Some days you eat the bear...

(adapted from my blog, a tale of my second call night on Critical Care)

…other days the bear fucks you straight up the ass.

The nice thing about working in the ICU is that all the information you need–flow sheets, charts, computer data, etc.–is usually within reach of the patient, and if you need to know anything, the nurses are hovering right around you. The bad thing about it is…the nurses are hovering right around you.

“Are you covering Critical Care?” “Are you covering Critical Care?” “Are you covering Critical Care?” Fingernails on a chalkboard have nothing on this piercing sound, pelting the resident at least every five minutes while he has the misfortune of being on the unit. Most of the time, these are not important things; they’re small items they certainly wouldn’t call you about if you weren’t sitting right there on the floor. But, you know, since you’re there…

Other times, these interruptions are for slightly more important matters.

“Are you covering Critical Care?” the nurse asked, as I sat down to start the first of three admissions we got all at once. She didn’t really wait for my answer. “12 has been a little tachy all day, and her heart rate just dropped to about 30 with some ST elevation on her rhythm strip.” I really wished that the answer to that first question didn’t have to be yes. The patient in 12 was a fairly young but very sick patient whose chances of ever leaving the hospital were slim to none, but who had at least been stable for a while. What the nurse was telling me, in layman’s terms, was that her heart was trying to quit.

“That ain’t good,” I said. Part of the dark humor that doctors engage in to get them through the day is dramatic understatement; we will look at a man with a rusty spike driven through his skull and say, “Wow, that probably smarts a bit.” “That ain’t good,” in nearly all cases of MD-ese, can be translated as “That’s really fucking bad.”

I ordered a stat 12-lead EKG before I asked the operative question: “Is she a No Code Blue?”

“Well, she’s a limited code blue.” Fuck.

A word here about code status. At least one study that I know of has suggested that code status ought to be like pregnancy–either you are or you’re not. Limited codes–in which particular things like being intubated or being shocked or certain drugs are to be held, but everything else done–are almost never successful. There are many reasons for this, not the least of which is the time lost while the exact wishes are clarified.

I walk in, and she’s as unresponsive as she’s been since I’ve seen her, but her heart rate was indeed in the 30s. Fortunately, there were some family members there, so as I waited on the EKG and tried to find a pulse, I tried to grill them for exactly what she might or might not want. In about fifteen seconds, I managed to get from them that she didn’t want CPR and she didn’t want to be shocked.

That’s where we were when she went into asystole.

We couldn’t shock her, but there were a few things we could have done at that point–we could use epinephrine and atropine, and we could try pacer pads, which is technically shocking them but isn’t like defibrillation. So here I was, faced with my first real split-second life-or-death decision. To my credit, I feel like I acted swiftly, decisively, and appropriately.

I did nothing.

“I’m not coding her,” I told the nurse, as I turned the alarm off on the monitor and listened to the silence of her chest. Her pupils were already fixed and dilated. This was a woman whose chances of recovery were slim to none before she arrested, much less afterwards. The main reason I didn’t push things any harder, though, was the look on the faces of the family members who were there, which was not one of fear, but one of acceptance. The time had come, and it was never going to get easier for them than that. “I’m sorry,” I told her sister, as I pronounced her at 6:25 PM.

Her grandmother, who had raised her, did not take it so well. She collapsed in the middle of the room with a blood-curdling wail. It tore me up; I instinctively left the room, fearing that I’d be seen as the one who did it. I had nothing more to offer at that point but pain.

Would everyone agree with the choice I made? No; some doctors would have put pacers on her or pushed the drugs despite the asystole and the pupils, or would have called a code so her final moments could be spent in a frenzied swarm of medical personnel and shouted orders. The end result would have been the same–if not right then, probably within hours or a few days. My attending (who finally showed up an hour or so later) said that he would have done the same thing. If I had it to do again, so would I.

A lot of things about this job keep getting easier. I hope that making decisions like that one never does.

Dr. J

Fuck reality TV!

Keep makin’ them hard but right decisions, doc. I hope I get someone as smart as you when I get in that situation.

