She’s Back

There is a list of names in every Emergency Department that is well known to each individual that works and fuels that ER. And I’m telling you, it is never a good thing when you are the patient with the name that we immediately recognize upon popping up in our waiting room. For the most part, it indicates that you are chronically sick and chronically in need of emergency healthcare.  This runs the gamut of chronic illness.  You may have a weak heart that frequently gets overloaded and you end up short of breath with fluid filling your lungs.  This may mean you have failing kidneys that cause your electrolytes to go dangerously high as they cannot be filtered through your kidneys. This may mean you are an alcoholic with poorly managed diabetes coming in with abnormally high blood sugars. This may mean that you have mental illness that causes unmanageable panic attacks or leaves you feeling unsafe and suicidal.  This may mean that you have chronic pain and frequent exacerbations of uncontrolled pain.  This may mean you are addicted to narcotics and doctor shop for refills on pain prescriptions. This may mean you look for providers that will give you IV medications to give you the high that some pain medications can provide.  Whatever the reason, a familiar name in the Emergency Department is never a good thing.

On this particular day, I stepped into the chaos of an already bustling Emergency Department.  My colleagues mid-hustle, moving swiftly and deftly about the chaos of a busy day.  And there, waiting to be seen was a name I was all too familiar with. She is a mother, a wife, a member of our community, a person who struggles with mental illness and self-harm.  Triggered by events that send her stress into an insurmountable wall.  I don’t pretend for one second to know what she lives through on a daily basis.  I don’t pretend to understand these uncontrollable urges.  I don’t pretend to understand what it must feel like to come to the same emergency department, see the same healthcare providers, anticipating how they may react, judge, or act. I don’t pretend to comprehend how difficult, how humiliating, or how much courage that must take. What I know is that she comes into our emergency department on a regular basis with undeniable self-inflicted wounds that take a prolonged period to repair.

There was a time when I called for social services every time she came in.  She always gently declined their services.  Even when they came to talk to her anyway, she dodged and ducked out of their way.  She will assert how she has a therapist appointment right around the corner. That her therapist knows she is here.  That she is working through some very hard things.  I’ve called her therapist on occasions and she has corroborated what she has told me.  It is a difficult case, her therapist tells me.  During one instance, she was admitted to the hospital for a more intensive mental health evaluation and management.  It turned out, this only snowballed her mental illness and made her spiral deeper down a dark hole.

I’ve seen her enough to know she means it when she says she is not suicidal.  She often greets me cheerfully.  Talks about the weather, about her day and her week and her kids, as if she wasn’t there for self-inflicted injuries, but just for a regular slip and fall. In the same conversation, she gives instruction and suggestions on how she would like her repairs done.  I slow my breathing and try to wrap my head around how I should act.  This is not normal and I cannot help her normalize this behavior.  On the other hand, she is a mother, a wife, a member of a community that is deserving of basic human courtesies and respect.  She is a human being that is struggling.  Struggling so hard to just live a daily life accepting all the triggers and finding a way to assimilate them in a healthy fashion.

If I am being one hundred percent honest, it can be hard for us with patients we see frequently to not see them through a lens of judgment.  The patient with a weak heart that is on a low salt diet that eats ham and gravy over the holidays with his family.  The patient with failing kidneys that routinely misses one or two rounds of dialysis and is in need of immediate intervention to ensure his heart doesn’t go into a lethal rhythm.  The alcoholic patient that has uncontrolled high sugars and will continue to drink when he is discharged from the hospital.  The young patient with debilitating anxiety convinced he is having a heart attack that comes in monthly to have it checked and is in need of persistent reassurance.  The patient with chronic pain that comes in with abdominal pain regularly and requests large doses of narcotics.  The patient who has been to every Emergency Department in the local vicinity in the last week, accumulating narcotic prescriptions, who yells aggressively when confronted.  My patient who inflicts harm on herself on a regular basis and wants us to do nothing but fix her wounds.

