It’s been a bad night. I’m on the night float service which means I cover the general medicine teams from 5:30pm- 7:30am. Tonight when getting my sign-out, one of my co-interns warned about their new admission. He was “sick” my coworker said, meaning not just the kind of sick that lands you in the hospital, but the kind of sick that makes your heart beat a little faster every-time the pager goes off because you just know that things are going to get worse before they got better. This patient, Mr A, had an infected joint and was septic from it, causing his blood pressure to be low. He had gotten a lot of IV fluids to try to raise his BP which worked nicely, he was getting antibiotics, and the surgeons were planning to take him to the OR tonight to wash out the infection. I stopped by to see him soon after coming in and he looked okay, better than I thought he was going to, and I felt like things were moving in the right direction.
About an hour later I got a call that he was having a hard time breathing, so I hustled over to his room, where I found him working hard to catch his breath and with decreased oxygen levels. Mr A had a DNR order in place, meaning that if his heart were to stop or if he were to have extreme difficulty breathing, he would not want to be resuscitated. He had discussed this with his family, and he understood that his condition was quite serious and there was a chance he could die. When I came to his room, we increased his oxygen and gave him a breathing treatment. We also gave him medicine to get rid of some of the fluid from his lungs, a consequence of all the fluids he got to maintain his BP. He was agitated, panicking because he couldn’t breathe well. “I’m dying”, he said, “I’m going to die”. His nurse and I reassured him, “we’re right here, you’re doing okay”, we said, holding his hand and encouraging him to take nice deep breaths. His oxygen levels kept dropping. And then I realized he wasn’t fighting anymore, that his eyes were open and staring at the ceiling.
“Mr A”, I bellowed into his ear, “Mr A, look over here at me”. Nothing. My interior panic alarm went off. I asked the nurse to call my senior resident. The nurses and I looked at each other, silently asking what we could do. With his DNR order in place, there wasn’t much left. I felt for a pulse in his wrist and couldn’t find one. I went to his other side, where there was no pulse. I felt in his groin for a pulse, and found nothing on either side. His heart was still beating on the monitor, but not strong enough to pump any blood. “Well”, I said to the nurses, “can anyone think of something we haven’t done?” We all agreed that without formal CPR or intubation, we had done all we could. I went to call his wife to let her know that things weren’t going well, to give her a warning shot for the inevitable final phone call. I returned to the room, where we stood, silently, while this man’s oxygen levels decreased, and his heart rate decreased. His nurse held his hand and stroked his hair, and told him I had called his wife, and she was praying for him and sending her love. He never responded, he never moved again. Thirty-five minutes after the nurse first called me, he died. I called his wife and told her that her husband had just died; predictably, she completely fell apart. I told her how sorry I was for her loss, and felt not for the first time how inadequate those words really are. But what else is there to say?
This story is somehow about compassion. Mr A died quickly, relatively peacefully, with a kind nurse holding his hand and stroking his forehead. Such a small act of kindness, to really attend to a dying patient, to comfort and care for him even when he can’t respond to your attention. And his wife, who came to see his body, said he had been ill for some time, and that she was glad he didn’t have a lingering death. She was grateful for that. And me, after I hid in my call room and cried a little bit, and called my husband to tell him I love him, had to attend to a host of pager calls; fevers, nausea, rapid heart rates, and the problems of the living. The nurses rallied around me, telling me how sorry they were that my patient died, asking how the family was, asking how I was doing. That empathy, maybe undeserved but badly needed, was unexpected and humbling. Death touches us all, and while I could never grieve as much as his family, you can’t watch a man die and be unmoved. At times like this, what else is left but compassion?
For Mama Says Om.