The First One

Let me tell you about the first one. 

This one particular lady was brought in under my care for having a mild heart attack, and was waiting for a cardiac catheterization (otherwise known as a dye test).  However, she had several other issues that made it unsafe to have this test, and required some medical stabilization.  (I’m deliberately being vague, in the interest of patient confidentiality). 

A week later, this poor lady had another heart attack, but one that required an emergent trip to the cardiac catheterization lab, where the cardiologist opened up her coronary artery that was causing all the trouble, and her EKG seemed to go back to normal, and her chest pain was pretty much gone.   Awesome.  My only wish for her was that we could have gotten her other medical issues under control sooner, so that her second heart attack could have been avoided.  Still, things seemed to be going well for this special patient of mine.

A few hours later, I got called to the Coronary Care Unit, with a sense of urgency in the nurse’s voice as she said “we need you in bed 3, right away.”   A first for me, I’d never been called to assess a patient urgently, they’ve always been stable, and I can just mosey my way to the patient without worrying too much.

I arrived in the CCU, to see my patient from earlier that morning, writhing in the bed, agitated and moaning with pain.  She looked very grey, not the normal pink vibrant colour that healthy patients always have, and wasn’t responding all that appropriately to verbal commands and to speech.  It was quite easy to figure out that something was very wrong with this woman, but the difficult part was figuring out what the issue was.

So, with the help of some other residents who were on call that night, we did several investigations, the first of which showed that my patient’s blood had become very, very acidic compared to what is normally acceptable.  So, based on that fact, she was electively intubated (a tube put into her airway, so she could be hooked up to a machine that would breath for her).  We brought her over to the xray department, wheeling her stretcher through the narrow hallways, and into the CT scanner, and back to the CCU again to await the results.

The Code

That’s when it really started.  While the other residents were attempting to get IVs and ART lines (special IVs that go into an artery and measure blood pressure in real time), I noticed her EKG starting to change.  When I became convinced (which was very quickly) that her heart tracing looked an awful lot like VT (one of the rhythms that we’re taught in first aid that an Automated External Defibrillator will shock), I mentioned it to the other residents, and checked her carotid pulse at the same time.  Nothing. 

I have taught, as a first aid instructor, and one of the changes that was made in recent years was the elimination of the pulse check.  Initially I thought that was ridiculous, but now I understand; the uncertainty attached to not finding a pulse is excruciating.  Nonetheless, for the first time in my career, I called “a code.”

The nurses rushed into the room, and put a hard, clear plastic board underneath my patient’s back.  I climbed up onto the bed, placed my hands on her sternum, and proceeded to administer chest compressions.  The first compression is always the worst, because it’s the one that breaks all their ribs.  I heard that awful cracking sound, and felt the vibrations right through to my shoulders, a sensation that haunts me even now, and brings tears to my eyes when I think of it.

But there was no time for tears then.  I counted, cycles of thirty, for 2 minutes.  No need to count, really, because she was intubated, and so ventilation and chest compressions happen independent of each other.  Still, it’s ingrained, and I counted until I felt my compressions were deteriorating, and I asked another resident to switch with me.  Once I had gotten down from the stretcher, it then became my responsibility to “run the code.” 

Keep track of the time.  Monitor chest compressions for effectiveness.  Give 1 milligram of epinephrine every 3-5 minutes.  Rotate people through compressions.  Check for a pulse every 2 minutes.  Rinse and repeat.  4 milligrams of epinephrine, 10 units of insulin, 3 ampules of sodium bicarbonate, 1 ampule of calcium chloride, a sodium bicarbonate infusion and 2 Our Fathers (which I said quietly when I wasn’t telling other people what to do) later, we checked the pulse, and she had a perfusing rhythm (meaning that her heart was effectively pumping blood around her body).

Right, so back to what we were doing: trying to figure out why this poor woman was suddenly trying to die.  By this time, the results of the CT scan were back, and our patient was bleeding into her belly, and had lost a significant amount of blood.  The collection of blood was putting pressure on her other organs, causing her bowels to become starved for oxygen, putting her into a medical condition called ischemic gut. 

So we consulted the surgeons, all of who said that this patient was not a surgical candidate, because she would die on the table.  “For medical management.”   So we tried to establish better IV sites for large bore needles that would allow fast infusions of various fluids.  A new ART line was needed, but we couldn’t seem to establish one in her radial arteries, which had been put into spasm by the number of times they’d been poked with needles. 

