The night started out as any other night that month. Night float, 12 hours of cross covering patients for teams that have been hard at work trying to treat patients and get them back home to their loved ones. The Resident teams worked hard during the day to work up and appropriately triage and treat these patients. We came in at night to give the numerous doctors a much needed break and to continue to allow the hospital to function at night. The admissions had already started rolling in as I was receiving checkout from the day teams. After checkout, I swiftly ran off to start churning through the ever growing list of admissions. We already had lined up five admissions and and it was only 7:14pm. I knew it was going to be one of those nights.
My life was about to change. I didn’t know it yet, but I was about to get a harsh reality check tonight. I got the page from a faithful nurse starting her shift as well. Mr. J was feeling nauseous. He was admitted for COPD exacerbation. She asked for something to help with his nausea. I ordered the typical anti-emetic, rattled off a standard order and went back to my admissions.
30 minutes later, another call. Mr. J again. Again? Why? Mr. J’s nausea is much better, but the nurse wasn’t sure. She said he didn’t look right. Can I come up and take a look? I asked why? Does he have a third arm? What do you mean he doesn’t look right? She couldn’t put a finger on it, vitals normal, he is awake, eating yogurt, just finished drinking a supplement (nausea was better obviously), some shortness of breath improved with oxygen and albuterol. I sighed, “I’ll be right up.” I told the nurse. I logged out of the computer in the Emergency Room and started heading to the tower where Mr. J’s room was.
Mr. J was a regular at the hospital. I knew him. I had admitted him a few times in the last year and had met with his wife and daughter. Both sweet people, loving, caring, and always worried about Mr. J. He has been in and out of the hospital numerous times over the last 2 years and the admissions were becoming more frequent. Why couldn’t we keep him out of the hospital? He was a elderly man, large and obese with a large belly. He had a large white beard and bald head. He honestly looked like Santa Claus, but his beard was always rough and unmaintained and he was always angry. I felt the elves had done something again. I joked with him about it, he laughed, and then went back to being angry again. He was quite a character, and I had grown to enjoy his company, though I am sure he didn’t see me in the same light. I was always there when something went wrong and he had to come back to the hospital. I can’t blame him. Who would be happy to come back to the hospital over and over again?
There was always something. His pain, his shortness of breath, his heart, his recurrent infections. Recently, he developed dysphagia (trouble swallowing) and the doctors recommended he stop eating and get a tube to feed him through his stomach. He refused. He was going to eat, and it didn’t matter what some two-bit 27 year old was telling him. It didn’t matter they all wore long white coats and were trying to do what was best for him. Hence, his anger. We didn’t listen to what he wanted. This decline coupled with his worsening kidney disease and diabetic neuropathy had recently, in the last six months, led to a severe infection of his foot due to uncontrolled diabetes. Unfortunately this infection continue to progress and eventually led a below knee amputation. He had grown even more angry since then.
I left the ER and started heading to the main hospital tower which housed most of the patient rooms. I decided to take the stairs as I was not getting much exercise and 5 flights of stairs at the time seemed like a good idea. I was young. Then it happened. Code Blue. Mr. J’s room. The blood drained from my head. I could feel my heart racing and pounding. I knew this patient, he was one of my patients, he was one of ours. I knew the family, I just spoke with his wife a few weeks ago. We all knew he was sick, we all knew something would eventually happen, but tonight? No way, not on my watch.
I was already half way there. I started running the rest of the way, up the stairs and down the hallway. I ran into the room, out of breath, to see the nurse standing over Mr. J doing chest compressions. What happened I yelled. The rest of the code team started arriving. My Senior Resident came running into the room a few seconds after me. The crash cart arrived and the round after round of epinephrine, atropine, bags of saline, chest compressions started.