It is easy to make quick judgments. It is easy to feel as if they are less than.  It is easy to push all the fault on their shoulders.  But who are we to judge?  We come from a place without heart failure where we can excitedly enjoy an unrestricted holiday meal when reuinited with our families without worrying about our breathing.  We come from a place without three day a week dialysis, a place where we are sober, a place where we are not crippled with anxiety, a place where chronic pain doesn’t have a vice grip on our lives, a place where we haven’t fallen to the addictive properties of narcotics, a place where we have never experienced or worked through mental illness that urges us to harm ourselves.

Who am I to judge? I am no different. I am a person with my own issues; I am just exceedingly lucky my issues do not lead me to the Emergency Department on a regular basis. So, I’ll work harder to challenge myself.  I am not here for judgment.  I am never here for judgment.  I won’t fault myself for being human, but I will check myself and know the bottom line is that my patients are in need.

They are in need.

Whatever that need may be, in the Emergency Department, we are better equipped to help them navigate it at this moment than they can do by themselves.

That day I took a deep breath.  I checked my judgment.  I repaired all of her injuries.  The Emergency Department outside her room was bursting at the seams, but she deserved my full care like everyone else.  It took me about an hour.  I looked her in the eyes, mother to mother. Wife to wife.  Human being to human being.  I asked her openly if there was anything else I could do for her today.  “No”, she said.  “That is all.”

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Never How it Should Be

Also published at: https://www.kevinmd.com/blog/2019/02/when-a-baby-arrives-dead-in-your-emergency-department.html

When a baby arrives dead in your emergency department

When a baby arrives dead in your emergency department

When a baby arrives dead in your emergency department

The world stops. You stop breathing. You are gasping for air.

She is limp, she is cool, she is pulseless.

Chest compressions on the tiniest 6 month old I have ever met are done with the finger pads of my index finger and middle finger. Quick, synchronized beats. I look at her blue, blue lips. It should never be like this.

Her eyes are fixed and dilated telling me that she has been like this for quite some time.

We stop and check for a pulse. No pulse. Chest compressions resume, we work to put a tube in her mouth to help her breathe. It is how I imagine a doll’s airway must look like. Stiff, tiny, a small pink flap over the throat.

There is a cool calm, a cool horror, a cool this-is-never-how-it-should-be. We work deftly to bring her back. But she is gone. She was gone before she arrived. She is gone now. She is gone.

There is hysterical sobbing heard by the family. Our insides are gutted. Our hearts, shattered. But the emergency department keeps pulsing, and we need to keep it afloat.

I meet my nice gentleman with the irregular heart beat in the 160’s. I check on my patient with the migraine headache. I discuss at length with my patient with the extraordinary high blood pressure and horrible headache the need to do a lumbar puncture to rule out a head bleed. She ultimately leaves against medical advice despite my coaxing and persuading. I evaluate a diabetic with intractable vomiting and abdominal pain. I see a sweet woman with severe pain who is now wheelchair bound and whose 80-year-old husband can no longer care for her at home. His shoulders relax and his eyes sigh in relief when I tell him I am going to admit her to manage her pain.

Throughout all of this, the weight of a dead 6 month-old suffocates me and holds me captive. My heart is in pain, and I am devastated, and this is too catastrophic to set aside to mourn later, but I do. I do, because this is what I do. This is what we do.

I’ll never forget walking into this. That sweet purple, lifeless, limp 10 pound baby on a huge white stretcher. The tiniest of chest compressions giving her heart an external beat. For those suspended moments in time, she was all of our child. We loved her, we ached for her, we didn’t want anything to harm her. We will all weep in our own ways over the days, weeks, months to come. Not even the usual armor that we constantly garner will keep these feelings at bay. This is one that will rattle us. Keep us jarred.

