Post Cable Day #2... death & rebirth

i worked last night after nearly a week off... Even after the span of merely a week, you need to see a few tough patients to shake the dust off. Fortunately for me, a familiar barrage of patients with inexplicably chronic abdominal pain, gastroparesis, and chronic pancreatitis flooded in to help sharpen my clinical acumen and test my resolve. In the midst of wading through them, i heard the secretary's shrill voice, "we need a doc to room 18"... i was called to a narrow exam room with a morbidly obese, elderly woman being wheeled in by EMS after a sudden cardaic arrest. She had just completed an outpatient CT scan of her chest and abdomen. In fact, she had been transported to the hospital, completed the scan, and was being loaded back into the ambulance when she suddenly stopped breathing. I rushed to the room, yelled for the story, and called upon the ACLS algorithm - monitor, pads, IV, IV fluids, Epinephrine, and most importantly, more help...

The paramedics explained that she had come from a nursing home for this study, and that she had "looked great" just a few minutes ago. I was irritated. Everyone looks great in the moments before they arrest. Ultimately, they said they were only transporting her and knew nothing about her. She lay there with eyes already glossy and a large, thick mass of tongue half-protruding from her mouth. Her chin was swimming in the girth of her neck. Fortunately for me, she already had a tracheostomy, a hole carved neatly through the midline of the neck into the trachea, allowing patients to be ventilated using a machine. As we initiated the code, we flooded her body with medications: Epinephrine, Vasopressin, Calcium Chloride, Sodium Bicarbonate... I thought about the irony of instilling her with preservatives to stave off death. As my mind raced through the potential reversible causes, I took her in... I remembered her from months earlier, a jovial woman presenting with a chronic cough and breathlessness. She had come into the ER one night after getting her hair done, tight bands of white corn rows laced to her scalp. I remembered a deep, smoldering smile. Tonight, her corn rows were lines of unravelling, wild fibers, her chest exposed, being thumped with compressions, her generous abdomen spilling over the stretcher. She lay motionless and still. Her face came to look like so many of the faces I had already seen, vacant, where the flicker of life was already extinguished.

Her body habitus made it hard to find a reliable pulse. At first, she responded to our heroics. I used a doppler to confirm a distal pulse. At about 20 minutes, we regained a reliable pulse with a very low blood pressure and initiated vasopressors, medications to force the heart to beat harder and push more blood around the body's vital organs... As in many aspects of life, pushing things uphill only gets you so far... Simultaneously, i asked one of the nurses to pull up her CAT scan. The scan showed a body riddled with cancer and effusions, collections of fluid in every possible body cavity - her very organs weeping from her cancer. As I turned back to face her, we lost her pulse, and again resumed CPR. We continued on for nearly 40 minutes to no avail. Finally, I stepped out of the room and told her daughter what she already knew. Her mother had said goodbye... i couldn't help but think that she wanted to show us all, family and physicians, how far her cancer had spread... so there would be no lingering doubt, when she finally said farewell...

i called her primary care provider who was stuck with disbelief. i hung up with his voice echoing in my head, "she was doing so well...".

i came home spent and went straight to sleep. This morning, i fished out the bottle of generic vitamins I bought a few weeks ago and never opened. I popped one in my mouth and chased it with a glass of water. I took our dog to the dog park. I've been listening to music again. And to NPR. And finally, after a long hiatus, last night I started reading again...