Tuesday, July 17, 2007

Almost coded

Late this morning, while finishing up the last of my work and hoping for an early exit from the hospital, I rounded a corner of a hallway to have my heart sink within me. For as soon as I rounded that corner, a group of nurses at the other end of the hall turned and said "there's a doctor!"

This is almost never a good thing. But in response to their earnest gesturing, I hurried to the room to see a very pale woman lying on a bed gaping at the ceiling with eyes closed. Meanwhile, in one ear I was hearing "just checked on her, was smiling a minute ago," and in the other I was hearing "there's no pulse on telemetry, just bradyed down and stopped, I think she might be DNR."

I am, in looking back, pleased with my calmness as I said "bring the code cart and her chart, see if she's DNR/DNI." By the time I reached the patient's bedside though, a nurse was standing in the doorway with the chart, telling me this patient was DNR/DNI. The code cart was pushed back to its familiar home and the crowd started to disperse.

I told the nurse to page the resident of the primary team and the staff physician as I felt the carotid for a pulse. Feeling none, and hearing no heartbeat, I realized I had just seen my first death in the hospital. First death ever, actually, which is an odd thing, I think, a sign of our times, a mark of the twenty first century, in which people die in small rooms away from home, attended by a select group of people to whom the experience becomes familiar. And until you join that group, you are insulated from the event, one that comes to us all.

The intern from the primary team drifted in. Though it may not have been the right thing to do, I let him pronounce the death.

"Time of death, July 17, eleven fifty AM."

It would be false to say this affected me greatly. I had never seen the patient before, never spoken with her, never heard her story, except her diagnosis. And I wonder what to make of that. I came into medicine partly because it allowed me to treat people, to be around people, who are dealing with real questions, and to deal with them myself. Somehow the presence of the "unveiled mysteries of life and death" seemed to add profundity to my experiences.

I thought as a medical student. As an intern, I'm harried to the point that thought beyond "what do I need to do now" is difficult. If I'm not moving, there's something wrong. I'm so used to hearing my senior resident say "what aren't you writing this down? You should be writing this down, Nathan" that it has become a bit of a joke. All this action, all this doing, keeps me from thinking.

And so, as I stood in that room, a little nervous, a little relieved that I didn't have to run a code, and a little awestruck by the whole situation, I wasn't really processing. I wasn't having grand thoughts voiced by Longfellow or grim ones by Thomas. I was tired, and after the details were passed on to the primary team, I went to grab lunch before heading back to work.


Anonymous said...

Nathan, this detachment is typical of many in the medical field who are as busy as you are; and was, as you say, influenced by the fact that you did not know this woman. You are not weird, unfeeling, or heartless; you're an overwhelmed new doctor.

Emergency and health care workers modify their visceral reaction to events based on the role they are playing at the time. I think it's a self-protective feature of our minds, and not a negative one.

I would imagine, knowing about you what is evident from your writings, that this will stay lurking in the back of your mind for a while. There undoubtedly will come a time when you WILL have known the pt. who just expired, and maybe will have done all you could in the code, and then it will likely affect you more.

But even then, you MUST go on to the next patient with a focused and clear mind; so you put aside those thoughts of grief/ guilt/ anguish and turn smiling to the next person. Sometimes it's only later in the night that you process those thoughts you had earlier in the day.

i can still remember vividly certain babies i cared for in the NICU over 30 yrs ago. i always wonder what happened to them after discharge, or what happened to grieving parents after they had a baby die. Maybe we'll find out in heaven.


Ryann said...

Nathan – thanks for sharing what could not have been an easy day. I think it is safe to say your writing does help you process, and I’m glad you’ve had enough time to reflect here, albeit briefly, on what will probably become a familiar event. If you haven’t had a chance, read Ibid’s post from 7/13 on the normalcy of death. I was surprised to feel that as my grandpa died; the sorrow, grief and sadness were overshadowed by how simple it was to pass from this forgettable life to the complete fulfillment that awaits us in heaven.

tmu – It’s difficult for those of us in the non-medical world to understand what this must be like to deal with routinely. I think you are right on when you say that it is a protective measure to desensitize (somewhat) to the pain and death you see around you and, in short, are reasons why you’re called to be nurses, physicians, care-takers, etc.