affair with young, tender peas). She consistently partakes in all the things that I only do on a sporadic basis. But, here we are, on vacation, and she's the one whose ass is dragging. I would take one for the team, in a heartbeat, if I could spare her this misery. But, I have to admit, for once, it's nice to not be the adult in the house getting the kids' spill-off illnesses.

She's not a complainer (of the two of us, that would be me), so when she asked me if there were any medications she could take to feel better, I knew she was not feeling well.

We went out as a family to WalMart to buy her some medication for her symptoms. The irony of it--driving fourteen hours to go to a store that exists five minutes from our home--was not lost on me. But to our credit, we did try the local grocery store first.

I walked into the store, very clear about what kind of medicines she needed to get back on track. How hard could this be, really? She and the kids grabbed a cart to fill-up on our needed supplies for a week of condo-living. I searched out the pharmacy section. "I'll meet up with you in a few minutes," I had said. On hindsight, a stupid statement.

I found the cough and cold medication aisle quickly. I started picking up the boxes to read the active ingredients. Cough suppressant? Cough expectorant? Nasal decongestant? Antihistamine? After sorting through all of those options, then, I had to decide if I wanted acetaminophen (Tylenol) or ibuprofen (Motrin or Advil). Okay Jim, I comforted myself, just take your time and start over.

I decided a different approach--let's go with the proclamations on the front of the box. Cold Multi-Symptom (regular or severe), Sinus Congestion, Headache and Sinus, Cough and Headache, Sore Throat and Cough, Sore Throat, Cough, and Sinus...you get the picture. If nothing else, I appreciated the selling of every single variable you could squeeze out of the common cold.

So picture it, you are at the store shopping and you see a guy scratching his head, rubbing his chin, pacing back and forth, picking up a box off the shelf just to replace it back in seconds, and that would be me. With all of my infinite medical wisdom.

I finally sorted through all of these options before realizing, "Wait, she'll need both a daytime and a nighttime medication." I sure didn't want my wife to get tired in the daytime during our time at Hilton Head, right? Possibly risk sleepwalking through our vacation? So, guess what? She'd need the nighttime version, too. Unfortunately, though, the daytime formula I had decided on didn't have an alternate nighttime version (it's usually just an addition of some form of antihistamine). So what did I do? Well, of course, I started over.

The minutes dragged, the active ingredients blurred, and the box-front symptoms united to form one big blob of an illness. Finally, after much frustration, I picked out what I thought was the best option for my wife's illness.

"Daddy," I heard my youngest call, just as I was wrapping up my choice. Looking down the aisle, I saw my smiling family approach me. "What took you so long?"

I held up the boxes I chose for my wife to see. I must have looked like the village idiot, extreme pride radiating from my pathetic face, eagerly anticipating my wife's approval of the two $2.68 boxes of miracles. Please, please, I remember thinking, tell me how good I did.

What she asked next was like fingernails on my brain's chalkboard. "What about the liquid, Jim? How's that?" I think I stomped my feet, my mind screaming "No, no, no" while my voice remained silent. "Or," she continued, walking down the aisle, scanning the options, "maybe I'll just do gel-caps." She looked at several boxes quickly, scanning each's front and back in just short of ten seconds. "Yeah," she said, "I think these will do." She had found a combo-box of both daytime and nighttime medication with, evidently, just the right active ingredients to treat her symptoms.

I think I'll just place this whole experience in the "knows too much," category, thank you very much. I might just be giving myself too much credit, though, on that one.

Now, if you don't mind, I have to go take a couple Tylenol for my headache. Or maybe Motrin. Oops, I mean Aleve...

As usual, big thanks for reading. Next post follows on Wednesday, March 17. Hope everyone is well...see you then...