23 March 2006

How Quickly We Leave This Life

Betsy was 85 years old, living independently, and in near-perfect health. Her daughter brought her in when she abruptly became short of breath. I saw her with her three adult daughters at the bedside. She was a bit gray, had labored breathing, with an irregular pulse at 135, and hypoxic. She certainly looked critically ill, but was cheerful and as talkative as the circumstances permitted. Her oldest daughter was a CCU Nurse Supervisor. I went over the differential with her – MI, Pulmonary Embolism, Atrial Fibrillation, Congestive Heart Failure, Pneumonia – and sent off a slew of labs. Her EKG was fast but unexciting, and her chest x-ray was essentially normal. Labs came back unusually quickly, and were unremarkable except for a mildly elevated Troponin, a heart enzyme indicative of a heart attack in progress. Just then the nurse told me that her EKG had changed and that Betsy had developed severe chest pain.

Sure enough, a repeat EKG showed an obvious, massive heart attack in progress, with marked ST elevation. This was actually a good thing, since a) now I knew what was going on, and b) it was treatable. I discussed the options with the family, and they indicated that they wanted the full treatment, so after quick call to the on-call cardiologist, who was dubious but professional, the cardiac cath lab was called in. I wrote the standard orders – morphine, beta-blocker, heparin, etc – and moved on to the next patient in the queue. The Emergency Department was just swamped, with waiting times over three hours. No sooner had I finished examining a young lady with pneumonia than I was paged overhead stat to Betsy’s room.

When I got there, she was dead. Unmistakably so. Her skin was waxen and yellow, and she was not breathing; the monitor reflected a heart rate of 30, but I knew that there would be no pulse if I checked her wrist. It is amazing how obvious it can be when the vital force has departed a body. Taking this in a fraction of a second, I reflexively said “Well, this isn’t good.” Her daughters looked at me with tears in their eyes and the eldest said “We know. We’re okay with it.” I turned off the cardiac monitor and removed the oxygen mask from her face. A few words of condolence and I left them alone. I called the cardiologist back, a bit ruefully, and cancelled the case. We called the chaplain, and I moved on back into the realm of the living.

It’s a bit curious. I’ve always said: “As an ER doctor, most of my patients come in alive and will leave alive no matter what I do; a few come in dead and leave dead. Rarely someone comes in dead and leaves alive, which is a victory, and occasionally someone comes in alive and leaves dead, which I take as a personal offense.” But in this case I wasn’t offended. It was the most natural, wholesome (if there can be such a thing) death I have ever been privileged to witness. It was quick and relatively painless, the whole family was there, and everybody was emotionally in tune with it. I hope I go as well. I’m still kind of shocked at how quick it was. As an ER doc, I see a lot of death, and it’s usually more of a process than an event, and there’s usually a longish time between when it begins and when it is irreversible. Not so with Betsy. There one minute, gone the next.

Godspeed.

6 comments:

pegadoc said...

Shadowfax - She's lucky she died before all the invasive stuff started. Or maybe it was a (sub)conscious decision on her part. At any rate, it sounds like a "good death", and thank goodness her family was there.

I was thinking that she could easily have completed the whole process at home, if someone hadn't been on the ball and brought her in. She basically had her whole fatal heart attack right there in the ED. Unusual.

Nice of you to honor her publicly here. Godspeed indeed, Betsy.

Internal Medicine Doctor said...

It's amazing how much is left to chance.

You say you take it as an offense when someone dies but if you take a good look at many of our treatments and examine how much they actually increase a persons chance of survival, you'de be shocked at some of the meager results...

It's interesting then to realize how much of the consequences are just pure "luck"

Josh Gentry said...

Like pegadoc, I think its slightly a shame they brought her to the hospital.

shadowfax said...

I was impressed at the way the family was able to switch gears. When I first saw her, she was definitely not moribund, and they were appropriately thinking she could get treated and hopefully just go back to living independently. As soon as it became clear that it was the BIG ONE, they did an immediate reality check and dialed back. Tough to do, but man, was it the right thing to do.

And, IM Doc, do know that it's tongue-in-cheek that I saw it's an offense. Actually, I prefer to say that when patient die on me, I lose style points . . . and I hate losing style points.

Charity Doc said...

The toughest part of the job, without a doubt.

Teddy Roosevelt said...

I watched my father die of Cardio Pulmonary. He was ok one day and the next day we went to see him they had him on a rebreathe mask and he was breathing like a freight train. He breathed like that for about 8 hours. I often wonder why the doctor did not remove the mask so we could try and talk to dad. The doctor did awaken him and get a response and all he said was why. Then without even asking us he put the mask back on. How did he end up in hospital? Six months prior to death he was complaining of stomach problems. Finally he dropped to the floor one day and they took him to the hospital. The surgery six months ago was to put a wrap around his aorta as it had an embolism; he did this to help continue his life. What happened was the job was done in an outpatient procedure and the heart man needed a surgeon. Meanwhile as my dad is in the room they are paging the surgeon. When I asked the doctor about this he said "Oh he just had to sign a piece of paper and leave. The heart man did the surgery up through the peritoneal cavity and he caught CDIFF. He went to his primary care doctor and he issued Cipro. The Cipro ate up the good bacteria in the gut and let the CDIFF run wild. They got the CDIFF under control, but then he caught Pneumonia twice in the hospital and his breathing became very bad as he labored under the fluid built up by the use of cheap morphine. He died and he died in pain. That last eight hours should have been left for family and a little bit of talking. I could tell he was upset about that mask.

Then six months later I watched my mom die in the same hospital. They had to take 18 inches of colon out and they sent her home. Where are the hospital people that help seniors put together at least a program for a nurse to stop by each day and teach her how to use he bag. The bag thing did not work out to well she just got sicker over the month of April 2012. One day she was ashen colored and vomiting so I had he taken to the hospital. Mom had Myleo Fibrosis and he white count had gone crazy. They had so many tubes in her she looked like a Borg from Startrek. Anyway she caught a special hospital only blood infection and proceeded to go into a great amount of pain and all the nurse could do was give a morphine shot every 3.5 hours as she would awake screaming and pulling her mask off. She could have lived with proper home health care and never gone back to that hospital to catch a blood infection. I do not like Doctors. I grew up around hospitals, as a kid I could visit dad at the hospital lab, so I respected and aspired to be a doctor myself. I am the only brother who was a companion to my parents all the way to the end. It is just a shame that what really killed them both were hospital infections that aggravated the present health situations. I remember the days of Candy Stripers and Crisp White Nurse uniforms and hats. Instead now you see scrubs, dirty tennis shoes, nurses talking to the patient and eating at the same time. And god forbid you wake up the nurses desk on the graveyard shift. They are nasty. Something has happened over the last 3 years or so. Doctors have a definite look of dissatisfaction when the find you are a Medicare patient. They are also very quick to blame everyone else but themselves. Doctors need to challenge what is going on, using the same solidarity they use for fellow Doctors. The energy has been misdirected to anger at the patients political persuasion. The time is quickly coming when Doctors will not treat Medicare patients at all. Baby Boomers are coming on line and I predict that there will be an unusually high mortality rate with bonuses from the Govt. for reducing the boomer population. My parents were 86 and 85 and I miss them very much.