every time i think i’m getting used to things, i find there’s another bump in the learning curve – and it’s not always the information curve. there’s an emotional curve as well, which seems to be the steep one right now.
sometimes i can feel myself slipping through the gateways between the pragmatic tasks, the analytical aspect of patient assessment, the intuitive level of assessment, the relational exchanges between myself and patients/families/coworkers, the sense of myself reflected in what i do, say, and others’ responses to me, and the inner reflective levels where i or my mind is trying to make sense of it all, incorporate it into my being and understanding. other times i can’t feel those movements at all, but find myself unexpectedly affected or returning over and over to particular images or situations without reasons that i can identify or understand.
two nights ago i found myself in what somehow seems to have been one of the most painful and upsetting moments (if a moment can be 7 hours long!) thus far…. an elderly gentleman brought in from a nursing home around 11pm, accompanied by his wife. when he arrived, he could talk, said he felt weak…. looked terrible. dehydrated, probably septic. according to his wife he’d been treated for a bowel infection. getting a line was a nightmare – the resident got one in his neck, they tried for a femoral but couldn’t manage, eventually put in a subclavian. he coded within the first hour. we thought he was a full code, which means that we “do everything”- cpr, intubation, epinephrine, etc. – it was enough to get a pulse back. respiratory came down with the ventilator. his mouth was full of bloody secretions, so in went a nasogastric tube. and there he was – in the bed with all the blood, vomit, diarrhea, all the tubes everywhere. we started some heavy drugs to maintain his pressure by pushing the blood to his vital organs. he wasn’t very responsive to them, although we had been pouring in liter after liter of fluid. i titrated up and up and there he was still in the 50s, the 60s. meanwhile his peripheral circulation was shutting down… extremities cool, colorless… could barely even get a blood pressure.
the attending who was working that night is really lovely – easygoing, pragmatic, with a totally unassuming and warm bedside manner, humane, smart, and receptive. he had the patient’s chart from the nursing home which said there was a do not resuscitate order, but hadn’t been able to confirm. unless we know that an order like that is totally legit, we are obligated to do whatever we think might help. and the wife, who was there, was saying “please save him, please help my husband.”
“doing everything” for him also meant doing everything for her – trying to support, inform, and educate even in the midst of flying in and out of the room, starting different medications, monitoring vital signs, maneuvering around everyone else at the bedside – residents, techs, other nurses, even a med student that night.
she clearly had been a beautiful woman – it seems unfair to say that in the past tense somehow. she was well groomed, with white hair down to her shoulders and bright, clear blue eyes. but there was something a bit off about her. she had some sort of speech impediment, which made her speech slow and a bit garbled. and what she said seemed a bit confused – i had to explain to her so many times that we were trying to help her husband, and she would get so upset about each procedure as it arose. sometimes she would become upset and shout that i was hurting him as i was trying to clean or reposition him, and sometimes she would wax eloquent about how wonderful i was. she took to calling me “big eyes,” telling me should would never forget me, or that she trusted me, or that i was taking good care of him. still, despite her being a bit erratic, the attending wasn’t convinced that she wasn’t capable of making decisions for him. he continued to try to contact the patient’s primary doctor, the one who had signed the paperwork that had come from the nursing home.
she was obviously upset, and with good cause. but it was so clear that she didn’t grasp what had happened, or how far gone her husband really was. she kept asking whether he’d be able to leave the hospital that night…. then saying she wanted to take him home because he’d be able to recover there… then another time, saying she wanted to take him home to die. the attending and i, as well as the cardiologist, tried to explain to her that he wasn’t able to go home, but she was insistent…. then later when i came back into the room, she confronted me, said, “big eyes, i know you will tell me the truth, tell me if he’s going to get better.” i explained it again, that he’d had a very serious problem with his heart, that there would be consequences to that as well as side effects from the medicines we’d given him, that we didn’t know what they would be, and that though he might improve, he would not be as he had been – he would not “get better”.
even as i was telling her these things, trying to be as clear, objective and truthful as possible and yet with the acknowledgement that there was no way for me to predict the future, i also knew that he really didn’t have much of a chance for any kind of recovery. she seemed to understand a bit then, to grasp the gravity of it. she said, “i have to talk to him. can you take out the tube so we can talk about it?” i said, if we take out the tube he won’t be able to breathe, because the machine is breathing for him. she said, “i have to ask him.” she began to talk to him anyway. she said, “can he hear me?” i said, i don’t know. i left them there, i closed the curtain so they could be alone. i don’t know what she heard – from him, from within herself, from any being of whom she might inquire.
the reality was that he was dead by 8 that morning, an hour after my shift had ended. when i came back the next night, i heard the rest of the story…. that his heart had stopped again, that his wife had consented not to resuscitate and/or the validity of that do not resuscitate order had been confirmed, but that afterward she became so upset that she started hitting the nurse who had taken over for me with her cane and was made a patient herself. she was sedated in the room next door to where he had been the night before.
it wasn’t as if we could have done much of anything differently, or could have done anything to keep him alive. but over and over again, i just found myself thinking what a horrible way for things to end, what a horrible way for her to see someone she deeply loved, with the tubes taped in his mouth, with the tape covered with the blackish bloody vomit that i hadn’t been able to wipe away when i cleaned the rest of his face, with his body already turning the colors of death.
but at the same time i’m not sure what else could have happened. there obviously had been some conversation around end of life and interventions, but the lack of clarity meant that we spent hours giving this patient treatments and procedures that he may not have wanted. the truth is that even when those conversations took place, i’m quite certain that neither the patient nor his wife had the slightest idea of how it would really look in the end.
a good friend of mine who works at another metropolitan ER has commented on how strange it is to be with strangers in these intense, momentous experiences- the loss or illness of a loved one being one of the most profound and significant moments in life. there is simultaneously a distance and an incredible intimacy. it is possible to be too perfunctory, to be too familiar, to make assumptions, to overlook certain significant things. in each situation, with each person, it is necessary to learn what is possible, what is required. i hope, too, that it is possible to learn.
i keep seeing them, keep hearing her voice, keep wondering how to answer.
