Thursday, December 07, 2006

Keeping Things in Perspective

Tonight was one of those shifts that puts the world into perspective for me.

I was the primary nurse for a man who had a sudden-death cardiac arrest; his wife heard a loud thud, turned on the light, and saw her husband of fifty-two years crumpled in a heap in the doorway of the bathroom, blue and dead. She was a small woman, and he was rather tall. She could not get him out of the doorway.

She called 911, and seven minutes later, the paramedics arrived, find the guy asystolic (no heartbeat) and then started CPR.

Mark this: seven minutes dead. No oxygen to the brain. If CPR had been started the moment the guy dropped dead, he would have had a seventy percent chance of getting out of the hospital alive. With every passing minute, the survival rate drops like a cow off the high dive.

Paramedics work on the guy for 30 minutes. Nothing works. Not the drugs, not the shocks, nothing. And the man has an internal defibrillator that goes off every once in awhile. It was obviously not working either.

So the medics get authorization to call the code. The man is pronounced dead. The medics start packing up their gear.

But then, somebody thought it would be a good idea to check for a pulse. He had one.

So the medics open their bags, call us, give report, and arrive ten minutes later.

I was the primary nurse for this guy. We got the word from the MD about what had gone on, and I say to the Doc, "So this guy's been dead for about 45 minutes so far?"


"Advance directive?"


"Is this the same guy you gave authorization on a while ago?"


"Okay," I said with an exasperated sigh. "I'll square the room away."

So the ER Tech and I gather the tools and get the staff together. Since I am primary, I will receive report and direct the nursing care. There will be at least two other nurses and two other ER Techs involved. Ten minutes later, he arrives.

I take one look at the man and know he is "circling the drain." His extremities are ice cold, his eyes are open, his pupils are fixed, irregular, and nonreactive; his legs are mottled; he has no bowel sounds; His heart sounds are disorganized. He is breathing with the help of a ventilator. His BP is 81/64, pulse 134 at the wrist, and he looks just horrible.

But he had a good pulse.

The medics gave me report while my team descended on the man like a Formula One pit crew. Every appendage the man had had a tube sticking out of it within three minutes. After receiving report, I checked with the team that all the major stuff had been taken care of. I then assessed the patient myself. It was not reassuring.

Then the wife came in. She was a lovely woman in her mid-seventies who looked much younger. She carried herself with grace and calm. I introduced myself and hurriedly tidied up the room. I explained what my role was, what we had done so far, and what we intended to do. She signed the necessary forms and sat in a folding chair just near the man's head.

After a few minutes, she got up and pulled some papers out of her purse. It was a living will. I looked at it, and said, "So your husband does not desire resuscitation?"

"No, he doesn't."

I looked at her quizzically.

"I was afraid to tell the ambulance people to stop. I was just afraid."

I paused and asked "Do you have power of attorney?"

"Yes, I do."

"Let me get the doctor."

I got the doctor and had her run the whole thing by him. The doctor finally asked, "Ma'am, what do you want us to do?"

The woman paused for a little while, reached out and put her hand on the patient's forehead and said, "He's been gone too long. We need to let him go."

The doctor verified the woman's legal status, verified her request, had her sign all the necessary forms, and the team withdrew life support in accordance with the stipulations in the living will and the woman's power of attorney.

I hovered over the man, watching his vital signs, listening to his heart and lungs, and then stepped back.

Suddenly, the man's body stiffened, his hands flailing outward. His internal defibrillator had fired. I looked at the monitor. He was in asystole. I looked at the woman. Her eyes were on me. I wished they weren't.

I got the doctor in the room. He looked at the monitor, assessed the man, and finally told the woman, "He has no pulse, no heartbeat, and he is not breathing."

The woman looked at the doctor, and looked at me. The she said, "Let him go."

She stood up, took her husband's hand, and kissed him on the forehead. I moved her chair closer so she could sit down next to him. The doctor looked at me, said "Time of death, so-and-so," patted the woman on the shoulder and asked, "Is there anything more I can do?"

"No, thank you. I am fine."

I asked her likewise, and she answered likewise.

Over the following hour, the woman sat in the room with her head on the man's chest. I busied myself with the postmortem arrangements, and finally informed the woman that whenever she was ready, her husband could be transported to the morgue.

She said, "I'm ready now. I'll be going." Her son had arrived and was to drive her home. She kissed her husband's forehead and left the room with her son holding her hand. Her husband's body was taken to the morgue upon her departure.

I had no other patients and my shift was over, so I simply punched out and went home.

When I got home, I went to the internet to check my email, as is my habit. The glaring headline on my ISP was "TOMKAT TO HOLD NUPTIAL BASH IN LOS ANGELES."

So frigging what?