So we started giving her units of packed red cells (which is what we mean when we say a blood transfusion), fluids and medications to keep her pressure above 90 mmHg systolic.  Then we sat back and waited to see if all our interventions would help her to improve. 

A relatively short time later, 2 nurses burst out of her room, and called the second code blue on this patient in a single night.  So I ran the code again.  By the grace of God, this code was mercifully shorter than the first, and we established another perfusing rhythm in our patient.  Nothing short of a miracle the first time, much less the second time.

I hardly slept at all that night.  Terrified to leave the CCU for fear that I would just get to sleep, and my code pager would alarm, and I wouldn’t wake up, I took a chair and propped myself up across from this patient’s room, and dozed for 5-10 minutes at a time over the course of an hour.  When I finally left that morning, my patient was still alive, and I was full of hope that we had kept her alive with the possibility of a full recovery. 

First the patient, then the doctor

My patient was the first to go into shock, but of the physical kind.  When I left the hospital, and decided I was going to forgo sleep for another while and go straight to church, the stress of the entire night washed over me at once.  I fought back tears, reminding myself that the patient was still alive, and I had done everything I could.  I made it to the church, where I met my wife who was already there, got a cup of coffee, and we started to walk to our seats in the congregation.  I got a half dozen steps inside the sanctuary, and I suppose I had let my guard down enough by then that I was able to slide into emotional shock.  That’s when I broke down.  I walked out the back door of the sanctuary, wife in tow, sat down and sobbed. 

Until that day, I had never been prayed over.  I had prayed over others, and other people had prayed for me, but never over me.  Our good friend Ron, who had previously prayed for my salvation many years before I’d ever met him, saw my distress and came to talk to me.  He prayed over me that day, and I don’t even remember much of the prayer, but I do remember knowing that God was with me in that moment.  Then Ron said something that I carried with me for the days to follow: “God knew you could handle it.  He’ll never give you more than you can handle.”  I didn’t think I was qualified to handle what God brought my way that day, but God knew otherwise. 

I went home and read the sermon on the mount in the Gospel of Matthew later that day.  What spoke to me most on that eventful day was this:

“Therefore I tell you, do not worry about your life, what you will eat or drink; or about your body, what you will wear. Is not life more important than food, and the body more important than clothes? Look at the birds of the air; they do not sow or reap or store away in barns, and yet your heavenly Father feeds them. Are you not much more valuable than they? Who of you by worrying can add a single hour to his life?

And why do you worry about clothes? See how the lilies of the field grow. They do not labor or spin. Yet I tell you that not even Solomon in all his splendor was dressed like one of these. If that is how God clothes the grass of the field, which is here today and tomorrow is thrown into the fire, will he not much more clothe you, O you of little faith? So do not worry, saying, ‘What shall we eat?’ or ‘What shall we drink?’ or ‘What shall we wear?’ For the pagans run after all these things, and your heavenly Father knows that you need them. But seek first his kingdom and his righteousness, and all these things will be given to you as well. Therefore do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.”  (Matthew 6:25-34) 

I found a peace after reading this, feeling like I could face whatever the outcome was to be for myself and for my patient that was hanging on to life by a thread.  I prayed to God for her, knowing full well that she may not be alive when I came back to the CCU for my next shift.

Still Alive?

Return to the CCU I did, repeating to myself as I walked through it’s heavy double doors “Do not be anxious” and “God never gives you more than you can handle.”  I looked into the room where my patient had been, to find her still lying on her stretcher, with the sound of the mechanical ventilator essentially the only sound in the room.  I read through her progress notes from the night before, and found that she hadn’t required any CPR since I had left, but that she did need to be cardioverted (shocked with defibrillator pads) for a rapid heart rate that caused her to lose all her blood pressure. 

I spoke with the nurse who had worked with her through the night, and found that she had a list of problems that were new since I had seen my patient last.  She hadn’t made any urine in 48 hours, which meant that her kidneys had shut down, and her electrolytes had now begun to shift in a way that would require dialysis.  There was blood in her stools, which meant that her bowels had begun to break down from the previous lack of blood pressure and oxygen.  She was on multiple drugs to keep her heart going and her blood pressure at an acceptable level.  Her liver enzymes were at a level I didn’t even know were possible, indicating a condition called “shock liver,” which is another sequela of having no blood pressure for a period of time.  Worst of all, she had stopped responding appropriately, and even though she was no longer sedated, the only thing she could do was withdraw from pain.