I looked down, seeing Mr. J. He can’t be dying. What happened? This can’t be happening. I pushed the second nurse who was now performing chest compressions to the side, let me take over. Deeper, harder. She was getting tired, I could see it. The code team could not get the breathing tube down him, they tried a couple of times. “No, no, no,” yelled Alex, “just bag him, give me bit and we can try again.” I could see blood pooling out of his mouth into the mask. Suction I yelled, and the nurse suctioned his mouth and continued to bag him. I could feel pops as I continued to do compressions. It had only been a few minutes. Then more pops. I felt his ribs give away as I was performing CPR. The first time I had experienced that in my life. I felt the poor man’s ribs breaking as I did everything I could frantically to save his life. Was this torture part of what I needed to do to save his life?
Mr. J was not responding. We had pumped him full of adrenaline, pushed fluids, were pounding on his heart. Nothing. It was coming on 15 minutes. I looked at Alex, my resident. He had that look, Mr. J wasn’t going to make it. He looked at me, and I whispered back to him give him some more time. I think deep down he wanted to stop, but he also wanted Mr. J to survive. We all did. We kept going. We kept pushing through, hoping for a miracle.
The chances of him surviving this horrific event were looking dimer and dimer. Just then he lurched. Or I thought he lurched. Mr. J Vomited. All the food he was eating after he started feeling better. All the partially digested vanilla ensure he had drank with the yogurt. He threw up on me. The vomit covered the bed, covered me, drained down and spilled into the floor. The smell was awful, I started to gag, but kept doing chest compressions. My feet now slipping side to side as the floor was covered with vomit and we were all sliding. Nurses scrambled, frantically grabbing and throwing towels and blankets on the floor for us to stand on.
Anesthesia was called due to the code team not being able to get the airway. They again tried to intubate Mr. J, and were able to get the tube down after two more attempts. 17 minutes in. I had to step back, the smell was making me sick to my stomach and I was starting to get tired. More adrenaline, more medications. 22 minutes in. Mr. J was not responding. He was not going to pull through, we all could see it. Yet we kept going.
31 minutes in, Alex looked at me and at the scene. He had seen enough. We had put this poor man through enough. He asked everyone to stop. He said, “He has had enough.” Coming on 32 minutes with no pulse. 32 minutes of minimal blood to his brain, to his organs. “Leave him alone and let him die in peace.”
I stood there, defeated. Covered in vomit, my toes feeling very wet, not something I signed up for when I decided to become a doctor. In the back of my mind, I thought, die in peace? this was by far the furthest thing from the definition of dying in peace.
I walked out of the room, not making eye contact with anyone. I walked over to the nearest stair well. I let the door slam behind me and slid down into a heap. What had I just experienced? Probably one of the most horrific deaths. What had we put this poor man through? I screamed at the top of my lungs, sat there for 5 minutes, too shocked and enraged to even cry. I stood back up, went to take a shower and get new scrubs. I was forever changed.
I understood that a blissful and peaceful death is a gift. It is only given to a few. We just have to understand what we are being given and have the courage to act and choose to accept it.
I, with a heavy and humble heart, write this detailed description of what a code is. I do this to allow patients and families to understand what they ask for when they say, “Yes, I want CPR.” Most medical professionals know what this means. We know what we must do to try to save a life. We know that most individuals we code die anyways. But they die after we have put them through similar ordeals. But do patients and families know? Do families realize when you say “do everything” as your loved one is dying is robbing them of a peaceful death? Do you understand you are telling me to stand on top of your 90 year old grandmother doing chest compressions, breaking her ribs, jabbing tubes down her throat, putting multiple large IV’s in her, pumping her full of adrenaline that will make her feel as if her heart is going to explode? Do they realize the fluids we pump her full of makes her feel she is drowning? I do this knowing deep down, the changes of her surviving are extremely poor. And if she does survive by some miracle, she will never be the same person again likely suffering brain damage and organ damage. Yet, we continue to do everything because we don’t have the courage to tell families what they are asking for.
Do everything? Are you sure you know what that means?