In the ER

There are days I feel like I've not done much good. Belly pain after back pain sent home with no diagnosis and a hollow assurance that "nothing life-threatening seems to be causing your pain" will force you to doubt your previously unwavering belief that medicine is your life's calling. Television make-believe also serves to reinforce the idea that being a physician means running from critical patient to surgery, then back to the emergency department where you save lives one after another, hero one minute, saint the next. The truth of 30-hour calls and 10-plus-hour emergency shifts wear on your youthful vigor. My hair has become peppered with gray in the year-and-a-half since residency began. So when I feel like I leave a shift having provided real comfort and therapy, I am satisfied.

The night began conspicuously enough. A nurse was splashed with blood in the eye, and I offered her rapid HIV and hepatitis testing. With less than 10 patients in the ED on a sub-freezing evening in Akron dusted with snow, the night started to deteriorate after a trauma transfer of a 17-year-old girl ejected from her subcompact car during a motor vehicle accident. Two assaults of gentlemen enjoying the evening with the aid of adult beverages, a 25-year-old woman making her 28th visit to our emergency department for abdominal pain, and domestic assault with a hammer to the temple of a man whose girlfriend didn't appreciate his cheating ways made it a dubious night.

Near five o'clock a.m., my attending took a squad call. The paramedics were assessing a man who'd become short-of-breath in the night. He had known lung cancer and recently had fluid drained from his remaining functioning lung. He had called 911 when his four liters of oxygen at home failed to relieve his symptoms.

Our charge nurse approached me first. "Could you see the gentleman in room 32?" she asked. "His blood pressure is low, and he is short of breath." I agreed after finishing a conversation with a pharmacist currently on hold inquiring about switching an antibiotic for a patient with a drug interaction. With such a low blood pressure I asked that the patient be moved to a more acute room with monitoring capability.

Mr. "John Doe" was 80 and healthy, save his long-standing diabetes diagnosis, until this past December when an episode of dyspnea uncovered adenocarcinoma of his left lung, the most common lung cancer affecting non-smokers. Chest tubes, needles to drain fluid from his lungs, chemotherapy, and long stays in the hospital had filled his life for the past two months. Now despite his home treatment with oxygen, his dyspnea was getting the best of him. His family took me aside and told me that his family doctor had confided that he believed Mr. Doe had about a month to live. They also said he had a living will, but they didn't have the paperwork with them.

"Do you want me to shock your heart or put a tube in your throat and connect you to a breathing machine if your heart or lungs quit on us?" I asked.

"I don't want any of that. I'm ready" he replied confidently.

I filled out the paperwork and watched him reproduce an elegant signature born of eighty-years of life. I assured him and his family that we'd continue to do all the same things I'd do up to and until he needed intubation or cardiac defibrillation. I explained that Mr. Doe seemed to know exactly what he wanted and that I wanted to respect his wishes. A chest x-ray didn't reveal increased fluid or a collapsed lung, both relatively simple problems to correct. It didn't reveal pneumonia either. The easy answers were being rapidly eliminated.

Mr. Doe responded positively to fluids, raising his blood pressure to a level where I felt comfortable using pain medications to help his discomfort. He was in shock, a state where oxygen doesn't reach your body tissues, though, and I didn't have an easily correctable explanation. I tested his urine, discovered a decubitus ulcer from sitting on his backside, ordered blood work and a cardiac panel. We started antibiotics hoping to treat any infectious cause of shock.

Then I was called into the room. Mr. Doe had a short run of ventricular tachycardia, a cardiac rhythm that responds to defibrillation, the very modality he had asked me to avoid just minutes before. Mr. Doe responded to sternal massage from the nurse and came to, asking why so many people were hovering in the room. I discussed more directly then with Mr. Doe and his family the critical state of his heart and lungs, and despite his desire to return home, he begrudgingly agreed to stay in the hospital. I printed a copy of the rhythm for the medical record and placed it in the chart, starting an anti-arrhythmic to avoid a recurrence of the potentially deadly cardiac rhythm.

Then it happened again; V-tach. Mr. Doe looked ashen and wasn't responding. I ran into the room, putting a bewildered squad on hold during their presentation of a patient they wanted to bring to the ED for low blood sugar. We drill and memorize algorithms so that our reactions become automatic, so that we do the right thing even if we've not slept for twenty-nine-and-a-half hours. Everything in me wanted to shock Mr. Doe, but I remembered that I agreed not to. I also remembered a technique that had fallen out of favor because of lack of good data of its efficacy, the precordial thump. Mr. Doe had said nothing about hitting his chest. I cocked my arm, striking a blow to his chest, jolting his sternum with my clenched fist, the same way I'd seen my attending do once before and bring an elderly woman back from the dead as an intern. He gasped and I watched the monitor display the resumption of a perfusing heart beat. I smiled. The nurses patted me on the back.

I told Mr. Doe I thought there was a good chance he'd pass away soon. "What do you mean?" he asked.

"I think you might die soon." I replied. "Do you still want us not to shock your heart or put you on a breathing machine?" I repeated.

"Do you think I'll live another month?" he asked.

"No." I said.

"I don't want it then."

I called the intensive care unit residents involved in the case, hoping to admit him to the hospital for close monitoring. But I left the room feeling that Mr. Doe was nearing the end of his eighty years. I took Mr. Doe's sons aside and told them to call in other family members to say goodbye.

7:30 a.m. arrived and so did the next resident fresh for their day shift. It was time for me to leave for home. Another night shift awaited me in thirteen hours. I walked back into Room 2 where Mr. Doe and his gathered family waited for a hospital room. I took Mr. Doe's hand, explaining to him that my shift was over and that I'd told other nice doctors about him and that they'd be taking care of him now.

"You always take good care of me here, thank you." He said. "I hope to see you again."

"Me too," I replied, knowing it wasn't likely.

I left dumbstruck. My skills of intubation and cardiac life support were of no benefit to him. My medical knowledge seemed lame in the face of a dying man and his family. No algorithm explained what to do when a patient declines your life-sustaining modalities of treatment, but maybe the best thing I did that day was take the hand of a man, listen, and look into his eyes when I talked, telling the plain truth to someone who had lived his eighty years and was ready to accept the end of his life as vigorously as he'd lived those eighty years.

--Andrew Jacques ('05)