You did the right thing, and you know it. You’re a credit to your profession.

A DNR is such a crucial thing and a blessing for the patient, their family, and the doctor. Indeed, where is the human dignity in shocking a 97 yr old with terminal cancer.

I wish you strength.

My thoughts exactly, and the primary reason that I watch so little television these days. By the time I get in from work, I have had quite enough of reality, thank you very fucking much.

Oh, and to clarify, before someone calls me on it–when I said, “We couldn’t shock her…” above, I don’t mean that we would have anyway. In fact, we would not have defibrillated her, since you don’t shock asystole. You can try epinephrine and atropine or pacer pads, but in all honesty, asystole + no spontaneous breathing effort + fixed and dilated pupils = round up the relatives.

Dr. J

Good job, Doctor J.

I remember similar experiences in residency. It’s those painful harrowing times that make (or break) a physician.

DoctorJ, Thank you for sharing this with us. It personally puts my daily trial and tribulations in a more proper perspective.
Stay strong.

How do you guys do that job? I couldn’t take it.

Just so I can understand, let me apply a weak analogy. If I design and build something, I have a lot of responsibility for it. If it breaks down, I disassemble it and figure out what went wrong, then I design a fix and reassemble the thing. When the testing cycle is over, you go to production and ship the thing. If I’ve done my job correctly, I should only have to worry about normal wear and tear, which I designed for, and everybody knows the service life of the gadget.

You don’t have that luxury. You didn’t design what you’re working on, but people expect you to put it back into perfect working order when something goes wrong. You can’t disassemble it and put it back together to diagnose the problem. If you try a fix and it doesn’t work, you can’t always try again or try something else.

How do you do it every day?

You did the right thing, Doc. If I ever become badly ill or hurt, I’m calling you.

That’s a good question. After this episode–after which, you’ll recall, I still had three fairly sick unit players to admit–I was fairly useless. It threw me for a loop. I was hearing that grandmother’s screaming in my head all night long.

A lot of what bugged me was being the authority. They looked to me to figure out what to do. I was the only one who heard the family’s quick discussion of what they wanted, and I was the one who essentially interpreted those wishes into a No Code Blue. I was the one who carried out that order by not doing anything. Then, finally, I was the one who decided when she was dead. It was my call all the way through–I did call the attending quickly when I first heard, but he wasn’t much help–“call me back when you get the 12-lead”. It seems like you work for years to get this authority, and then they hand it to you all at once, one evening, with no one around to warn you.

I’ve always had someone to defer up the line to in a situation like this, even though I might not have done so. This was without a net. I don’t know how high the stakes were; she really wasn’t leaving that unit, so it was now or weeks from now.

I love having that “Dr.” in front of my name, not because I consider it glamorous (far from it), but because I love what I do. Sometimes, though, I want to go somewhere and introduce myself as Mr. J, and make decision after decision of no consequence whatsoever–say, Guinness vs. Sierra Nevada.

Dr. J

MHO:

You gave her family, and her, a peaceful, respectful death. You didn’t try to sustain her extensively when she was in a persistent, vegetative state. She wasn’t brain-dead for months, just waiting for something to go wrong. The death wasn’t prolonged, and it had been expected for enough time that the family had been able to ready themselves for it. And when the time came, the time came. No unnecessary measures, and I think it’s safe to say from what we know that you did as they and she wished.

Would another doctor have tried to extend her life beyond what she had? Possibly. Maybe more than possible. However, is that what the family wanted? My guess, and I think your guess as well, is no. And in cases such as the one you described, I (being no medical personnel of any sort) think you made the right call medically and emotionally. Leaving the room when you did, respectfully and quickly, made things easier for them because they could relax and start the grieving process (that which applies to death, not impending death, anyway).

In short, you did as you were asked and handled the situation well.

You did great, DoctorJ.

The grandmother is one of those who just can’t accept death, IMO. Some people can’t. I’ve noticed that a lot of them are old folks like my in-laws and my dad, who wouldn’t admit it when they were dying and wouldn’t admit to a dying spouse that he was dying. They’re going to be taken by surprise anyway.

