“We sometimes encounter people, even perfect strangers, who begin to interest us at first sight, somehow suddenly, all at once, before a word has been spoken.” - Fydor Dostoevsky
Photo by me.
I never talk about my patients….
It was ER triage duty for me today and also my first time to do postmortem care. I’ve seen and attended codes before but this one was different for a reason I do not know. One of the patients we admitted in the ER today was a 53-year-old woman complaining of difficulty of breathing. She was awake, tachypneic (32 breaths/min), tachycardic (142 beats/min) and hypotensive (80/50mmHg). It was difficult to get an accurate background information because both she and her husband cannot tell us her previous medical history except for a thyroid problem she had before. The resident told us it might be thyroid storm and admitted the patient. She was still able to walk inside the ER and was able to sit on the gurney when I asked her to. Since we were able to endorse her condition to the ER doctors inside with an ominous feeling something might happen, I went back outside because 2 ambulances are waiting. Two hours later, a code was called inside and since I was attending a patient admitted for caustic ingestion and another bleeding patient, I was only able to join the team after several minutes. When I got there, they were trying to revive that same woman I assisted earlier. And I was right, something was going to happen. She was already intubated and cyanotic. She first went into ventricular tachycardia and defibrillation was done followed by pulseless electrical activity. Continuous ventilations and compressions were given but she was still in PEA which was later followed by asystole. The team members rotating in giving cardiac compressions were all getting tired already (trust me, two minutes of doing compressions is draining) because her body was already getting stiff. After 30 minutes of doing resuscitation, 8 ampules of epinephrine and no response, the patient was pronounced dead at exactly 11:55 AM.
The team exited and left my partner and I with the patient and her crying family. We removed her IV and I pulled her endotracheal tube out and asked the family to close her eyes and positioned her properly. I cannot say she died with dignity the same way my Central ICU patient did a week ago because everything was so sudden. Today blurred my idea of what it means to die with dignity. When I go on duty and see death take people away, it never fails to cross my mind that people who die mean much to those they love. They may not be my mother, my father or siblings, but there will always be someone on one corner of the room mourning because they were afterall, someone else’s mother or father, sibling or friend.
Two weeks ago, I cried for nights and even in front of 8 groupmates, a clinical instructor and 4 masters students while discussing the case of my 77-year-old patient who never woke up after her 24-minute cardiac arrest post mitral valve failure after coronary artery bypass graft for her myocardial infarction. She had hypoxic-ischemic encephalopathy, absent brainstem reflexes, renal failure, and eventually went into persistent vegetative state, then disseminated intravascular coagulopathy. Every morning, when I receive her from the previous shift, I would tell her, “Lola, umaga na sa CENICU! Rise and shiiine!” even if my buddy nurse would laugh at me because she will never respond. I would tell her how lucky she was to have me as her “stylist” everytime I will comb her hair and sponge her face in the morning. I would tell her we would have breakfast when I give her feedings and medications in the morning via nasogastric tube. I’d tell her we’d brush our teeth together when I clean her mouth with bactidol after suctioning her endotracheal tube. I would tell her that Raphael (her mechanical ventilator) would be there to nurse her when I’m not around. I was in denial during the first week, hoping that she wake up, or that she have positive dolls eye reflex or her pupils become reactive to light again. She was having cardiac arrest almost every other day, if not episodes of bradycardia. She was dependent on mechanical ventilation for breathing, on insulin or dextrose to keep her glucose levels within normal, on drugs to keep her heart beating, on hemodialysis to excrete toxic wastes in her body. On my last day, she had melena and 200cc of upper GI bleed, she would vomit the feedings given as well as the medications given per NGT, her CBG and blood extraction sites were not closing, her extremities are all too heavy because of massive edema, and her 1 month old CABG harvest site wound was leaking with her interstitial fluid and pus. She died 2 days after my Central ICU duty ended.
I guess seeing death takes a lot of getting used to. I learned there’s a time to hope the patient would do well, a time to be aggressive with the treatments, a time to do all means to resuscitate… but there’s also a time to let them go. I never thought it would make my heart break to see perfect strangers die and leave. It happens.
“Nobody notices when we leave. I mean, the moment when we really choose to go. At best you might feel, a whisper or the wave of a whisper, undulating down…. I was here for a moment, and then I was gone. I wish you all, a long, and happy life.” - Susie Salmon, The Lovely Bones
