Mortality

They say you never forget the first time.

The EMS call came in around 7:30 pm: "48-year-old female, collapsed at home in front of witnesses, arriving by ambulance in 10 minutes, CPR in progress."  The last three words meant this was no simple blackout or seizure, and we were jolted into action.  The trauma bay was fully staffed and ready to receive the patient within moments.

The tension hung heavy in the air, as it always does when awaiting the arrival of a catastrophically ill patient.  Several ED residents donned surgical gowns and face shields, and we all put on gloves.

And then we waited.  Nobody said anything; there was nothing to be said.  This was an outstanding Emergency Department that was used to handling critically ill and injured patients, and everybody knew the correct place to be.  I wasn't quite sure how I could help as a fourth-year med student, so I looked at my resident and raised my eyebrows; he pointed at a spot in the trauma bay and I went to it.

After an eternity, we heard an ambulance's siren, faintly at first, then gaining strength as it approached.  At the end of the hallway, the ambulance bay doors flew open, chilling us with a blast of cold November wind.  A gurney appeared along with a pair of EMTs, one squeezing an AMBU bag connected to an endotracheal tube, the other straddling the patient and performing chest compressions.  Several nurses quickly converged on them, and together they ran down the hallway toward the waiting trauma team.

Within seconds, the gurney was beside the trauma bay bed; then we all reached to take hold of the backboard; then someone shouted "One, two, three!" and we all lifted.  The senior ED resident, only seven months from completing his residency, immediately took charge, calling people by name and giving assignments: "Keep bagging!  Resume chest compressions!  Get her on our monitors!  Hook up the defibrillator!  IVs!  A-line!  Drugs!  Record!"  I was assigned to deliver extra IV and a-line supplies to the appropriate team members, and to take a turn performing chest compressions when others became tired.

Most of the code became a blur after that.  I rotated through my turns doing chest compressions, feeling the unsettling scrape of cartilage against bone under my hands, feeling the sickening crack as I managed to break a rib that had miraculously remained intact through CPR.  I was vaguely aware of the EMTs giving what little information they had to the attending and senior resident.  The senior resident called for epinephrine and it was given.  Sometimes he asked for vasopressin.  Sometimes we stopped doing chest compressions so the defibrillator could evaluate the patient's heart rhythm.  It was PEA.  PEA isn't a shockable rhythm.  We resumed chest compressions.

Time dilates during a crisis.  For what felt like an hour, we did CPR, gave drugs, and checked the defibrillator.  The senior resident was running the code perfectly, so the attending excused himself to go talk to the family for a few minutes.  He asked me to join him.  I looked at the clock as we left the trauma bay.  The "hour" of CPR had only taken fifteen minutes.

We went to the counseling room where the patient's family had been brought.  I stood back and watched as my attending spoke with the husband.  He was a big man with a full beard; he looked like a man who loved to ride motorcycles, drink beer, and dote on his daughters and granddaughters.  He tearfully told us that his wife was a home hospice patient, but he wasn't able to tell us what she was sick with.  He told us about a couple medication allergies.  Then he pointed at my attending and said, "Doc, don't you pull that plug unless I tell you to!  Don't pull the plug unless you hear those words come out of my mouth!"

How do you respond to such an order?  No doctor wants to see a patient die, but everyone's story ends the same way.  One last breath.  One last heartbeat.  And then nothing.

The attending was as gentle as he could be.  He told the grief-stricken husband and family that there was no plug to pull since their wife and mother wasn't on a life-support machine.  He told them that her heart wasn't beating and his team was trying to start it again.  He told them we'd do what we could, but we couldn't keep going forever.

I followed my attending back to the trauma bay.  Nothing had changed there.

"Epinephrine, one milligram!" called the senior resident.

More chest compressions.  Then another defibrillator evaluation.

"V-fib!" announced another resident.

"Everybody get clear!  Shock, 200 Joules!"

"Charging, 200 Joules.  Everybody clear?  Shocking in three, two, one!"

The wiry-thin patient jumped just a little from the shock.  Nothing like what you see on TV.

"Resume chest compressions!" ordered the senior resident.

Several more rounds of CPR.  Several more shocks.  Coarse v-fib became fine v-fib, then the heart monitor went flat.

"Call it?" asked the senior resident.

"Call it," confirmed the attending.

"Time of death, 2025."

We all stepped back from the patient, sweat-drenched and exhausted.  Then, unexpectedly, the pulse oximeter gave a lone beep.  We looked at the monitor.

"...no way..." breathed the senior resident.

Sinus bradycardia.

Someone felt the patient's carotid artery.  "Pulse is very weak and thready...fading...fading...gone."

"Resume chest compressions!" ordered the senior resident.

And so we started the code again.  More chest compressions.  More epinephrine.  Defibrillator evaluation showed PEA.  Several more rounds of compressions and meds.  Then coarse v-fib.  A shock.  Compressions.  Drugs.  Fine v-fib.  A shock.  Compressions.  Drugs.  A flat line on the monitor.

"That sinus brady was probably because we pistol-whipped her heart with so much epi," the attending opined.  "Call it."

The senior resident's dejection at this defeat was clear.  "Time of death, 2047."

We left the trauma bay in silence, taking off our protective gear as we went.  Someone turned off the monitor.

A few nurses and techs who hadn't been in the code went into the trauma bay to clean up.  They cleaned the vomit and blood from the patient's face, and extubated her, and closed her eyes.  They got clean sheets and covered her to the neck.

My shift ended at 9 o'clock that night, a blessing after my first time watching another person depart this life.  But even though my work was done, I couldn't leave.  Instead, I went to a quiet hallway behind the ED.  I stood there for nearly thirty minutes watching the snow gently falling outside, placing my hands on the glass just so I could feel the cold.  Though it may seem strange, I didn't think about the patient or the experiences of the evening.  I just needed solitude.  I needed to consider my own mortality.  I needed to turn my thoughts toward God.

And then I felt the quiet after the storm, and I knew it was time to go home.  I went to the resident workroom and got my coat and backpack.

As I passed the trauma bay, I caught a glimpse of a young man about my own age, tears streaming down his face as he grieved for his mother, a young lady encircling him with her arms as she wept with him.  I averted my eyes and kept walking.  In a moment of such desperate grief, even the mere gaze of a stranger is hateful.

It's true what they say.  You never forget the first time.