[JD, please post this one. This is the one without the typo. Sorry for the confusion, and thanks for such kind words on my last submission. It means so much coming from you. Xoxo, Roseberry]
To all those who never got to say their last goodbyes:
I wanted to share a story with you from a professional point-of-view.
Yesterday, I was ready to go home and, more importantly, go to bed after my 24-hour shift. Of course, my shift is never really done at the 24th hour, but I get to turn my work phone off and focus on the job I have left. I was speeding through the morning routines to get home early as possible, preferably by 27th hour. To my annoyance, my private cell phone began ringing non-stop while I was performing a sterile technique. I was half-tempted to ask the nurse to pick it up for me, but I ignored it and finished it before checking the phone. Apparently, there was a patient transfer waiting to take place, and the chief resident wanted me to go in place of a senior resident. This had nothing to do with my skills per se; it was just that several residents were away on a conference and senior residents were short-staffed as it is; and since I technically had 12 hours off (I had less since I was already working overtime) before returning for my next shift, I was the one who was free to go on a transfer (I don’t know why my colleague who didn’t have a shift lined up wasn’t chosen, but hey, I don’t get to complain). So I finished my morning duties and wrote patient notes while waiting for the chief resident to call back. When she called me back at 27th hour of my shift, I hoped that she was going to tell me that the transfer had been cancelled; of course, these things never go the way I want them to, and I was asked (meaning ordered) to come up to the ward and see the patient.
The patient was a terminal cancer patient in her 60s. She was already in coma, mechanically ventilated, and had so many lines and tubes connected to her that it would have traumatized any layperson. Apparently, the patient had been receiving treatments at multiple facilities over a year. $150,000 spent on recent treatments alone. They have tried everything possible. But with a recent bout of pneumonia, she was in the state of septic shock (it just means there are so many germs and their products in your bloodstream that your blood pressure is dropping). The staff wanted to constantly monitor her as she was so unstable; but at her husband’s constant insistence, she was planned to be transferred at 25th hour into my shift, which was why I was alerted so early in the morning; however, her blood pressure soon began to drop at an alarming rate. Blood pressure are written out as systolic/diastolic. Normal range for systolic blood pressure (SBP) are 90~120. Normal range for diastolic blood pressure (DBP) are 60~90. Hers were 70/40 in the morning. The fact that her blood pressure was so low means her heart is not able to pump out blood properly and her body is not getting the blood supply it needs. The attending and the residents knew that she had high probability of dying within hours at this rate. So they tried everything to persuade her husband to stay at the hospital instead of going on a transfer to a hospital nearly four hours away; but their plea fell on to deaf ears. Her husband, who was already so tired from trying to save his wife just wanted to go where the rest of her family members were waiting to be with her during her last moments. So the staff made sure they had written documentation and agreement that he was fully aware of his wife’s condition and had even received a DNR (Do Not Resuscitate). They had barely stabilized her blood pressure before calling me to come up. The chief resident pulled me aside and informed me of what’s been going on. She emphasized the high probability of her passing away during the transfer and the fact that they have already received a DNR. DNR has a lot of ethical and moral issues, so when I confirmed with the chief resident if I should break it in case the patient goes into cardiac arrest, she told me that I should just ask her husband if he wants manual chest compression. If he wants it, I should ignore the DNR, she said. When I asked about AED (electrical shock to restart the heart), she shrugged. In all technicality, DNR gives the legal responsibility/freedom for physicians to stop all life-saving procedures, and it was up to me if I really wanted to go that far to save a patient who, in all practicality, wasn’t going to stay alive for long.
To be honest, I was not comfortable with this journey from the start. I’ve had patients and/or family members making understandable, but impractical, requests before (one of the most ridiculous one was where the patient “demanded” that I organize her air transfer on a military aircraft to a Florida hospital, because she’s a wife of an Air Force veteran and she deserves to die on U.S. soil. TWO surgeon generals had to personally reject her request, because my words fell on deaf ears as I was just a “Missy” to her.). So I’ve had my share of experience with stubborn requests as well as numerous transfers; but I never went one unassisted so far away with such an unstable patient before. I’m not an EMT; I’m a house physician; even with unstable patients, I ALWAYS had a backup and a line of medical equipment on a standby. Needless to say, I was nervous going on this transfer alone; but like a lamb to a slaughter, I knew I didn’t have a choice in the matter.
By the 28th hour of my shift, the patient was loaded onto the ambulance. I heard her husband distinctly mutter that if they knew that she was going to die anyway, they would have spent the last year travelling instead of in the hospital. I empathized with him, but there really wasn’t much I could say to him. All I could do was give him a comforting pat on the arm. With the husband sitting up at front next to the driver, and me sitting next to the patient, we were off. The sirens were blasting and all the cars were making way for us. Highway seemed endless with bumps along the way. I monitored her heart rate, her oxygen saturation, and her blood pressure manually and regularly.
