Tuesday, November 15, 2016

Roads

One of my patients died today, and I feel so selfishly devastated.

B was strong, sinewy, and very alive when I met him in November of 2014.

I was a resident working in the ER and we had had a long and very messy code blue. A man found down in the cold, on the side of a quiet gravel road. It looked like he had been walking home alone and had collapsed. His knees were skinned through his faded jeans and it looked like he had vomited blood on himself, the bright red ice crystals clung to his faded grey hoodie. He was dead, frozen stiff. But, as the brutal saying goes, 'you're not dead until you're warm and dead'.

So we committed ourselves to warming this man every way possible, in the hopes that we might bring him back to life. Warm forced air under warm blankets, warm ringers into his shin bones, warm saline through a long needle into his abdominal cavity. We worked on him for a few hours, and eventually the patient was pronounced warm and dead.

My hands felt heavy as I picked up the first chart in the full rack, a glance showing all the non-emergent patients who had arrived while we were busy in the trauma bay. You can't help but think, do any of you really need to be here? That LAST guy needed to be here, HE was an emergency. I just wanted to sit down. I wanted to try and mentally file what had happened. But, there was a chart in my hand and already I was opening the door to the next room.

"Headaches"

Oh brother.

Headaches, toothaches, back aches. Drug seekers. T3 refills. I tried to shake the bias that starts creeping in the moment the presenting complaint is read.

B was sitting on the stretcher. He looked like someone who could still run a fast mile, chop more wood than a teenager or two-step until the sun started to streak across the horizon. He looked embarrassed to be there, his wife looked determined. His was an easy smile, hers was a worried face.

Headaches. Getting worse. Never had them before. Worse when he lifted something heavy at work. Feeling...cloudy. Walked around the house for ages trying to find his gloves, only to realize he was wearing them.

I tried to find something, anything on physical exam to bolster the story I was going to have to sell the radiologist in the city in order to get this guy a CT scan. Maybe some papilledema? Was I imagining that? Maybe something off with his gaze convergence? I couldn't hang my hat on anything but a hunch.

My attending was trying to clean up the waiting room full of people while I made calls to ER departments and radiology departments. He was going. He was gone.

I never talked to B again. I saw his CT that afternoon which showed a massive brain tumor, cerebral edema and a midline shift.

I ended up leaving that rotation and losing track of him. I couldn't remember which attending I'd been working with that day. I updated my phone and lost my notes, one of which was his health card number so I couldn't look up his imaging. I thought about him and his wife often and wondered what had happened and how things had gone for him.

And then I found out.

I came into work last week for hospitalist rounds and as I'm settling in to start my morning the nurse tells me, oh you had one admission during the night, a guy with a brain tumor who is here for IV steroids.

I knew it was him. I turned to the stack of charts and saw his name. I know him!

I headed down to his room and open the door. I was still in my scrubs and OR cap from an early morning case. His wife was sitting by the bed. I introduced myself and she greeted me politely.

"We've actually met before...you might not remember me..."

She slightly cocked her head before her eyes widened a bit and she replied,

"Two years to...the...day. We met you two years ago today."

I felt the hairs on my arms rise.

We exchanged stories of how we'd each lost track but hoped we'd somehow meet again. We let our eyes rim with tears at various points in the telling of the journey. B was settled in the bed and though he didn't open his eyes or say any words, his big hand squeezed mine when I grasped his. He still looked well. It was so incongruous. He didn't look faded into the bed, or sallow, or weak. He looked like he was having a quick kip before heading out to hockey practice.

I visited them daily and got to meet his kids, and hear about his grandchildren. Over the weekend he went to the city for further treatment. A hail Mary, so to speak. I kept in touch with his wife while they were out of town, just to check in. Things weren't looking good.

This morning, I woke up just after 5am. I couldn't sleep. I came into the lounge to try and get some reading done for an upcoming course. Shortly after 6am I received a text.

B had passed.

She thanked me for my part in their journey with a beautifully written note. It didn't seem right to cry, but it didn't seem right not too. As I got ready for work I tried to listen to some distracting music. Tears fell into my sink, onto my bathroom counter.

