Note to readers: The following contains irony. I am told that irony is dead but I cannot resist picking at the corpse.
If you have to die, you might as well die at a time convenient for your doctor.
I was at home in my usual state when I am on call -- in my ottoman in front of the TV, my cell phone on the right armrest, beeper on the left. Since neither one had gone off in about an hour, I was contemplating resting my eyes, which in this case meant accomplishing the feat even as I was thinking about it. The last thing I remember was the sunlight cast through my living room window lengthening and reddening, the motes of dust drifting senselessly in its shaft, and then, tragically, the beeper going off. I recognized the number as the intensive care unit.
"We're coding Mr. Brown," the nurse said.
Mr. Brown was my partner's patient, someone I didn't know. The first thing I would ever know about him was this: He was dying.
"His heart rate suddenly dropped to zero," the nurse said. "There was no warning. The ER doctor is in the room and they are doing chest compressions."
"I'll be right in," I said.
I didn't waste any time, but truthfully there was no hurry. Once his heart had stopped, Mr. Brown had 20 minutes at the most. By the time I got there, it would all be decided.
Over the years, I have grown rather fatalistic about cardiac arrest, also known as code blue in hospital lingo, or sudden death in the medical literature. Perhaps it should come as no surprise that a condition known as sudden death would carry a poor prognosis, but that is the medical fact. All the CPR and Advanced Cardiac Life Support (ACLS) training medical personnel get is of little avail. If a person keels over and stops breathing in a mall, under ideal conditions (collapse witnessed, collapse cardiac-related, defibrillator applied within 3 minutes), his chance of surviving until hospital admission is anywhere between 30 to 50%, depending on which study you believe. But in the hospital, where patients already have underlying medical problems (or they wouldn't be in the hospital in the first place), witnessed sudden death ends with the patient discharged alive less than 15% of the time. Not great odds.
It looks good on TV, the pumping, the shocking, the wild effort to push in IV fluids and medications, but in the real world it doesn't usually work. When I get paged for a patient who is deteriorating but not in cardiac arrest, that is when my heart starts thumping. Those patients can be saved. But when a nurse calls me about a code in progress, my visit is usually perfunctory.
At it was in this case. I slipped into the hospital through the back door and threaded my way to the ICU. The ER doc was already headed out. "I called it about a minute ago," he said.
Now, as the attending doctor on call, it was my turn. Mostly paperwork. I went into the room to make certain the patient was dead. Not that I have ever encountered a mistake in this area, but I might as well check. The staff was busy cleaning up the room, making it presentable for the family. I went out and filled out the death certificate.
The nurse manager was waiting for me at the nurses' station. She told me the family had been moved to "the grief room." In other words, they didn't know yet, and it was my job to tell them.
One might think that telling a family a loved one has just died would be the most difficult job in medicine, but for me it has not been. Most of the time, hospital deaths occur at the end of a long illness and families are not all that surprised. Moreover, people of all walks of life seem to have a remarkable composure in moments like this, much more so than one might expect. This is not to say that patients accept the news with stoicism or aplomb, only that they usually understand that in the hour of death dignity is the best response. I think only medical personnel, clergy, and funeral home directors see this enough to really notice it, but it is remarkably true.
I looked over the chart. This was my partner's patient, and I had never seen him, ever. I would have to break the news after no more than a 5 minute crash review of Mr. Brown's entire medical life. I perused the daily notes, and asked his nurse a few questions about his reason for admission, why he was in the ICU, and how he had fared most of the day. Then, with the nurse manager, I went into the grief room.
There was only one person there, his sister. The death was sudden, and the rest of the family had gone home to dinner. I intended to employ the only strategy I know in such cases, the blunt approach. Sometime long ago during my medical training, a fool counseled me that the way to break bad news is to give the family a narrative, explaining everything that happened, how we responded to it, then ending with, "unfortunately, despite our best efforts, the patient died." This is supposed to "cushion the blow." I eventually decided it is idiocy to try to cushion news like this. The best approach, unfortunately, is to simply come out with it. Never in my life have I heard anyone say, "When John died it would have been such a shock, but the doctor explained to to me so skillfully and cushioned the blow so well that I wasn't all that upset at all."
If you end a 3,000 word essay with the words, "Your father died," the person listening to you hears a three word essay.
So I sat down at the end of the table and in an even voice simply said, "I don't know if the ER doctor has talked to you yet, but Mr. Brown died five minutes ago."
She took it with the calmness I had hoped for. She paused momentarily, and blinked back a few tears. "Well," she said, "he was been sick for a long time. I was expecting this." Then the nurse manager begin asking a few standard questions: Who did she want to notify, did she want a chaplain to come, what funeral home did they intend to use. The sister had no medical questions, at least not at the moment, and I saw that in less than 2 dozen words my job was over.
So I left the nurse manager to the details, went back to the nurses' station, and wrote an order to release the patient's body to the morgue. I told the nurse at the station to call me if the family had any further questions, and left for home. It was still daylight when I got back, and I checked my watch. Total time, 45 minutes. Hardly put a dent in my evening.
Shortly I was back in my chair, cell on the right armrest, beeper on the left, when my preschool son came up to me with a card game in his hands. I spent a good part of the next hour on the floor in the living room playing the game, which consisted of rolling dice and asking each other trivia questions about North American animals. He won; I let him.
I can't say I thought too much about the patient. At least not then. I hope he didn't mind that I observed the end of his life by going on with mine. One day my son will be burying me, and I expect him to do the same.
