Sudden Death - What to Do When Someone Dies

Excerpted from
Just Here Trying to Save a Few Lives : Tales of Life and Death from the ER
By Pamela Grim, M.D.

It's FIVE A.M. WHEN YOU GET THE CALL. Ambulance 18. "We've got a full arrest from Lake Village Nursing Home." Everyone groans and you groan too. "Eighty-two-year-old female, severe short of breath. Doc. she arrested, stopped breathing, just as we got here. She had a pulse but now we've got nothing..."

You can hear the banshee wail of the siren in the background.

"We've intubated her, and have a line established, normal saline and all. We'll be there in two."

You hit the transmit button. "I assume the patient is not DNR." Do Not Resuscitate.

"That's an affirmative, the nursing home says she's a full code." A full code means the whole enchilada, chest compressions, intubation, the pharmaceutical resurrection cocktail.

You shake your head while ram M., the nurse in charge tonight, raises a hand and says, "We know you have a choice when choosing your emergency department and we want to thank you for choosing Hope General Memorial Hospital." She drops her hand and walks away in disgust. Pam is rarely cynical like this, but Julie, who is standing to Pam's right, is the embodiment of peevishness. She throws a clipboard down on the desk. "Why do they even bother to do this? It's so stupid. Like we are going to bring back an eighty-nine-year-old full arrest. Get real."

"Eighty-two," you say, but you know she's right; everyone in the ER knows she's right. You glance at your watch and think, this shouldn't take long.

One of your classmates decided he wasn't cut out to be a doctor when, one night during his first week of internship, as he performed CPR on a patient, he found himself hoping that the patient would just die because he was too tired to take care of her if she lived. You, too, have had this thought more than once-the irony is that you never took it to mean you shouldn't be a doctor. You have always felt that death can sometimes be a release for everyone involved, not excluding yourself. Tonight, for example, you are hoping for something easy: a quick death.

There's an old saw: "It is the duty of a doctor to prolong life. It is not a doctor's duty to prolong the act of dying." You believe in it.

Everyone shuffles off to the code room. Pam, as charge nurse, commands the crash cart while you fiddle around trying to get suction to work. The sense of utter fatigue, that five A.M. slump that occurs at the end of every night shift, steals over you. You feel as if you are doing everything underwater-as if exhaustion has exaggerated the drag coefficient of air so that every movement, even breathing, has become a major effort. You abandon the suction equipment, fold your arms and sag against the cabinet, looking around, seeing nothing.

The ambulance doesn't take long to get here-you hear the backup signal, then the doors bang open. The paramedics, panting and sweating, sweep into the code room. One is doing chest compressions, the other is ventilating the patient. Firefighters maneuver the gurney.

"I told you guys to stay out of trouble," you grumble at Jack, one of the EMTs.

"Trouble loves us," he responds brightly. He's counting out chest compressions Lawrence Welk style, "and a-one and a-two and..."

Everyone moves to take over from the paramedics, transferring the monitoring leads, switching off on CPR. The respiratory tech takes over the Ambu bag. Julie climbs up to replace Jack for chest compressions. "This is so stupid," she observes once more.

You look down at the patient and then close your eyes tight. Full code! you wonder to yourself. How could anyone think this patient should be full code? There is barely anything human left to her. She couldn't have weighed more than sixty pounds, each bird-like limb bent, arms to chest, knees to belly-the fetal position except she's been fossilized there. The paramedics had a hard time just doing CPR because they can't get her to lie flat on her back. As you lean over her you smell that distinct odor, the odor of old age and of nursing homes, that curdled milk and rotting blood smell with overtones of decayed feces. You know the rest too, without even looking. The peg tube in the stomach, maybe a colostomy, an indwelling Foley catheter draining silt, and, always, massive decubitus ulcers. (Decubitus: from the Latin decumbo, to lie down.) These are pressure sores, great potholes eroded through the skin-sometimes even down to bone. They occur when someone lies in one position in a urine-soaked bed for months or years. As this woman probably has.

From the Latin... actually, from the Greek. It was Eos, you think. Goddess of Dawn, that fell in love with a mortal. She went to Zeus to ask for eternal life for her lover but forgot to ask for eternal youth. Eos realized what she had done when her lover's hair turned gray. She left him and he went on alone to age and age and age into all eternity. Eventually he shriveled up and became so small he turned into a grasshopper.

You shrug at the thought. Your fate as well, perhaps.

Pam must be thinking of the same thing. "Just kill me when I get like this," she tells you.

"What'd she get?" you ask Jack, meaning drugwise.

"She got three of epi and three of atropine."

"Hold CPR," you say, hand up. The patient is now connected to your monitor and you want to see the rhythm.

Flat line. Zippo.

"I feel like I'm not doing CPR," Julie says, "I feel like I'm beating a dead horse." She folds her arms, glaring at you, daring you to have her restart CPR.

You glance back down at the patient and the glance confirms your first impression: it's criminal to go on.

You raise a hand. "Anyone object to terminating this code relatively early?"

Julie glares around the room. No one else moves.

You check your watch. 5:38 A.M. In the hour of the wolf.

Code called 5:38.

The nurses are drifting out of the room when Father Minke, the priest on call in the ER this month, peeks in. "Am I too late?" he asks.

"Well, Father." You are peeling off your gloves. "I guess it depends. She's been declared dead, if that makes any difference."

"Okay," he says, paging through his prayer book. You look at him again, quizzically. You didn't call him for this death.

"Father, what are you doing up this late?"

He hmmms, distracted.

"Father?"

He looks up at you. "I was watching TV," he says, as if that explains everything. He goes to the foot of the bed, opens up his prayer book and begins, in an almost imperceptible whisper, his bedside prayer for the dying and the dead.

Everyone gets this, regardless of creed, if Father Menke is in the mood.

You stump away, back into the ER. Your job is the secular side of death.