By the 30th hour of my shift, I knew something was going wrong. Her blood pressure (BP), which was so low in the morning, was off the charts. It was over 200/150. Hypertension (high blood pressure) starts at 140/90, so such high BP could do some serious damage. I reduced the dosage of norepinephrine (which increases the BP) by 2 units. When I measured her BP again 2 minutes later, it dropped to 150/90. I was ordered to keep her SBP (the top number) at between 110~120. So I reduced the dosage again by 1 unit. But 2 minutes later, her blood pressure was 80/50. I increased the dosage again by 2 units, and 2 minutes later, it was 180/110. This pattern of increasing and reducing the dosage went back and forth; meanwhile, her heart rhythm was beginning to show signs of monomorphic ventricular tachycardia (meaning her heart rhythm is becoming irregular). As tempted as I was to perform DC cardioversion (electrical shock), the indication for such treatment is unstable vital signs (low BP); and such rhythm was only appearing briefly when her BP was actually stable! The chief resident called me in the midst of this confusion, and when I told her exactly what was going on, she reminded me that the reason for arrhythmia is the norepinephrine. Reduce it as much as possible, and it will keep the arrhythmia at bay, she said; but I couldn’t reduce it too much without compromising her BP. The patient entered a somewhat homeostasis status of slightly higher SBP than targeted at 130~140 without arrhythmia with norepinephrine alone, and I didn’t have to start epinephrine. I breathed out a sigh of relief.
By the 31th hour of my shift, her line suddenly went flat. There were no preceding arrhythmia. On the inside, my stomach was flipping out, but I couldn’t display my shock outwardly. I calmly checked her radial (her wrist) pulse. It didn’t exist. I calmly checked her carotid (her neck) pulse. It didn’t exist. I unwrapped the stethoscope around my neck and listened for her heartbeat. It didn’t exist. Her heart had stopped completely. I started epinephrine and notified the husband in the most professional manner that the patient’s heart had stopped and asked if he would like for me to start chest compression. Despite being so assured of his wife’s condition and despite being apparently so quick to sign all those papers and DNR before the journey, he agreed in a heartbeat. So 50 minutes before the estimated arrival time, I started chest compression. I could see her heart rate monitored at 0 and the heart rhythm began appearing whenever I pressed down on her chest. I started out in a kneeling position as the guideline specifies, but there was no way I could maintain it. We were speeding down the highway at 120 km/hr. I had to stand up between my seat and the patient, while constantly monitoring her other vitals. 5 minutes in, I could feel bile rising in my throat. I was bending up and down, while the car was travelling sideways. I didn’t have anything to actually throw up as the only thing I was able to eat for 31 hours was a couple bites of cereal, but I was getting extremely dizzy. The husband turned and watched me perform compression on his wife. He looked away, then asked if he could do it. Chest compression are very physically demanding, which is why American Heart Association instructs switching of hands every TWO minutes; but only those who are certified are allowed to perform CPR; he wasn’t certified. He was sitting up in the front with the driver as they had so much luggage stacked in the seat next to me, meaning we would have to stop in the middle of the highway even if he were certified. Also, I didn’t want his last memory of his wife be the one of performing compression. So I didn’t have any backup. There was no one I couldn’t ask for help, and I couldn’t afford to stop.
Then as suddenly as it went, her heartbeat came back, and I felt my own heart skip a beat. I leaned back, and saw it maintain itself for several seconds before flat-lining again. I started the compression again. I felt her sternum break beneath my hands. I had to perform 2 chest compression every second. My arm was giving out under me, so I used the bumpy roads as a way to bounce myself up and down and make chest compression more effective; but I could feel myself giving out. The chief resident called, and I picked it up immediately to notify her of the situation; but the minute I tried to speak, I broke down in tears. I had to garner every ounce of strength to stop myself from breaking down completely and maintain professionalism. I don’t get to cry when the husband himself is maintaining composure; but my arms were numb and I had thirty more minutes to go. I really couldn’t do it anymore. Her heart rate was coming and going as if it were taunting me, and all I wanted to do was give up.
Then, as if the situation couldn’t get any worse, her oxygen saturation began to drop. She was receiving oxygen at the maximum setting. So the senior resident said that if the oxygen level drops below 90%, I should stop the mechanical ventilation, get the ambu bag (bag valve mask) and manually ventilate her; but I couldn’t do that in this case. Under no circumstance am I allowed to stop the chest compression. All I could do was watch helplessly while her oxygen saturation dropped to 80%s then down into 70%s. It would come back up to 90%s like the heart rate would, then drop back down. I never felt so helpless.