Because there is nothing natural

When a baby arrives dead in your emergency department

The Man That Scares Me and The Man I Love

Republished at: https://www.kevinmd.com/blog/2018/10/the-man-that-scares-me-and-the-man-i-love.html

There is a man. He is in my house. I don’t know where he came from. But he just came into my house. And now he is living there. And I am afraid of him. I do not know who he is. There is a man in my house. I am so scared. I don’t know why he came. But he is there. And he tells people he is my husband. And he is not! He is not! And no one believes me. Do you believe me? He is not my husband. I am so scared. Do you believe me? I am a good person. I have seven children. I am an honest person. There is something wrong. I know there is. I know there is.

 My patient. Age 68. She perseverates about this man. She is insistent. She was found wandering in the hospital parking lot. No one is with her. She wants to let out her fear in screams, but her voice is thin and frail. She is so frightened.

 They told me she has early onset Alzheimer’s dementia a year and a half ago. Last week I found her standing outside in the rain. A few days ago she had walked down to the neighbor’s house three doors down at 11 o’clock at night without a coat on. Today, she had an accident in the bathroom. She hollered for me to come to the bathroom and then hurried me away because she said she was going to clean it up. I went to check on her and she was gone. She had taken the car and left. She drove herself here.

 My patient’s husband. He is soft-spoken. His left hand tremors as he stands. His face is slightly glossy and his expressions are muted. I explain that she currently is confused. She thinks he is not who he is. She may be frightened to see him.

Sometimes she gets like that. She yells at me. “Get out! Get out! You don’t love me! You don’t love me! You son of a bitch! Get out!” It hurts my feelings. It does. It really hurts my feelings. And then sometimes she tells me she loves me. She thanks me for being her husband.

He speaks with a hollow, flat voice. He stares at me with foggy, pale blue eyes. His sadness and defeat lean into me. He tells me to wait for his son. His son is arranging for her to go to a center. He’ll have the details to tell me.

We’ve been married 44 years. We have seven children. And 16 grandchildren! She is my world. Can I go in?

 We stand outside her room, and his eyes fall on the closed door handle. I tell him that she seems frightened at the moment, but he knows best. If he thinks she will be comforted by the sight of him, he is more than welcome to go into her room. If he thinks it may make matters worse, he is welcome to wait in the waiting room. Whatever he thinks would be best for her.

Well. I think I’ll try, Doc. If she shouts and hollers and shoos me away, I’ll go outside. But if I go in quietly, sometimes I can talk to her and she is okay with me staying there. And then sometimes she warms up to me. I’m going to try.

 He is soft spoken but resolute. I peer through the crack he leaves in the door as he slowly inches in. He leans over the railing of the bed. He straightens her white crisp hospital sheet. She looks at him and I can’t hear their conversation, but that is relieving. He settles into the seat next to her side.

The next time I enter the room, the husband has left with family to rest and the patient’s son sits at the bedside. He loves his parents and he tells me that they are arranging for her to go to a memory care center.

He won’t be far behind her. He can barely take care of himself, let alone her. It’s just been too much for him, you know?

 The last ten days has been draining on their family. This seems like a quicksand downhill plunge. They have been in and out of hospitals. She was at her neurologist’s three days ago and there is nothing to do. Maybe these new medications will help. They will take time. In the mean time, they are chasing her in the rain.

I come back when the work-up is finished. I am relieved. She has a urinary tract infection. I am not relieved there is something wrong with her but I am relieved there is something fixable. You see, urinary tract infections can make you more confused than normal. Confusion can be the absolute only sign that you have an infection. And there it was. The last ten days of rapidly losing this adored wife, this beloved mom, this treasured grandmother, explained with a urinary tract infection. IV antibiotics were started and I admitted her to the hospital where she would not wander into the rain and she would get better.

I am not saying this is the end of their battle, that it won’t still be a declining slope, but I am saying that maybe they haven’t completely lost her the way they had thought.