Caring for patients and their families has unexpected side roads. These paths are not on of the map of our training, and no one tells you how to navigate them. No one can guide you or tell you when the road will suddenly become bumpy, or if it will lead you to the most amazing panoramic you can imagine.

Tonight it seems those roads are often one in the same.




5 comments:

Lisa said...

A year ago we took my sister off of life support. She'd been found on the side of the road two days earlier. Apparently, she was taking a walk when she had a massive heart attack, three arteries with 100% blockage. A neighbor saw her collapse. It was less than an hour before she had stents implanted, but she never regained consciousness. I knew she was gone right away. It took the doctors and her daughters two days to realize that. I sat helpless for two days, grossing over the amount of attention that her dead corpse required. I felt helpless for those who waited though migraines and ear infections while she took up resourses. She was obviously dead. Her last joke was to die on Friday the thirteenth. I loved my sister, and I have missed her every single day of the year since she died. The doctors on the day she was wheeled in might have thougt she was the emergency. For me, she was dead. The person with the migraine needed help.

PainControllerUK said...
This comment has been removed by the author.
Stuart said...

I've long since left the Healthcare profession but your story reminds me of something that happened about 16 years ago.

I was coming towards the end of my nursing career, already transitioning into my new found profession and as such was working exclusively for agencies. Back in 2000 the NHS relied quite heavily on agency staff so working on the same ward for weeks at a time wasn't unusual.

During that summer I pulled a lot of shifts on an elderly rehab ward. Not the most glamourous of postings but the patients tended to be there for weeks or months rather than the much quicker rotation found on the wards I was used to working on.

'A' was one such patient. She had originally been admitted for a fractured NoF but had experienced some complications post surgery. She was in her mid 80s and loved to talk. She had many tales, a lot of them relating to the War, most of them fascinating. Until her accident she had been very active and still volunteered in her community. She was one of those patients you couldn't help but grow fond of.

She recovered after due course and was discharged back to her own home. The work on that ward dried up and although I stayed within the same hospital I didn't work on that ward again.

My first shift of 2001 was on New Year's Day. It was a late shift (14:00 - 22:00). It was on the EAU (Emergency Admissions Unit) ward. For non-medical readers EAU came in to existence to reduce admission times from A&E (ER). Patients who came to the hospital via A&E and needed to be admitted would be sent to EAU as soon as possible where they were held until they could be admitted to a specific ward. Effectively it is an extension of A&E so cases were many and varied.

Around 16:00 that afternoon A was admitted. She was dying. We knew she was dying. Her family knew she was dying. Back in 2000/2001 there was a lot of trouble in the UK over DNR orders so there was a very specific process that had to be followed before a DNR could be put into effect. We fast bleeped (paged) the Senior Reg to come and speak to the family so that the order could be signed. Before he had chance to reach us A arrested.

We spent 40 minutes in a 'Crash' situation despite the fact that nobody considered this appropriate. A herself had told me that she wouldn't wish to be brought back. But, because of bureaucracy, we had no choice. We kept her going.

The Senior Reg eventually got the signed order and we let her slip away a few hours later.

I went home to my girlfriend that night and recounted some of the tales she had told me over several large drinks.

Approaching 16 years on, I still remember a few patients, A being one of them.

Albinoblackbear said...

@Lisa Your perspective is unique, and not often the way family members see things (unfortunately). I've seen a lot of 'bad deaths' and though none have been my family, that feeling of helplessness is there. We don't like to admit the fact that 'medical futility' does more than use financial and logisitcal resources. But, like you point out, it does. I'm sorry you had such a painful experience and that you had to watch your sister die like that. Thank you for your comment.

@Stuart What a gift to have met that lady, and to be able to share parts of her life with people you love. But such an awful scenario for her end of life. It's one of the reasons I could never work in an ICU. More and more often we see "heroic" measures, which should really be called "fear of litigation" measures taken up and people becoming protoplasms that exist only for the machines and devices ensuring it. Thank you for posting.

skyjockbill said...

Such wonderful writing, Erin. My sister just read Atul Gawande's Being Mortal and loved it. You're following in great footsteps as well as charting your own path.