Sunday, January 24, 2016

Stories from the Shadows Part 1

It happens every single day in the ER. Multiple times in a trauma center. Why does it still get me?

Someday I hope to be numb to it. To be calloused to Death while still reaching out and comforting the loved ones in mourning.

He came in by EMS. He was noticeably ill, but nothing we don't see every day. We've had a ton of patients with pneumonia this winter and I've started just drawing blood cultures on everyone with any respiratory complaint.

I helped him transfer over. He looked over at me and smiled. His wife was with him. They'd been married years and she watched with a loving concern as we began to get him settled and ask questions. He could only respond with a "yes" or "no". According to her, he slept much longer than normal and hadn't been the same since she woke him up. He had dealt with a cough for weeks, but today he spiked a fever and after dialysis just wanted to sleep. A terrible sleet storm was raging outside and she thanked the EMS crew for helping them with a ride and being so kind.

My crew was great. It was like the "A" team. My girl from another area jumped in and in about 8 minutes we had him changed, lined and labbed with two sets of blood cultures, fluids hanging, EKG complete, straight cath'd, and charting done. His heart rate was a bit high and he had a slight fever, so we began a septic protocol and sent him to CT to clear the possibility of a problem in his head.

He returned, still smiling and as I rechecked his blood pressure, I noticed him just lean his head back and close his eyes, as if to rest. His wife was seated next to him, still watching with her sweet and loving eyes. I'll never forget the two of them. They both had peaceful, sweet eyes.

They were from up North and would come down every winter to spend it with their children in the Carolinas. Everyone was snowed in apparently and the family they had stayed with were out for the evening. His wife had chatted with me about the snow up North and how thankful they were to not be stuck in it.

He still appeared to be resting his eyes. His BP returned as 60/40. That can't be right. I rechecked. He only had one good arm. His other vitals hadn't changed, but again I got the same reading. The doc had come in to just say hi and we immediately kicked into action. Fluids were grabbed and started. A second IV was established. Respiratory therapy was notified to be on standby. A resuscitation room was reserved. His pressure continued to drop.

A note about blood pressure. You have to have it at a certain level in order to maintain perfusion to your brain. It's just part of life. It needs to be around 110-120/60-80 (people argue about exact numbers but this is a rough estimate).

His heart rate hadn't changed and he still had a pulse. As another nurse and I prep'd vasopressors, his breathing suddenly became more shallow and I noticed him becoming blue. We grabbed the bag and began ventilating him with a bag-valve-mask.

As soon as he had arrived, his wife had been asked about his "code status". Essentially, if something were to happen to where his condition would decline, would they want us to perform CPR and stick a tube in his lungs to breathe for him. She had been on the fence. As his condition declined, one of the Docs pulled her out in the hall and explained that she needed to make a decision. Green light. We were intubating.

He was quickly sedated, paralyzed, and intubated. We got great breath sounds and his blood pressure had begun to improve as a result of the medications. His HR was still fast but had remained unchanged and he still had a pulse. The decision to move him to the trauma bay was made and we began to roll.

As we began moving, suddenly his heart rate began to drop. It dropped so quickly to 60. By the time we were in resus, he was down to 40 and no longer had a pulse. CPR was initiated. Medications were given. We had nothing on the monitor that was sustaining life. His wife was present, watching the entire thing. We do that to make sure the loved ones know we are doing our best and trying everything. Also, we needed her to tell us when to stop. She called it. Time of Death, 2330.

Suddenly, there he lay. Blood coming out of his ET tube. Life slipping away from his body and the color slowly disappearing as rigor mortis set in. His wife muffled her sobs into her kleenex and held his hand closer to her chest as if to grasp some of the life slipping away.

It is heart-wrenching. I don't know how to describe any of the feelings. Mostly we supress them and hope they don't ever come out. Usually we box them up and distract ourselves with our families and friends while secretly begging God that we are never the one making that decision on the other side of the stretcher. Scrubs are like a shield that protect us while we deal with the tragedies of others. Unfortunately a part of caring for people is allowing yourself to empathize with them and to do so you must feel. Hence the obvious difference in scrubs and armor. We do carry a certain part of the pain and suffering of our patients and must figure out what to do with it or we will take it home for our families to deal with.

Nothing more to say. Often I process by writing. There was no happy ending to this story. Only a reminder of life being precious and more "practicing of medicine". One day maybe we will perfect it.

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