So I consulted the surgeons again, but got the same answer as before – not a surgical candidate, would not survive the operation.  I consulted the kidney specialists wondering about dialysis, and received an equally dismal response – would not survive the drop in blood pressure associated with dialysis.

All that, combined with a CCU nurse’s proclamation that what we had done to this patient wasn’t in the patient’s best interests any longer, I knew then what God had in store for me that day.  I summoned up my courage, and asked the nurses to call the patient’s family.  So I had my first family meeting, just myself, one of the CCU nurses, and the patient’s close loved ones.  I explained that it would not be in her best interests for us to provide CPR if her heart stopped working again.  I emphasized the gravity of the situation, and I told them in very frank, honest words, that the only one who could save this patient now was God, because there was nothing we could do to cure her current condition.  To add to this, we all agreed that the patient that we had all talked with, laughed with, smiled at so few precious days ago, was no longer really with us.  So it was that between myself and the patient’s family, we decided that my patient would have her treatment withdrawn, and her life placed firmly in God’s hands, where it had been all along.    

I returned to the CCU, and informed the nurses there of the new developments.  I went into the room with my patient, while the family waited outside, unable to bear to watch what was about to happen.  One of the nurses took the patient’s hand, and I followed suit and held her other hand, which also had a set of rosary beads tenderly wrapped around her fingers.  A respiratory therapist disconnected her from the ventilator, and another nurse pressed the power buttons on all the IV poles that were running the drugs that were keeping her alive. 

I’m not sure if I breathed very much for the next few minutes.  I held her hand as I watched her face, and the cardiac monitor that hung just above her head.  She took very tiny breaths, and it looked for a very brief time like she might hang on for just a little while longer.  Within less than a minute though, her blood pressure tracing started to lose amplitude (meaning that the top and bottom numbers of her blood pressure started to get lower, and closer together).  I held her hand tightly as her body struggled to keep its grasp on this world, and she looked as though she were fighting with every last ounce of her strength.  The first to go was her breathing.  Her shallow guppy breaths ceased altogether, with the intermittent agonal gasp.  Her heart began to slow, and her blood pressure dropped to incredibly low proportions. 

And then nothing.  All the lines on the monitor became flat, and the heart tracing read “asystole.”  The nurse and I held her hands for another few moments longer, and then it was time for me to do the last part of my job.

I took off my stethoscope, and placed it gingerly on her chest.  I listened for breath sounds and heart sounds that I knew would not be there.  I pressed on her sternum with my knuckles and did a sternal rub with no response.  Finally, I took a flashlight and shone it into her blankly staring eyes, and her pupils did not move in response to the light. 

The next words out of my mouth: “Time of death, 11:27.”

I think my voice was devoid of emotion, but my eyes showed otherwise.  I could barely hold back the tears, but I managed.  And inside, I was a hurricane of emotions, beating against my insides. 

I left the room to go inform the family that this beautiful woman, a mother, a wife, and so many other things in life, had ended her struggle and had passed on.  I walked down the hall to the room where they were waiting, and stopped just outside the door.  Swallowing back my own tears, I took a couple of deep breaths, and then opened the door.  I simply said, “It’s time.  She’s gone.”  There wasn’t a need for any more words than that, but as I lead them to say their final goodbyes, I looked at each of them and said that I was sorry about the loss of their mother, their wife.

So I ended my role in the care of this patient.  I sat in the CCU, processing all that had occurred in the last three days.  I sat wishing that things had gone differently, that we had figured out her problem earlier, that I could have done something differently that would have saved this woman’s life.  As I sat withdrawn into myself, a mother and her young child were passing by my seat.  The boy, no more than 2 years old, looked at me and smiled and laughed.  I felt an overwhelming sense in the gaze of that child, that God was looking at me through his eyes, telling me that everything was ok.  There hasn’t been a child in the CCU before that day while I was there, and there hasn’t been since.  God works in amazing ways.

So now you know the story of my first one.  The first patient that I’ve ever lost, a woman that I don’t think I will ever be able to forget, whose memory I will carry as a burden and a blessing in my heart for the rest of my days.  Such is the life of a new doctor.  However, I am comforted by the fact that I have God on my side, for if God is for us, who can be against us?  Not even death.