Friday, May 08, 2009

Expiring

"Doctor, I do have one more question:  Can I kiss her?"  He asked the intern as I stood off to the side.  Neither of us had ever met this strong and kind-appearing man in jeans and a brown plaid shirt.  We'd only spoken with him on the phone several times that night.  Each time with worse news.  Matt, a bright and kind intern, had called him to consent for an arterial line when her blood pressure was dropping into the realm of other worlds.  He'd spoken with him about his wife's state.  He'd done everything he could with the two small peripheral intravenous catheters that he could.  He'd called me when she needed intravenous medications to keep her blood circulating.  Medications that usually have to run through a more invasive central venous line--medications you only can use in the ICU.  

I'd met her two days before.  But she'd died two months before I'd met her I later discovered as I read through her records.  Six months before she'd gone in for surgery to replace both of her knee joints due to severe arthritis.  One became infected and they tried antibiotics.  A lot of antibiotics.  Some of which she was, as it now seemed, deathly allergic to.  She got a rare condition in which the top layers of skin separate from those beneath.  She had "toxic epidermal necrolysis" over 90% of her body.  

Your skin is your largest and possibly most important organ in your body.  It keeps in what needs to be in and it keeps out what needs to stay out.  They'd taught us that in medical school.  And the woman I met two days before proved it to be true.  

In the time since she'd developed TENS, she had undergone multiple rounds of bacteria in her blood and low blood pressure and months of ICU care and central venous catheters to deliver more antibiotics and blood pressure medications.  Then her kidneys failed from one of her episodes of low blood flow and she stopped making urine and needed a larger central catheter to be on dialysis.  These catheters got infected along with her blood.  The bacteria that she started growing in her body became resistant to all but the strongest and newest antibiotics that we have.  Then on February 2nd, she'd died.  

She went into cardiopulmonary arrest, or as we say, she "coded," necessitating extreme measures to resuscitate her.  And the resuscitation worked in the sense that her heart restarted and her brain kept the centers that told her body to breath.  But the rest of her brain was gone, having suffered massive strokes as a result of the intervention.  It was like the little babies I'd see who don't get enough air to their brain when they're born.  Sometimes they live for years, but they only know to breath reflexively.

Her skin was the color of a severe sunburn.  And it sloughed off wherever tape or catheters were attached, and even in several places where nothing was attached.  Her hair had almost completely fallen out; what was left was in greasy curly wisps across her scalp.  She was swollen from what I imagine were high doses of steroids to keep her body from attacking its skin and from the large quantities of fluid we'd given her to keep her alive those last few days.  She smelled of infection and we put on the yellow "contact precaution" gowns when we went into her room, not wanted to transmit her infections to ourselves or our other weakened patients. 

That night when we were losing her blood pressure, I called her husband and told him we would need to start medications to keep her blood pressure going.  It was the first time I'd spoken with him but I knew from the chart that he'd had several conversations over the last months about his wife's state of health and her impending death.  The next days he'd planned on moving her to a hospice facility so she could die comfortably.  

To preserve her live that night what I really needed was a large central line--one for pressors and dialysis.  It would be difficult to get on her and it would be painful.  He didn't want to keep trying to perpetuate what remained of her life, however.  I supposed that I could try peripheral pressors, which don't take long to burn through veins and cause longer-term complications which I knew would not be an issue with her.  She was out of "long term" on this earth.  

I offered that to him, only wanting her to make it five more hours to 8 am when she could go to hospice and die comfortably.  I suspected, though, that she would not make it that long.  And I knew she wouldn't unless I gave her those medications. 

It had taken him months to come to terms with the fact that she was going to die and finally, he was ready to let her go.  But I didn't think I could keep her alive much longer.  He'd only recently changed her "code status" to exclude compressions and shocks (she'd had a tracheostomy tube placed months before).  But he said we could still use code medications, which are temporizing at best without the other interventions.  

So I started a pressor peripherally; and it worked for a while, but then we were using as much of it as we could and her blood pressure was still falling.  She started to die at 6 am and I went for the "chemical code," which ended up feeling futile as we stood around her in our yellow mourning dresses and injected epinephrine into her small peripheral lines which made her blood pressure temporarily jump to 210/150 and then trickle back down to 70/30 and keep falling.  I asked the nurses to call her husband as soon as we'd started and fifteen minutes into the code I called him myself from the room.  We'd talked several times by then and I knew he lived far away and had just gotten out of the shower and was planning on being there at 8:30.  We weren't going to last that long. He said it would take him 45 minutes to get there, "depending on traffic," he told me in a steady voice.  I begged him to please drive carefully, unable to truly imagine what he'd gone through those last several months.

I started another intravenous infusion to keep her blood pressure in the alive range until he got there and the nurses needed to give her boluses of epinephrine even with that.  They paged me when he arrived.  

By the time I got down to her bedside, Matt was already there explaining things to him and asking him to put on the yellow gown.  He did a god job--calm and sensitive and thorough.  He'll be a fine doctor.  I stayed back, not wanting to complicate matters more with one more face.  And, not wanting to see the pain in his stoic eyes any closer than I already had.  

He asked Matt if he could kiss her and Matt said yes.  

In the room, he spoke softly to her, telling her he'd tried everything he could to keep her alive, but now it was time to go.  Now she could go.  He kissed her red swollen mouth as her eyes roved purposely around the room.  I don't know what she felt those last moments, if anything.  He asked us to turn off the pressors and start a morphine infusion to ease her pain and calm her labored breathing.  He stayed at her bedside, whispering to her for the next few hours in took for her heart to stop its resilient beats.  

The social work note said her children found it too hard to see her like that.  A family friend was there with him for part of the time.  The social worker himself stayed for much of her slipping away, comforting and listening to her husband.  In his note he said they'd talked of God.  The note ended with him dictating, "I have just been informed that the patient is expiring at this time."  Time of death 2pm.

Ali had been working that night and tears were welling up in my eyes when I got back from the SICU to our medical ICU.  I knew it was time for her to no longer suffer, but her husband was so "dear" with her, as one of the nurses who'd helped code her said.  And soon she would be gone.  Plus I'd been up all night and hadn't eaten since lunch the day before trying to admit two other patients and keep her alive a little longer. I felt wrung out.  He kissed me before he left for breakfast.  I still had to present the patients I'd admitted and finish rounding.  

In debriefing the chemical code issue with the ICU fellow, she told me she didn't even offer pressors through a peripheral line, nor offer purely chemical codes.  They had no long term benefit.  The code had felt ridiculous from a medical standpoint.  I knew it could only end one way and we were simply delaying the inevitable and quickly approaching end.  

But sometimes, maybe delaying is enough.  It made no difference to the patient, who I still believe had spiritually left months ago.  But it made a difference to her husband--he was able to be at her side when she "passed."  He'd told me he wanted to be there.  I didn't stave off death for the dying, but for the living, for them to say goodbye in whatever way they needed.  

It was a hard code for me, really the first I'd "run" alone--long and immediately unsatisfying in its outcome.  But now, days later, as I talked it over with another of our interns, I think I would do the same if I had it to do again, though perhaps ask her husband to come in sooner.  I'd still keep her alive until he got there, if I could.  It's the least I could do.

I think if him hunched over her bed, holding her hand and kissing her face, whispering soothingly in her ear.  Maybe she was there.  Even if she wasn't it was  testament to what she'd been, and what they'd been together.  And what he would have to be without her. 

Death is not a fight we win or lose, though it sometimes feels that way.  And it's hard to meet the end of the known--and hard to send those we love, those with whom we thought we'd grow old, those with whom we'd shared a life off into the unknown away from us and alone.

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