I go back into the room to tell them. She is no longer tense and tearful. She is relaxed and loved and safe next to her son. I tell them about all the things I have done. Laboratory studies, CT scan, and that she has a urinary tract infection that is very treatable. She laughs out loud and all sense of that frightened woman I had met before seem to be drowned right out. She holds her hand up high in the air to give me a high-five.

Wow! Good job, Doctor!  So thorough! Thank you!  

She laughs joyously like I have just uncovered the eighth wonder of the world for her to see. I thank her for the first high-five of my day. We all chuckle together like old friends and it feels good.

There it was. A glimpse of her real self. All the charisma, all the spunk, all the warmth. There was the woman he has loved for 44 years. There is the woman that raised seven children with all the strength in the world. I see her now. I can see why this is so hard. To see her, then lose her, then see her. It would hurt my feelings too.

Hold close to those you love. Remember all you love about them. Tell them often. Let what you love imprint itself onto you, because you never know which way life may turn.

 

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Therapeutic Tears

Also published: https://www.kevinmd.com/blog/2018/05/a-doctor-cries-therapeutic-tears-with-her-patient.html

He wasn’t particularly likable on first encounter. He wasn’t apt to answer questions asked. He had a long pause and a long drawl and a tangential, winded story–and back story–all of which he was bound and determined to tell to its detailed completion. With an irregular heart rate in the 170’s and a respiratory rate in the 30’s, I tried to steer him in the direction of concise answers so I could obtain as much information as possible and do my job. This is an emergency. He is an emergency. An emergency who had waited until the last possible millisecond; we did not have the luxury of time.

But he was not to be rushed. My mind raced around his long pauses. My hands flitted around. Feeling his pulse, feeling his distended abdomen. Feeling the smoldering, red, hot cancer that took over his right thigh. I had never seen anything like it. It took my breath away and chilled me with impending fear of the extent of disease yet to be uncovered.

I tried to redirect him, but each interruption was met with a pause, and an indignant return to where he had left off in his storytelling.

It had been three years since he found out. Then, it was just a small bump. They told him it was cancer. It was easily covered up with clothing and easy to deny. He muffled it’s pervading presence with his stubbornness. He was indignant. This wasn’t happening. But it continued to happen. With or without his permission. It grew and grew and grew. And now, it was an undeniable monster. Growing on his thigh, in his liver, in his lungs. Filling up all his space, causing him to take staccato, labored breaths. Fighting to steal some room for oxygen every moment of his days.

His heart medications had gotten mixed up, confused, or refused. It was hard to completely tease out what had happened, as he wasn’t ready to be completely forthcoming. His stories took us farther away with every follow-up question asked. Now his heart worked in an overloaded chaotic state.

Infection had found its window of opportunity and seeped its way in to make sickness sicker—his organs on the cusp of failing.

His last name ended in an “-er”, like “Tyler” or “Kramer”. I brought the consent form for the procedure, he turned his head sharply towards me; we were practically nose to nose, as I had leaned in close so he could hear me in his good ear. “That’s not me. My name has no ‘S’” he said. I looked at the name I had written a top the consent form. I had mistakenly added an “S” to the end of the “-er”, like “Tylers” or “Kramers”. “You’re right”, I said. He gave me a gruff, indignant grunt.

We did what we could to stabilize him. I prepared for a procedure. “Have you done this before, Doc?” He looked suspicious. “No.” I said resolutely. “But I just looked it up on YouTube, and it looked really easy.” He was startled and appalled. I winked and smiled. “Oh, you got me. You got me good. That was good.” He let out a bellowing laugh like a man with all of his breath and strength. It filled the room. We both needed to share that.

I spent my time in Room 7 with him. Fluids, antibiotics, labs, imaging, procedures, talking. I softened. I grew to see his heart. His light. And I grew to like him very much.

I ultimately admitted him to the hospital. He may not have too much more time.

The next day was a day off clinical work, but I was at the hospital for meetings. My mind settled time and time again on Mr. “-er” with no “s”. I wandered between meetings up to his hospital room.

