dying | Elbrecht's Corpuscle

A Week in April

Posted on October 3, 2016 by Elbrecht

I had four patients die within one week.

When the totality hit me, I nearly lost control of my emotions.

On the Obstetrics service, a majority of all patient encounters are joyous and professionally reaffirming.

Each antepartum heart tone heard via ultrasound brings a sense of wellness and anticipation, both to the expectant mother and the caring physician.

But not every delivery has a pleasant outcome. Not every parent has a sense of anticipation. And not every physician can cope with those competing forces.

I delivered a 33-week-old neonate who precipitously declined within the first 24 hours of life. It had been an easy delivery, with the mother having given birth five times previously, and the fetus not yet having reached the period of greatest growth.

With one deep breath from her mother and a hearty push of the abdominal and pelvic musculature, the baby arrived, opening her eyes and taking her first breath while still cradled in my left arm.

She looked right at me. Deep into my eyes as she let out her first cry.

But despite our medical technologies and painstaking care, not every newborn baby survives.

She died in the neonatal intensive care unit 7 days later, an infection having made its way from the vaginal mucosa of her mother into her lungs and from there into her bloodstream.

The most aggressive antibiotics and procedures did not save her; there was nothing more we could have done.

Her death was unsettling. It came as the last of the four, but the one which nearly encompassed my entire being in darkness.

Two days after her birth, while awaiting another delivery on a quiet Friday night, the Code Blue alarms, indicating a cardiac arrest somewhere in the hospital, sounded overhead in the lecture hall.

My colleague, Dr O, was on medicine call that evening; she jumped from her seat across from me, immediately ending our conversation.

I glanced at my other colleagues remaining at the table and dutifully indicated I would join Dr O in case she needed back-up so they could complete sign-out.

The Code was called to a room at the furthest point possible from where we were seated, so rather than assuming I would eventually arrive to find Dr O having resuscitated the patient, I broke into a full sprint, clasping my stethoscope around my neck with my right hand to prevent it from flying off mid-stride, in case something went awry.

When I arrived a minute later, all hell was breaking loose, despite Dr O and a more senior physician, Dr B, deftly providing and directing life resuscitating efforts.

The woman, a 31-year-old mother of 6, who was admitted for nausea two days earlier, was accompanied in the room by her distressed and screaming 6-year-old son and her husband, who was shouting hysterically from her bedside, begging her to come back.

I stepped into hell incarnate and helped guide the husband and son to an adjoining room.

When I returned moments later, nothing had changed. She was still unresponsive. No heart beat was palpable; no rhythm identified on the cardiac monitor.

A deep sense of distress was evident in the room, despite the aggressive nature of our efforts.

The next hour lasted for an eternity, as Dr O, Dr B, and myself assisted the nurses in providing chest compressions, giving medications to stimulate cardiac contractility, and delivering electrical shocks to bring her back to life.

Nothing worked.

Her heart did not regain electrical activity. Her lungs did not attempt another breath.

Once we determined further efforts were futile, the husband, increasingly hysterical, was guided back into her room, to kiss the cheek of a lifeless body once belonging to the mother of his 6 children.

He begged us to try more. The despair in his eyes pierced everyone’s souls.

His son was sitting quietly in the adjoining room.

Physicians, nurses, security guards, and the chaplain cried; our emotions audible throughout the hallway.

I returned to the Obstetric floor after embracing my colleagues in a moment of silence. I stopped in the locker room to take off my sweat and tear-soaked scrubs and replace them with a new pair.

I delivered a healthy baby boy an hour later. His parents thanked me incessantly before I left the room.

I left the hospital the following Saturday morning having delivered several newborn girls and boys into this world.

All the while knowing a loving mother had unexpectedly died and another child’s life was being sustained in the Neonatal Intensive Care Unit.

When I returned to the hospital on Sunday night, I quickly scoured the electronic charts awaiting my signature.

A new electronic tab had appeared in the toolbar for me to click on. It read “Death Notice.”

I anticipated having to re-read the harrowing and emotional report of the unexpected death of the mother from Friday night.

Instead, I was blindsided by the account of another of my patient’s death, whom I had seen only a few weeks previously in the office.

He had been brought to my hospital’s Emergency Department on Saturday night, lifeless, despite the heroic efforts of the EMS and subsequent attempts by the Trauma Surgeons.

In the early evening hours of Saturday night, he had been found lying in a pool of his own blood, a trail of that blood following him for a reported 50 yards.

A bullet had pierced his femoral artery, the largest blood-carrying vessel in the leg; it had shredded the artery, leaving behind a capable exit path for the blood to flow from his body.

With each beat of his heart, more blood would gush from the wound in his leg, causing the heart to beat faster as it attempted to compensate for the missing blood.

Instead of a life-continuing effort, in its paradoxical nature, the heart beckoned the same death it hoped to avoid.

After scouring the internet for more information, I learned the 50-year-old man had been minding his own business in the parking lot of his apartment building when a man and woman approached him. They pointed a gun at him and demanded his wallet.

Having had several colorful conversations with him in the office, I could easily visualize him telling them to “Fuck Off”, his East Coast upbringing shining bright.

The following morning I received a phone call from my Program Director. She had also received notification of his death and wanted to check in with me.

I expressed my thanks for her concern. I did not tell her about the lifeless mother or the neonate only a few breaths from death.

A third patient died in the next 48 hours.

Honestly, I can not recall the details. None of them.

They have seemingly been erased from my memory, perhaps in a fitful effort to suppress the emotions death has brought to the forefront of my medical training so that I do not throw my heart up in the air and declare all is lost.

But I know another patient, someone for whom I cared, whose family loved them, succumbed to the only outcome known to our species.

Death.

So I will document that death here; despite my brain’s greatest efforts to forget it, I will forever know the impact it has had upon me.

