ethics · PGY-1 · residency

Post-call

Three people died on my last call.

One was a middle-aged woman who overdosed on everything imaginable. Found down, apneic, cyanotic, brought in. God knows who called 911 on her. I called her family from the ER. They came in straight away, the father’s eyes rimmed with red, mother looking frazzled, a niece still wearing her ID badge from work. She was tubed by then, pupils dilated like belladonna, the beautiful lady. Six hours later, I sat down with the family, explained the situation, that she was gone long before we laid eyes on her, no reasonable chance of recovery. A pH of 6.7, I did not say but thought, is not compatible with life. They cried — I’d forgotten to bring in Kleenex, lesson learned — and decided on palliative extubation. Or in EMR-speak, “Withdraw from mechanical ventilation” and “discontinue pressors.” The parents hugged me and thanked me (which made me feel sick, because they were thanking me for their daughter’s death) and left, crying, clinging onto each other, through the big double doors of the MICU. I walked into the room with the nurse and respiratory therapist, we drew the curtain, and waited. Her pressure came down, slowly at first and then faster and faster like a small child tumbling down a slope. She brady’ed as her coronaries stopped perfusing and her myocardium shuddered to a halt. Pulseless electrical activity, and then asystole. RT hands me the stethoscope; I hate listening to a person’s chest who has died, it’s frightening because you expect to hear something in a chest, and the absence of that is bone-chilling. Thirty seconds after asystole, her face had already gone that horrible yellow-gray of death. So I pronounced her. I never knew what prompted her to kill herself. I’d never even spoken to her, and still I felt this indescribable sadness at her death, not at the waste of resources (which the nurse kept talking about) but rather at the waste of possibility. Maybe she was a horrible drug-seeking child abusing murderer, I don’t know. But I was in the room when her tracing went flat, and she was my patient.

Simultaneously overnight, across the hall, another patient whom I’d admitted earlier that day was hemorrhaging wildly into his lungs. My resident was intubating him and placing a central line. His wife stayed at the bedside the whole time, wrapped in a Fair Isle blanket. It’s cold in the hospital at night, colder when you are watching and waiting for someone to die. This guy made it through the night, and this morning, a long discussion with the wife and son, and they decided to extubate as well. I wasn’t there when it happened, but I like to think his wife was at his bedside, holding his hand.

And the third, an overhead code called in the middle of rounds, a new admission who suddenly unexpectedly stopped her heart in the corner room.  In a code, the first step is to take your own pulse. And mine was pounding in my ears as I slammed on her chest. Compressions for 45 minutes. Ribs snapped; they always do. She got a pulse back, briefly, lost it, returned, lost, and finally back for good. No brainstem function. They are cooling her in the hopes of saving something. I think she had overdosed as well, but accidentally.

I stayed another three hours, finishing my work, then left exhausted, arms aching.  I stopped by the local bakery on the way home, where the girl behind the counter was a college buddy but how have our lives diverged. She has a two-year-old, and I just killed two people (because they aren’t dead till a doctor pronounces, and it’s my signature all over the paperwork) and resurrected a third.

I don’t feel like a normal person right now. The sleep deprivation may have something to do with it, but it’s also the rawness of the ICU. I’m not a religious or even a spiritual person, but being so close to Death, and in that first case, standing in the room as it slipped itself around my patient, and you can’t help but acknowledge its power. Perhaps it was easier in the old days, when death and birth occurred at home and everyone was much closer to it. Now it’s in hospitals alone, behind drawn curtains, and we can’t talk about it outside, when the sun is shining hotly and the college kids are walking around in sundresses and polos.

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4 thoughts on “Post-call

  1. That’s really tough; I can’t even imagine how you feel right now . . . It’s one thing to deal with death as a student and quite another to have the responsibility of being the patient’s doctor when they die . . . even if there was nothing you could do.

    Having said that, I think you probably did a lot more than you think by giving the families the choice to extubate their loved ones in their final moments of life.

    Thank you for sharing this.

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