This thing I refer to as My Life

This is working a little reversed from what I expected. I expected to post here first and then copy it to the class site. If you search my name and "blog" you'll get a link to the public blog site. Here are a few entries I had over there:

DOD

It's a strange title. It took me a few moments to decipher what it meant the first time I saw it back in Medicine. It means Date of Death, as many of you have figured out. We had a patient transferred to our service that, unfortunately, did not survive. If I understand correctly, a surgical procedure was performed on an emergent basis and then transferred to our service for our care. My involvement began when the patient went into cardiac arrest at the start of my call day: 0615. I have been fortunate enough to be involved with around a dozen codes during my cardiology rotation and it became one of my most favorite things in the rotation. I know that sounds morbid, and maybe it is, but because the interns on my team were about to become seniors, they allowed me to participate in codes more at an intern level than a student level. I performed chest compressions, drew labs, administered medications, assisted with central access, etc. Since this was the first code with this team, I was less directly involved but happy to deliver needed supplies and help more from the edges. The patient survived the code and for the next 18 hours or so but expired while I was taking call. I dont know if the patient regained consciousness, but I suspect not. During my cardiology rotation about half of the patients that coded did survive but I have been told on many occasions that 50% survival is a fluke of sampling error. There is more I want to post because there are always emotions surrounding such events: the patient's, patients family, yours, your coworkers. No one walks away the same. I will, hopefully, go into all of that in more detail but now I have to study for tomorrows procedures. Health care cannot slow down for death because there are other people we need to help. If we run fast enough maybe it will not be able to catch up.

DOD part 2

To continue on a bit with this event, let me paint the picture with a little more detail: After arriving at the hospital at 0515, I went to pre-round see each of the four patients I was carrying on the service. One of my patients had just been moved to the floor after spending several days in the ICU for respiratory failure. He was now doing much better and was stepped down (its a step down in care, but its a good thing!) the day before. The team was to start the official rounds at 0615 in the ICU. As I walked up, I noticed the large red cart being rolling from the corner. Not fully realizing what was going on I said half jokingly to my intern,

Is someone about to crash?

Shhhhh...dont say that, the [spouse] is right there, he replied.

You see, I thought they were just moving the crash cart, not using the crash cart.

Not two or three seconds pass and three doctors surround what I suddenly realize is the patient that was added to our service. The senior resident was checking for a femoral pulse, another doctor was performing chest compressions and one of the nurses was administering medications. Someone asked the family to step back for a moment by the time there were about three layers of people. Thats how codes usually work: on the outside are runners, followed by a layer of people that are passers, getters (getting stuff that is close by, but they know right where it is) with the inner most ring being the doers (establishing an airway, ventilating, chest compressions, vitals, medication administration and drawing labs). Instinctively, I put on gloves, tucked my tie into my shirt and offered to assist with compressions. The patients heart started pumping again pretty quickly so I transitioned myself out to a runner and occasionally a grabber. One other thing I remembered to do was to check in the next room to see how the patient there was doing. Often overlooked, but in ICUs without walls, only curtains, the next patient knows something is going on and its probably not good. After my running to get sterile gowns was over, noticed the spouse sitting on the side in tears. This was the first code where a family member was present for the event.

Sitting off to the side, tears rolling down her cheek, he cant diehe just cant.

He was not an old man, it was not a serious operation: it was serious enough, I thought to myself. I held her hand as I squatted next to her for a moment. I dont really recall what, if anything, I said.

Over the next hour, he stabilized and most of the team went to rounds. My senior said to the students that someone should stay behind and I volunteered. By the time the wife was back at her husbands side not quite composed but not falling apart. I asked her if I could get her some orange juice to drink which she appreciated.

Much of the discussion between the physicians was identifying the actual cause. The two most likely causes were pulmonary embolism or florid sepsis. The decision was made to put him on ECMO (hear-lung bypass) which took place later that day.

As I write this, I notice that I have yet to speak of the actual emotions taking place. For me it covers a pretty full range: fear and excitement trying to keep someone from dieing when it is not their time. Happiness because you were there to help in the best way you know how when the person needed you most. Sadness because, usually, the patient either does not survive or experiences some significant hit either mentally or to some other organ system. Love and hate are in there, but its a little more difficult to explain. Maybe if you can put yourself into the scene youll understand.

Later that day one of the other students and I took some time to go back and see how he was doing. The ECMO team was there they taught us how the system worked. They also pointed out that they could tell he was not doing to well. With the ECMO they can see just how much oxygen is being taken from the blood as it passes through the body (just like how blood fresh from the lungs is red (arterial blood) and blood returning to the lungs is blue (venous blood). At this point, his body was not using up that much oxygen. They were just waiting for him to declare himself. Thats another one of the strange little terms. I did not think to ask how they tell when a person declares they have passed away when there is a machine doing all of the work for them. Not tan, but from the magenta color of his face he had already declared himself.

Early the next morning, while I was busy with other patients on-call, he coded again and was pronounced. I had asked earlier that evening if I could go check on him again but the opportunity never arose and it was too late when my shift ended at 0830 the following morning. I did not sleep that night; it was not peaceful for me. I hope it was for him.