When I received the call, I let out a deep sigh. I hung up as my eyes swelled with tears.

The fourth death. A seven-day-old child whose eyes I had stared into while holding in my left arm as she took her first breath.

Until the day I die, I hope to not forget the look I gave her. One of awe. And love. Excitement. And fear.

A gamut of human emotions, packed into one soul-penetrating experience.

I hope, despite her struggle for life, that in her final moments, the neurons in her brain grasped onto the emotions I transferred to her with our brief encounter.

That in the last beat of her heart and breath of her lungs, her mind went to the moment we shared; the look of awe and love and excitement drowning out the fear lurking deep in my eyes.

Death Becomes Us…

Posted on April 6, 2015 by Elbrecht

—–

If everything goes as imagined, my final breaths will be exhaled several decades from now as I look out upon the Atlantic Ocean.

Watching the waves crash upon the shore, I will be alone. By choice. Not wishing anyone I love to see me as a dying corpse, gasping for my last breaths. Hopefully the tide will come crashing in, and, in its return to the ocean, take my body too.

I will have said goodbye to my surviving friends and family while still upright and mobile. Exchanging long embraces, we will depart each others presence to live another day.

My wife, ever accustomed to my eccentric nature, will have laughed, and cried, when the day came for me to leave her, just as I had promised her long before. We will have sat beside our parents, friends, perhaps one of our children, and other loved ones while they succumbed to life’s final crescendo. They not wanting to leave us, and we, not wanting to leave them.

But, Death Becomes Us.

—-

—–

The first time I crushed a man’s ribcage, I was furiously trying to save his lifeless body. As a third year medical student in the ICU, I was tasked with performing chest compressions on a corpse who had, in written certitude, asked for all measures be performed to save his life.

As I felt the brittle bones disintegrate beneath my force, I continued in rhythmic fashion, counting under my breath, and wondering to myself:

“Did anyone see my millisecond of hesitation after the first rib snapped?”

—–

He did not survive. Despite medical science, unwavering will power, the love of everyone in his life, and perhaps a god somewhere in our cosmos, he died like everyone else who had ever lived before him.

He died. Just like I will. Just like you will.

In the three years since that time, I have been present for the deaths of innumerable people. I have lost count.

I don’t believe the number is actually any more than 50, but that’s enough for me to recognize I will die too.

—–

As a physician, I have had the responsibility to pronounce the death of a once-living person. The first time I was called upon to do so, I walked to the patient’s room, and therein, found an elderly woman sitting beside her husband’s dead body, surrounded by her adult children.

The body was already in rigor mortis, laying in the bed, with a crisp white sheet covering the torso, the arms extended beside the chest, and the eyes and mouth closed; forever.

I politely introduced myself to the family, reached my arm out to hold the hand of the widow, and clasped it in my hands for a moment.

I informed the family I would need a moment to examine the body, but they were welcome to stay at the bedside. The widow rose from her seat, looked at her dead husband’s body, and asked to be excused. She stepped behind the room-dividing curtain; one of her daughters joined her.

—–

The diaphragm of my stethoscope was placed over the Aortic region of the chest. My right hand made its way to the left wrist; the pads of my first and second fingers palpated for the radial pulse.

I closed my eyes and listened for a heart beat I knew I wouldn’t find. Simultaneously, my fingers pressed gently, trying to feel a pulse I knew wasn’t there. I moved my stethoscope around on the chest, never once hearing a heart beat or breath.

For completeness, I firmly pressed on the nail bed of a finger, trying to elicit the jerking motion a live man would provide. There was no response. I withdrew my penlight from my left chest pocket, spread the eyelids, and shone the light directly on the pupils. They were fixed and dilated; they did not react at all. I gently released the eyelids.

—-

—–

I respectfully informed the family my examination was complete and provided my condolences.

The widow appeared again and sat back down beside her lost love. I exited the room and proceeded to file my pronouncement of death. I entered a note in the now dead patient’s chart. I called the physician of record to inform he or she of the passing.

In the subsequent months, I have made similar appearances at the bedside, sometimes finding grieving family, other times a vacant room. Each time, the pronouncement was the same.

The time I spent in the ICU as a medical student was easily eclipsed by the four weeks I spent therein as a Resident Physician. Death was only an embolus, cardiac dysarrhythmia, antibiotic-overpowering infection, or apneic respiration away for each person. And on numerous occasions, those life-ending insults occurred simultaneously.

—–

The four weeks of care I provided in the ICU was tempered by the realization that some of it would be futile. A concerned son, seated at the bedside of his father, stopped me one afternoon and asked, “Excuse me doctor, what does it mean if the brain waves are prolonged?” I took a hard look at his father, a man I had never met, who ended up as my patient that morning after a massive heart attack deprived his brain of its needed oxygen, and then looked back at the son, himself a grown man older than I, and took a deep breath.

Nothing I could explain would bring his father back. Nothing we could do in the ICU would change his outcome. We are here for a finite amount of time. And in essence, I explained to a son that his father’s time had come.

I did not feel relieved that I could near-effortlessly explain the basic inner working of the heart, brain, and circulatory system to this man; all of which I had acquired after countless hours of study and dedication. Instead, I felt emboldened to never have someone utter the same nuanced phrases to my own son.

—–

Similar occurrences happened on a daily basis for four weeks. For the fortunate, the family would withdraw the aggressive machinations, which, if prolonged, would have provided a miniscule chance of survival. For the unfortunate, their own wishes (and sometimes their family’s) had been so misguided as to result in aggressive and invasive procedures, which, if successful, would provide only a miniscule chance of survival.

Yet, I know the final minutes, hours, and days provided to the loving members of those patients’ families was beyond worthwhile. To them. To the patient. And to me.

—–