Work in emergency medicine long enough and you get good at figuring out what patient’s medical problems are just by their appearance.
He had a pasty color as he was wheeled through the door. Anemic for sure. His abdomen was swollen. Liver failure is my guess. Probably GI bleeding. But he also had the blank stare of someone who was focusing on something other than the world around him. He needed help and he needed help in a hurry.
His blood pressure was low. His respirations weren’t keeping up with his oxygen needs. His focus was on getting enough air into his lungs. He was able to communicate in short sentences between his quick breaths.
“No chest pain.”
He had a history of liver failure due to chronic alcohol use. By the time he was able to get his drinking under control, it was too late. He had been in and out of the hospital for problems related to GI bleeding and for removal of the fluid from his abdomen. He signed a DNR order about a year ago, but his wife stated that he never had become sick enough where he might have to use it. Today was that day and he decided to rescind it.
We started out with BiPAP. That seemed to help a little. A repeat blood gas showed that his respiratory status improved slightly. However, his blood pressure was low, his hemoglobin was 6, his kidneys had stopped working, his abdomen was tense, and he had pleural effusions in both lungs. By no means was he out of the woods. We started him on antibiotics, gave him blood pressure medications, and ordered two units of blood.
His attending physician came to the emergency department to see him.
“He looks worse than usual. We need to send him to University Hospital.”
University Hospital is at least an hour away by ambulance. We called and they agreed to send the helicopter to come and get the patient. The only problem was that he needed to be on a ventilator for transport.
“No! No breathing machine!” was the muffled response from behind the BiPAP mask.
His attending physician helped explain.
“Listen, you’re too sick to stay here. We can’t help you here. You need to go there and your breathing isn’t good enough to send you in the helicopter without a breathing machine.”
“Then it’s my time.”
His wife leaned forward and gave him a shocked look.
“It’s my time.”
Tears streamed down his wife’s face as she tried to convince him to reconsider his decision.
A muffled “No tube. No transfer. It’s my time” became his canned response.
The attending explained all of the things that the patient needed to have done. The patient refused all of them. In a way, I admired him. He was in a staredown the Grim Reaper and he wasn’t blinking. How many other people who knew they would die within the next hour would have the courage to say “bring it on”? I don’t know that I could have done it.
So the nurse and the attending slowly stopped the patient’s medications, then his IV fluid, then his BiPAP. Without the hum of the BiPAP machine, the room went quiet. The patient and his wife held hands and looked into each others’ eyes … a picture I won’t soon forget.
I went about seeing other patients in the department, but I stopped in the room a couple of times to see what was happening. After 15 minutes, the picture changed.
The patient reverted to his blank stare. His eyes were fixed on the wall across the room. His air movement steadily diminished as his respirations became more and more agonal.
It almost reminded me of a macabre painting – a dark room illuminated by the spotlight overhead, the patient, his wife standing by his side crying while gripping his hand ever more tightly, and the attending hunched over while listening to the patient’s fading heartbeats with his stethoscope.
I went up to the patient’s wife and whispered in her ear.
“Talk to him. He can hear you.”
“What should I say?”
“Tell him something you want him to remember.”
She began crying harder. Between sobs, she started thanking him.
“Thank you for the wonderful life you’ve given me. And for our wonderful children ….”
I didn’t think it was my place to stand there and listen to the rest, so I excused myself and walked out of the room.
A short while later the door opened and the attending walked out.
“Time of death was 7:36 PM.”
I looked into the room and the patient’s wife was cradling his head in her hands and kissing his forehead.
Her eyes were red as she left with his belongings and his wedding ring. She stopped me in the hall on her way out the door.
“After I spoke to him, he squeezed my hand. I know he heard me. Thank you for telling me to talk to him.”
All I thought about after that was how much I couldn’t wait to go home and tell Mrs. WhiteCoat and my kids how much they mean to me … and how I wanted to write this story so everyone could do the same to their family members.
One day, you won’t have the ability to do so any more … and you never know when that “one day” will come.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.