Halfway through the third litre of saline he arose like Lazarus, asked for a drink of water, and held court with his family. When I asked him what his wishes were regarding end-of-life care, he confirmed he didn’t want CPR, defibrillation, intubation or mechanical ventilation. Intravenous fluids were fine, though; he was hoping to keep body and soul together long enough to participate in an exciting new chemo trial scheduled to commence in a couple of weeks.
“You do your job, and I’ll do mine,” he said to me with a mischievous twinkle in his eye.
Over the course of the next two hours Rick slipped in and out of consciousness. During lucid intervals he would reminisce with his family about happier times. Sometimes he spoke wistfully about up-and-coming treatments he had read about. Not once did he speak of death. Shortly after midnight he lapsed into a coma. I wrote admission orders and transferred him to the medical floor for palliative care. By 3:00 a.m. the emergency department’s waiting room was empty. I hung up my lab coat and drove home.
Three hours later my telephone rang. It was a nurse from the medical floor.
“Sorry to wake you, Dr. Gray, but Rick just died.”
“I’ll be there in a few minutes.”
I got out of bed, dressed and returned to the hospital.
Pronouncing someone dead is a strange ritual. It’s equal parts medicine, religion and magic. Like falling snowflakes, no two pronouncements are ever the same. Sometimes the body is alone in the room; shrouded in darkness, isolated and abandoned. Other times the room is well lit and packed with family members and friends. Sometimes the dominant mood is sadness. Other times it’s relief. No matter how many mourners are present, though, a palpable stillness descends when I enter the room. I become a shaman. My gift is closure.
On this occasion there were seven people clustered around the bed. When I walked in, they all turned towards me expectantly. My fingers gripped the stethoscope in my pocket. For a moment it felt like a string of rosary beads. I approached Tammy and squeezed her shoulder in sympathy.
“Thank you for looking after him earlier,” she said.
“You’re very welcome,” I replied. “I only wish we could have done more. Was he in any pain at the end?”
“No, he looked like he was comfortable.”
“Did he ever regain consciousness after he left the emergency department?”
“Yes, a few times. The last time was about half an hour ago. He opened his eyes and spoke to me. I think he must have realized he was about to die.”
“What did he say?”
“ The fire’s gone out.”
Rick was recumbent on the bed with his eyes closed. Although it was clear that his life-thread had finally been severed, I could sense his family needed me to confirm it. I lifted his cooling wrist and felt for a radial pulse. There was none. I assessed his carotids. Nothing. I placed the diaphragm of my stethoscope directly in front of his bluish lips and listened for breath sounds. Silence. I auscultated his chest for a heartbeat. Once again there was no sign of life. The last thing I usually do is check for a pupillary reflex. I put my right thumb on his left eyelid and gently opened his eye. A solitary tear broke free and tracked down his cheek.
Parenting 101
My next three patients are a young family with mild gastro symptoms. While I obtain a history from the parents their toddler Billy pokes around the room, happy as a clam. I examine the father. I examine the mother. Now it’s Billy’s turn.
I ask his parents to put him on the stretcher. When his mother leans over to pick him up, Billy goes bonkers. He windmills his arms and screeches, “No!” He then runs behind the stretcher and stares up at us defiantly.
“I don’t think he’s going to let you look at him,” his mother concludes.
“How old is Billy?” I ask.
“He just turned two.”
“I think we’re in charge here, don’t you? Please put him up on the stretcher so I can check him.”
She approaches Billy cautiously. He bares his teeth at her like he’s some kind of rabid ferret. When she lifts him up, he arches his back, kicks his feet and uncorks a blood-curdling, “No! No! No! NOOOOOO!!!!” Damned if she doesn’t put him back down.
“Billy doesn’t like doctors,” she reiterates.
I’m running out of patience.
“Look, this isn’t a democracy – his vote doesn’t count. It doesn’t really matter if he says no. Just put him on the stretcher anyway.”
At this juncture a tiny light bulb appears above her head. Aha! A brand new concept! This time she and her husband pick up Billy and deposit him on the stretcher like they mean business.
“Now you sit still, Billy,” she says firmly. After putting up a token show of resistance he settles down nicely. I begin my examination.
Adventures in Paralysis (The Ventilator Blues)
Every now and then we ER docs supplement our armamentarium with techniques borrowed from other specialties. Rapid sequence intubation (RSI) is one such purloined procedure. It involves using induction and paralytic agents to facilitate emergency endotracheal intubation. In plain English, this means we sometimes give patients who are struggling to breathe drugs that render them comatose and paralyzed. We then move their tongue out of the way with a device called a laryngoscope and quickly advance a hollow 12-inch plastic endotracheal tube (ET tube) past the back of the throat, through the vocal cords and into the trachea (windpipe). When the tube is in place we attach it to an Ambu bag. Squeezing the bag rhythmically results in 100 percent oxygen being delivered to the patient’s lungs. Depending on the situation, the ET tube can subsequently be attached to a ventilator.
As the name implies, RSI allows us to rapidly take control of a patient’s breathing. Anaesthetists have long used coma-inducing and paralyzing drugs in the OR, but it wasn’t until relatively recently that it was recognized there was a role for these medications in the ER as well. RSI is an invaluable adjunct, and it has bailed me out of a number of airway crises. Usually it goes off without a hitch, but once in a while things can get a little hairy. Here are three cases from my Yikes! file.
Are You Sure This Stuff Is Going to Help Me Relax?
Several years ago I was working in the ER when we got word an ambulance was on its way in with someone who had been trapped in the basement of a burning building. Before long the paramedics arrived with an uncooperative man in his early 20s. His clothing was badly charred and he was covered in soot. Inspection of his throat revealed a raw, beet-red palate, and his sputum was speckled with carbonaceous material. It was obvious he had suffered significant thermal damage to his upper airway. It is generally recommended that patients with this type of injury be intubated early. If you wait too long, late attempts at securing the airway may prove to be impossible due to massive soft tissue swelling in the throat. In situations where multiple intubation attempts have failed, oftentimes the only remaining airway management option is emergency cricothyroidotomy, i.e., cutting the front of the neck open to directly access the trachea. Rumour has it that incising the neck of a confused, combative burn victim isn’t much fun. Intubate early and save yourself a world of grief.
As we stripped off the patient’s smouldering clothes and started IVs I advised him of my concerns regarding his airway. When I told him I thought he needed to be intubated he said: “Are you saying you want to stick a tube down my throat and put me on a breathing machine?”