It always happens like this eh? Trying to start a 'big post' always adds some difficulty in the writing because I don't really know how to start it off. I guess the best way is to start with the most obvious point.
Today I witnessed my first patient death. Actually it was the first death I have ever witnessed live. Adding to that was being a part of the efforts in resuscitating the patient and you get an experience I'm going to never forget (especially now that this will be recorded digitally).
What had happened? Well, this gentleman who was in the cardio ward upstairs went code blue. The medicine resident I was shadowing for the day pretty much sprinted when he got the page and, thus, so was I. From the patient's room, a team had resuscitated him and got a BP going (there was enough time for me to even remark how timely it was to see a real-time EKG scan and the use of a bunch of ionotropic and vasoconstricting drugs since I've been learning cardio in class for the past 2 weeks). The patient was bagged and taken down to ICU where he'd be reassessed and maybe sent to the OR or interventional radiology.
But that's when circumstances took a quick turn down the 'poor outcomes' alley. Almost right when the patient was moved into the ICU bed, his stats plummeted and he went into VTach, and then asystole. Hemoglobin levels tanked too, which was particularly worrisome based off his morning numbers. The whole ICU team just was rushing around trying to stablize him, opening femoral lines, putting in catecholamines, and pushing more blood to restore hemoglobin/BP levels. Not wanting to look out of place, I rushed to join the Respiratory Therapists on chest compressions to restore a pulse. We were successful partially a few times, but no regular rhythm was continually restored. So for the next 2 hrs it was CPR for me. 2 minutes on, wait for the other RTs to do their turn, and then back to the pumping.
Now 2 minutes of chest compressions may sound like a short stint. But after a few cycles actually exhausting after a while. Especially considering how quickly and deeply you got to push. I'm lucky I'm a big guy, I couldn't almost believe how one of the RTs (a petite lady) was able to do her compressions. Girl must work out.
Unfortunately (but not surprisingly, considering the second paragraph from the top...) the patient wasn't responding and the family requested use to stop. CPR was discontinued, a few vasopressors were given to maintain a bare set of vitals while the family came in to say goodbye.
Truth be told, I don't feel too traumatized by it. I guess, walking into this field, it's a realization you got to make that you're going to experience some death sooner or later. Partially, I was so hypoglycemic (hadn't eaten since the early morning) and running off the adrenaline that I felt more in a runner's high during the whole process. Like how sometimes in a TV show the peripheral noise just fades and all the background imagery just blurs and the lights become a big overexposed. Yah. It felt like that.
Yet there are a few heavy memories of the afternoon I'll hold onto. The first was the image of the man's wife who came to watch the efforts of the team for a moment. That moment happened to be just as I was in midst of my round of chest compressions. And the look on her face...the tears...I'm just not eloquent enough to describe it. But suffice to say, no actress on her earth on her best day could pull that off.
The other memory was the moment the man passed, his family had just finished gathering around him. From the surface the change was hardly noticeable. But he just felt 'gone'. The vitality in his visage just left him, you didn't even need the machines to know. In that moment, I recalled what Dr. Colby's words of how an experienced clinician can just tell via their 'gestalt' if a person is going to be terminally sick. I wonder how many of these events did he see before he picked them up, and if this is really 'an ability' you'd want.
What's more, it just struck me that the man was gone. He was only in his 50s, with a whole family there. They would never be able to have his company anymore. All his hopes and aspirations and future plans, to never be materialized. And while I realize his progression had no other route but to his passing, it just seemed like such a binary distinction. One moment here, the next, gone. I guess it could be said that his family still had his memory and all the parts of his life that touched them to hold onto. But in the physical sense, he had just only a few hours ago described what he wanted for lunch to the nurses, and now...nothing.
Makes you ponder your own mortality and (as the medical student), your future role in this balance between life and death.
It's funny, even the way I jot down this entry reveals how influenced I am in the traditional notion in health care about death being some 'evil force' that must be combated to the very end. We're taught to try to change our perspective and start seeing death as a more holistic and natural completion to life, but that doesn't mitigate the action you take when a person codes. Nor does provide any comfort to the mourning relatives. And thinking about it, there was nothing really additionally noble in the way we were trying to keep the man going. Pumping away at his chest for hours until he started to resemble a person with pectus excavatum. Throwing in cocktails of drugs into what's basically a biochemical snafu. The longer it drags on, the more futile and more inevitable the final outcome seems, but the system (and those in it) continue to 'fight'. Because if we didn't truly do that, how could we (in good faith) tell a family member that we "did everything we could do"?
But can't we always do more? Isn't the all too common focus in medicine the pursuit to be better? To try to be perfect without, of course, ever admitting too readily that's the goal. But looking to do more is a pattern that can continue forever, and may not exactly be the best one for our patients. In the debriefing session following this case, the attending asked the residents to think of something they could have done different. Not better. But a different alternate path entirely than what was chosen.
Her reasoning was that, once the team decided to go on the path of resuscitate first and then call in radiology, they became committed to carrying down that path of endless CPR and attempts to stabilize. This is not to say more hesitation needs to be introduced into emergent care in an ICU, more so to point out how other options of treatment exist that could offer the possibility for a different outcome.
So the residents threw out their ideas, suggesting things like bring in a surgical team, running an earlier ultrasound to find sources of bleeds without radiology, and other options that I did not really grasp. But what is sticking with me is the underlying message that instead of toiling to strive to make more effort, different efforts may in fact lead us to better results. Perhaps it's not the medical practitioner that does more that will succeed but the one who does things differently. Hmmm.
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