If you have to die, you might as well die at a time convenient for your doctor.
I was at home in my usual state when I am on call -- in my ottoman in front of the TV, my cell phone on the right armrest, beeper on the left. Since neither one had gone off in about an hour, I was contemplating resting my eyes, which in this case meant accomplishing the feat even as I was thinking about it. The last thing I remember was the sunlight cast through my living room window lengthening and reddening, the motes of dust drifting senselessly in its shaft, and then, tragically, the beeper going off. I recognized the number as the intensive care unit.
"We're coding Mr. Brown," the nurse said.
Mr. Brown was my partner's patient, someone I didn't know. The first thing I would ever know about him was this: He was dying.
"His heart rate suddenly dropped to zero," the nurse said. "There was no warning. The ER doctor is in the room and they are doing chest compressions."
"I'll be right in," I said.
I didn't waste any time, but truthfully there was no hurry. Once his heart had stopped, Mr. Brown had 20 minutes at the most. By the time I got there, it would all be decided.
Over the years, I have grown rather fatalistic about cardiac arrest, also known as code blue in hospital lingo, or sudden death in the medical literature. Perhaps it should come as no surprise that a condition known as sudden death would carry a poor prognosis, but that is the medical fact. All the CPR and Advanced Cardiac Life Support (ACLS) training medical personnel get is of little avail. If a person keels over and stops breathing in a mall, under ideal conditions (collapse witnessed, collapse cardiac-related, defibrillator applied within 3 minutes), his chance of surviving until hospital admission is anywhere between 30 to 50%, depending on which study you believe. But in the hospital, where patients already have underlying medical problems (or they wouldn't be in the hospital in the first place), witnessed sudden death ends with the patient discharged alive less than 15% of the time. Not great odds.
It looks good on TV, the pumping, the shocking, the wild effort to push in IV fluids and medications, but in the real world it doesn't usually work. When I get paged for a patient who is deteriorating but not in cardiac arrest, that is when my heart starts thumping. Those patients can be saved. But when a nurse calls me about a code in progress, my visit is usually perfunctory.
At it was in this case. I slipped into the hospital through the back door and threaded my way to the ICU. The ER doc was already headed out. "I called it about a minute ago," he said.
Now, as the attending doctor on call, it was my turn. Mostly paperwork. I went into the room to make certain the patient was dead. Not that I have ever encountered a mistake in this area, but I might as well check. The staff was busy cleaning up the room, making it presentable for the family. I went out and filled out the death certificate.
The nurse manager was waiting for me at the nurses' station. She told me the family had been moved to "the grief room." In other words, they didn't know yet, and it was my job to tell them.
One might think that telling a family a loved one has just died would be the most difficult job in medicine, but for me it has not been. Most of the time, hospital deaths occur at the end of a long illness and families are not all that surprised. Moreover, people of all walks of life seem to have a remarkable composure in moments like this, much more so than one might expect. This is not to say that patients accept the news with stoicism or aplomb, only that they usually understand that in the hour of death dignity is the best response. I think only medical personnel, clergy, and funeral home directors see this enough to really notice it, but it is remarkably true.
I looked over the chart. This was my partner's patient, and I had never seen him, ever. I would have to break the news after no more than a 5 minute crash review of Mr. Brown's entire medical life. I perused the daily notes, and asked his nurse a few questions about his reason for admission, why he was in the ICU, and how he had fared most of the day. Then, with the nurse manager, I went into the grief room.
There was only one person there, his sister. The death was sudden, and the rest of the family had gone home to dinner. I intended to employ the only strategy I know in such cases, the blunt approach. Sometime long ago during my medical training, a fool counseled me that the way to break bad news is to give the family a narrative, explaining everything that happened, how we responded to it, then ending with, "unfortunately, despite our best efforts, the patient died." This is supposed to "cushion the blow." I eventually decided it is idiocy to try to cushion news like this. The best approach, unfortunately, is to simply come out with it. Never in my life have I heard anyone say, "When John died it would have been such a shock, but the doctor explained to to me so skillfully and cushioned the blow so well that I wasn't all that upset at all."
If you end a 3,000 word essay with the words, "Your father died," the person listening to you hears a three word essay.
So I sat down at the end of the table and in an even voice simply said, "I don't know if the ER doctor has talked to you yet, but Mr. Brown died five minutes ago."
She took it with the calmness I had hoped for. She paused momentarily, and blinked back a few tears. "Well," she said, "he was been sick for a long time. I was expecting this." Then the nurse manager begin asking a few standard questions: Who did she want to notify, did she want a chaplain to come, what funeral home did they intend to use. The sister had no medical questions, at least not at the moment, and I saw that in less than 2 dozen words my job was over.
So I left the nurse manager to the details, went back to the nurses' station, and wrote an order to release the patient's body to the morgue. I told the nurse at the station to call me if the family had any further questions, and left for home. It was still daylight when I got back, and I checked my watch. Total time, 45 minutes. Hardly put a dent in my evening.
Shortly I was back in my chair, cell on the right armrest, beeper on the left, when my preschool son came up to me with a card game in his hands. I spent a good part of the next hour on the floor in the living room playing the game, which consisted of rolling dice and asking each other trivia questions about North American animals. He won; I let him.
I can't say I thought too much about the patient. At least not then. I hope he didn't mind that I observed the end of his life by going on with mine. One day my son will be burying me, and I expect him to do the same.