Then, the worst of the worst scenario occurred. BOTH machines that monitor her norepinephrine dosage AND her epinephrine dosage began to beep next to me. The word “air” kept lighting up, meaning the bags were empty or there was something wrong with the IV lines. I maintained the chest compression at 120 beats/min all the while trying desperately to see if the bags were empty. Even if they WERE, I couldn’t really afford to stop the compression to set up the new bag, but they weren’t. I couldn’t tell what the hell was wrong with the machines. I had never used the particular model stocked in the ambulance before; I had SOME familiarity with the general machines used at the hospital, but even up in the ward, I only give out orders, and it’s the nurses who handle the machines; not me. I desperately turned it on and off with seconds to spare and tried to find the source of what was wrong while keeping one eye on the monitor to ensure I was performing compression correctly. The IV lines were fine from what I could tell. I was just about to call the chief resident when the ambulance turned the corner and we arrived at the hospital.
I maintained the chest compression when the door of the ambulance opened, and I saw family members waiting and heard a distraught wail from a woman who was clearly a daughter of the patient. I can still feel the chills I felt when she sobbed, “Mom, wake up! Wake up! I’m here! Why aren’t you opening your eyes?” Then she collapsed on to the ground and sobbed as if there were no tomorrow. The ER doctors who were notified beforehand of the patient’s unstable conditions and of the DNR were on the spot at the moment’s notice and motioned me to back away as they unloaded the patient. My part of the job was over. She was their patient now; theirs to declare dead. My knees gave out, and I broke down in tears when I called the chief resident to notify her of the arrival. One of the ER doctors gently led me to a reception area and sat me down then handed me a cup of water. I couldn’t stop myself from crying even when I was giving them the necessary paperwork. I felt like an utter failure. In those 50 minutes of chest compression, her heartbeat came back and went total of ten times. But what did that matter now? Who cared that she was already so unstable long before we set off for this journey? Who cared that I had to pinch myself and bite the insides of my mouth to stay awake so that I could monitor her vitals constantly? Who cared that I couldn’t stop my fingers from shaking and that the only thing that kept me from vomiting was the fact that I had nothing to bring up? Who cared that I had to try everything in my power from collapsing in that ambulance myself? My entire self-value at that moment seemed to be dependent on ensuring that the patient arrived alive, and because I had failed, I was worthless.
When I was getting ready to leave the hospital with the ambulance driver, I saw the family members. Her husband pat me on the arm and thanked me, and I felt my eyes well up in tears as I apologized for his loss. The rest of the family members thanked me and gave me a supportive rub on the back. Then, I saw the daughter. Like to the rest of them, I sincerely apologized for her loss, but she wanted none of it. She asked why her mother had died. I tried to explain to her that she was receiving IV medication and that her blood pressure and her heart rate were constantly monitored, but that her heart had stopped. She demanded to know why her heart had stopped if I really did take such good care of her. I felt my stomach drop at her confrontation. The rest of her family members pulled her back physically, and I knew if she weren’t carrying her son in her arms, she would have probably slapped me in her frustration. I understood her heartbreak and I knew she didn’t know what had happened in the ambulance. Even if she did, she didn’t care that I had just drained myself doing something I was legally not obligated to do (and something I could have been sued for if some odious family members decided that I somehow violated written DNR by agreeing to verbal request); I fully empathized with her loss, but I really just couldn’t take it anymore. So I apologized again, and climbed back on to the ambulance.
By the 36th hour of my shift, I returned to the hospital. The chief resident asked to see me when I came back, and when I met her at the ward to give her the copy of the paperwork, I didn’t have strength to cry anymore. She comforted me, reassuring me that it wasn’t my fault. The patient was a terminal case, and everyone involved knew that it was a matter of days before she passed away. She wanted to make sure the family members didn’t mistreat me. I thanked her for her comfort, and she gave me the night off so that I wouldn’t be working for 48 hours. I had a mandatory day off today, which was why I was able to send in this submission.
I will never claim that doctors and nurses suffer more than the patients and the family members themselves. We don’t, and that’s a fact; but we really do try our best when taking care of them, especially under emergency situations like this one. When we lose a patient, we don’t get to show it to our other patients out of professionalism; but it doesn’t mean that losses don’t hit us hard as well. This loss hit me hard enough that I donated blood yesterday on my way home to shake off some sense of guilt. I’m not saying this to complain or to whine or to get a recognition. I’ve wrote this out so that those who never got to say their last goodbyes will understand how losing your loved ones impact us too. The enormous sense of guilt we feel even when we lose the patients we know are hopeless is something I don’t want anyone else to face. Family members always have doctors and nurses to blame. Even the nurses can blame the doctors, because unless they’re nurse practitioners, they’re following the doctors’ orders. We doctors don’t get to place that blame on anyone else, because the buck stops with us. Please understand that we did try everything in our power to make sure that you got to see your beloved one last time. We really did, but we’re humans too. We understand your helplessness, because that’s what we feel when we realize there’s nothing left to do except to pronounce your loved one dead. Your loved one was never “just another patient” to us. They were never “just another checkmark on the list.” They weren’t. They really weren’t. They’re never going to be forgotten by you or us, because losing your loved one is what inspires us to study harder and work harder to become better doctors so that we can save someone else’s loved ones. May God bless all of you who’s suffered a loss.
Sincerely, Roseberrycupcakes (RCC)