A Good Man

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An emergency department is a stress pit, a lake of exhaustion washing over all who work there.  The demanding environment smothers physicians, nurses, paramedics, EMTs, and anyone else who dares enter the battle zone in the war to save lives.  For over thirty-eight years, I have worked as an emergency physician.  I know the terms of engagement.

For physicians, in particular, one of our most difficult duties comes with informing family members that their loved one has died.  How I wish the Grim Reaper, with his frightening black robe and scythe, was a less familiar figure in emergency medicine, but he’s not. He’s always lurking in dark, secluded corners, hoping to collect his prey, and to his delight, the targets continue to arrive.  Hardly a week goes by that I don’t see a patient who presents in cardiac arrest and dies, despite our efforts.

Some families, recognizing the deteriorating condition of their loved ones, prepare for death by having DNR (Do Not Resuscitate) papers signed, and perhaps have arranged Hospice care. With these measures in place, the terminally ill one is given the chance to die peacefully at home.

But sometimes there are those, in seemingly good health, whose heart unexpectedly stops, and they come to me strapped to a stretcher in the back of a speeding, careening ambulance with lights flashing and sirens blaring.  Soon afterward, terrified family members show up at the emergency department, clinging to the hope that somehow, someway, their loved one was pulled from the bank of the River Styx, back into the land of the living.

I understand why families cling to such belief. Nearly every medical show on television has amazingly high resuscitation rates, which creates the expectation that health and recovery wait in the emergency department. The assumption leaves the physician with a difficult problem in explaining emergency death to families who do not realize that, in the real world, in spite of our technological advances, the overall chance of survival after cardiac arrest is abysmally low.

In reflection, I admit that, as medical students, we were never given a course on how to tell family members about the death of their beloved one.  Rather, by observing our attending and resident physicians, we formulated our own way of handling this most challenging task.  Perhaps, in this day and age, with medical humanism coming more and more to the forefront, this important skill is taught.

As an emergency physician, when someone dies, I do the very best I can to inform families of their loved one’s death in a caring and professional manner.  In spite of my years of experience in performing this demanding task, it has not become easier, and I don’t expect it to.

When a patient has passed away, usually, the process goes something like this.  Shortly after I have pronounced the patient dead, I enter the family room with the deceased’s chart in hand and introduce myself.  After sitting down and facing the family, I don’t delay in telling the bad news.  People don’t want to hear a long, drawn-out story before I announce the dreaded truth.  As quickly and gently as possible, I let them know their loved one has died. After they’ve had some moments to grieve, I ask to hear the story of the events surrounding the death so I can tell their family doctor, and later the medical examiner, the details of what happened. Empathy and expression of my sorrow for their loss are important to provide, for at this critical moment they are likely as vulnerable as they have ever been; the world they live in has been changed forever.

Most of the time, the members of the family are too stunned to have much to say, but on one particular occasion, I remember a very different ending to the conversation, one that will be forever imprinted in my mind.

 

One chilly winter day, I was scurrying around the emergency department, trying to keep up with crowds of sick people, when one of the nurses approached me, scratching some notes on a yellow pad.

“Doctor Conrad, the ambulance is bringing in a seventy-eight year old male in cardiac arrest. Their ETA is ten minutes.”

“Was it witnessed?” I asked, knowing that those who are by themselves when their heart stops—and don’t receive immediate CPR—are very unlikely to be resuscitated.

“No. He was last seen two hours before.”

“What was his initial rhythm?”

“Asystole.”

No heartbeat at all.  Not good, I thought.

“What is it now?”

“Still asystole.”

“How long have they been working the patient?”

“Thirty minutes.”

I shook my head, thinking: This patient doesn’t have a prayer, but we’ll do what we can. 

Promptly ten minutes later, I was waiting in the Code Room with several emergency nurses, when I heard the sound of an opening door and smelled the exhaust of an ambulance.  In seconds, the paramedic and EMT hurriedly rolled the patient into the room, IVs hanging from both arms. A fireman was performing chest compressions on him, while another was giving oxygen by ventilating him through an endotracheal tube, a hollow plastic tube the paramedic had placed in the patient’s airway.