What better outcome could there be for this young woman? The rest of the family understood that.

You have a tough job. I’m glad you are doing it well. I hope somebody like you will be around when somebody in my family dies.

That’s how I want to be treated when it’s my time. If the quality isn’t there then please do not artifically increase the quantity. Thanks Doc.

A former boss’ response to this was something like, “I can see such a difference when everything works out for them.” He’s a pediatric cardiologist, and they see their share of very, very sick kids - babies with a congenital heart defect, kids who’ve been operated on a number of times for a heart defect (or these kids when they’re teens, or even as adults), kids or teens who had heart damage from rheumatic fever, and so on. He’s always so thrilled when he can help a very sick child become an active, near-normal or normal kid, and they grow up to live happy and decent lives. Not all of them do, mind you (though I only knew of a handful of deaths in the several years I worked in that busy office), but the successes apparently make up for those times when nothing seems to help enough.

Take care of yourself, DoctorJ - sounds like you made a good call.

I don’t have much to offer. Just wanted to say that I, also, think you made the right choice. Just restores my faith in humanity a little to hear about real people making good choices. Keep it up.

~Brilharma

Damn! NOt only are you a good sawbones, but you drink some good shit, too!

May I give you the view from the critical care nurse’s side?
Yes, we sure do pelt the residents with “are you on call for critical care?” Most of us realize that it’s a pile-on when you come into the unit, and we have compassion for that. But the reason it happens is that usually the things we’re pelting you with are “smallish” changes, labs that need to be addressed, orders that need clarified, requests for minor things. We truly do save up some things for when you are in the unit, rather than bang you with 27 pages in 30 minutes. (OK, not always, I know you sometimes get lots of pages for minor matters).
I guess it’s the nature of the beast. Critical care, for both of us, sometimes means handling a crisis situation as you described. But most often it’s handling the mountains of details, details, details that may prevent a crisis, or may make a person’s outcome better. There may be 12 of us, inundating you with all of our little things. I’m truly sorry about that. But these things need to be addressed, I know you know that, and so you unfortunately have to be the “monkey in the barrel” on any given day/night. Believe me, we LIKE protocols and standing orders; we’d much rather be able to handle things ourselves than have to bother you.
May I also add my compliments on how you handled the patient’s death. I know how hard it is to be there when a family experiences the death of a loved one. For the last two days I’ve been haunted by the cries of a loving husband who lost his wife on Sunday. You gave me a new insight into why MD’s leave the room relatively quickly. I hadn’t thought before about the possibility of your adding to their pain. Thanks for sharing that.

Otanabi–don’t get me wrong, I love the folks who work in our units, and I’d move the earth for them. I am particularly fond of them because they can think for themselves, and they don’t page me with every little thing. The problem is that if I’m sitting on the unit, they feel obligated–understandably–to keep me updated on every little thing. I normally don’t mind it, except when I’m trying to admit three patients and I’m trying to keep their details straight in my head.

As for why I left the room so quickly, when dealing with families in situations like this I think of myself as an advocate for reality. My job is to use the tools I’ve developed over the years to determine the reality of the situation and try to make that clear to the patient and the family, and to act on that situation to improve reality as much as possible. The problem with that, though, is that reality often sucks, and you’re the face of it.

It’s like being the prosecutor against someone who is truly guilty; you know you’re doing the right thing, and the killer’s loved ones have to know that intellectually, but you would never expect them to appreciate it. You’re still the man who sent their boy to jail.

(I made it very clear that if they wanted to talk, I’d be available. They never did, though. Some people want to know exactly what happened; others don’t.)

Dr. J

Doctor J, you did the right thing. The responsible, professional, and perhaps more importantly, the decent thing. Not to be crude or anything, but from what you described in the OP, this poor woman was circling the drain and nothing short of divine intervention was going to save her. Any human with a loving heart would have done what you did, and allowed her and her family a peaceful end, without the runing, screaming, frenzy of a ressucitation attempt. I can only hope that when my time comes, someone as dedicated and caring as you is standing by.