They moved the patient from their stretcher to ours, where I performed a quick examination while CPR was in progress. The patient looked older than seventy-eight.  Must have been sick for a while, I thought. My initial inspection revealed his pupils were fixed and dilated. No cardiac sounds. No voluntary respirations. Good breath sounds with bagging. Abdomen mildly distended.

I asked the paramedic, “Update me.”

Her shirt was soaked in sweat as she quickly and concisely spoke. “Mr. Evans has a long history of hypertension, non-insulin dependent diabetes mellitus and had a coronary artery bypass graft some years ago. He’s on multiple cardiac meds. You’ve heard the report I gave to the nurse?”

“Yes.”

She added, “He’s still in asystole.”

“How long has he been down?” I asked.

“About fifty minutes have passed since the call.  Who knows how long he’s actually been in arrest, though.  We’ve been working him for around forty minutes.”

“Meds?”

“Seven rounds of epinephrine, two amps of bicarb.”

“When was his last does of epi?”

“Three minutes ago.”

By then, the nurses had transferred the emergency department cardiac monitor to the patient.

“Stop compressions,” I said to the fireman.

When he paused, I felt for a pulse and looked carefully at the rhythm on the monitor.  No pulse.

Flatline.

I directed, “Confirm asystole in two leads and check for a pulse with a Doppler.”

The results were as I expected; asystole was verified on the monitor, and no pulse was heard with the sensitive Doppler probe.

He’s dead, I thought. I wish there was something more I could do for him, but there’s not.

I grimly told those in attendance, “This patient is DOA. Time pronounced is 1330. Let me know when the family arrives. Good job, everyone.”

 

Minutes later, as I worked on his chart, one of the nurses walked up and said, “The wife of the patient in the Code Room is here. She’s in the family room.”

“Anyone with her?” I asked.

“No.”

I felt sad that the wife had to deal with the death of her husband by herself, yet I grabbed the chart and fought my way down the cold, institutional hall through a thick barrier of questions, screams and unpleasant odors.  I knocked on the door of the family room, entered and discovered a slender, gray-haired woman who appeared to be in her mid seventies.

“I’m Doctor Gary Conrad,” I said. “Are you Mrs. Evans?”

She nodded.

I pulled up a chair and sat in front of her.  “I have some bad news for you.  Your husband has passed away. He’s dead.”

Her eyes filled with tears. “I knew he was gone,” she said softly.

I took a deep breath and asked, “What happened?”

“Charlie had not been in the best of health,” she explained. “He went to the bedroom to take a nap this morning because he wasn’t feeling well. When I went to check on him, he didn’t respond and wasn’t breathing.”  She repressed a soft sob and put her hand to her mouth. She took a few moments to regain her composure before she continued, “I then called 911 and did CPR, but I felt sure I had lost him.”

“I’m so sorry,” I sympathetically said. “I’ve already talked to the paramedic, and with Mr. Evan’s past medical history, I’m certain his death will be confirmed as natural by the medical examiner. Once that’s done, we’ll take out all the tubes and you can see your husband.  Do you have any other family coming in?”

“Yes, I do, but I want to see him as soon as possible.  I don’t care if the tubes are removed.”

“I understand. Once we’ve finished speaking, his nurse will come for you and lead you back to his room.”  I stood to leave and asked, “Is there anything else I can do for you?”

“Yes, Doctor Conrad, let me tell you about my husband.”

Surprised, I sat back down.

She smiled through the tears. “Many years ago, when I was a young woman, my first husband died and left me with three small children. Then I met Charlie Evans, my second husband-to-be, and we fell in love.  And you know what he did?”

“No.”

Tears now streamed freely down her cheeks and her voice began to break. “After we were married, he adopted my children . . . and raised them as his own.  He was a wonderful father . . . and a good man. I will miss him terribly.”

I felt my face begin to flush, and my eyes welled with tears.

She looked at me with probing brown eyes and whispered, “I thought you should know that.”

“I’m glad you told me . . . thank you.” I stood and gently squeezed her shoulder. “His nurse will be with you shortly.”

I left the room and walked back to my desk, grabbing some tissue to wipe away the tears. As I thought about what just happened, I realized that in emergency medicine we have a tendency to dehumanize our patients, for if we know them as fathers, mothers, grandfathers, grandmothers or any role in life where they loved and loved deeply, then it’s just too painful.

Mr. Evans was more than just a body—one we tried to revive that day.

He was a good man.

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