It took him a second to register who I was. My hair was down, and I wore normal clothes, not scrubs. “Oh hi Doc. Well, what are you doing here?” He asked breathlessly.

“I was just thinking I wanted to see how you were doing.”

“You want an update? Well, I can’t says it’s looking good Doc.”

He recounted his last 24 hours.

“I think I waited too long, Doc. And now my wife, you know. She’s home. She needs someone to take care of her. So, you know. We have to figure out how to tell her. My son was here, you know. He slept here last night. You just missed him.”

We sat for a long time. I watched his monitor. An irregular fast heart rate still in the 140’s. I listened to the rapid jagged, sharp breaths he sucked in and out.

“This must be tough. You have to remove yourself. You can’t let yourself feel. You see terrible things. All the time. But you have to Do, not Feel. It must wear on you.” In a moment about him, he made it about me.

“Well,” I said. “I just want you to know you have touched my heart.”

We cried. That awful stifling cry where so much needs to come out of what feels like a pinhole. I gripped his forearm with its weathered, dry skin. My finger scraped the edge of the medical tape that held his IV in place. He patted my hand with his other hand until the blood pressure cycled and forced him to straighten it out.

“Oh Doc. Thank you. For your therapeutic tears. They are warming. You worked last night, and now here you are. Right next to me. What a doc you are. What a doc you are.”

He lay with his eyes closed. Tired. Silent. Just his labored breathing.

Mr. “-er”, no “-s”, you are on my mind. Know that I’ll be here. Right next to you.

How Was Your Shift?

Also published: https://www.kevinmd.com/blog/2018/03/emergency-physicians-shift-really-went.html

She is 61 and she can’t help but smack her lips together repetitively. She has no teeth and the curvature of her spine makes her a miniature version of what she once was. Her frizzy hair is a purple-gray tone, and there are dark particles of something in the knots alongside her left temple. Her clothes are too loose and there are food stains on her shirt. The ambulance arrived at her home and there were pills strewn all over her floor and scattered pill bottles. She tells me that it wasn’t her. That someone had been in her apartment. That they were putting different pills in those bottles that weren’t hers. That pills were showing up on her floor. She was being followed when she went places. Her lips smacked harder as her anxiety mounted. She had to flush all the pills down the toilet because they weren’t her pills and so she didn’t have her own to take.   I ask if there is family I may call.  She stares back at me with hollowed eyes and does not respond.  She had just been released from the hospital a week ago for paranoid thoughts, but it is clear she will need to come back in.

He is 70 and his anxiety is like a storm cloud exploding in the room. He is overwhelmed because he cannot pay the bills and someone has stolen his identity. His furnace is broken and he is afraid the pipes will explode. He is concerned there is a carbon monoxide leak in their home and they are all being poisoned. At times he cannot speak because he is so overcome with his panic. He stutters and spits and cannot get the words out. I hold his hand and rock it back and forth as if to relieve the tremors that riddle his body.  I tell him it is okay over and over as I hold on; at times he appears momentarily calmed and is again able to speak until the next wave of emotions takes prey over him. His family arrives, and there are tears of fear, pain and love filling their eyes. None of this is real. No one has stolen his identity.  There are no broken furnaces and no carbon monoxide leaks. He paces at home and cannot eat or sleep. They have even called the fire department to the house to prove to him that there is no carbon monoxide leak. But it has not helped. These delusions have become his reality.

He is 57 and drinks every day and lives on the streets. He comes in one to two times a week for pain. Sometimes, he says his pain is so bad he wants to shoot himself. He says he has guns at his son’s house. This time he said he fell and his hip hurts. I help him take his pants off and he smells of urine and stool. Where can he go to take a shower? There are no bruises, scrapes, or cuts, but I x-ray his hip and there are no fractures. He says he won’t actually shoot himself if he can have a sandwich and bus tokens to go. He asks for a sandwich and bus tokens with every visit. He says his pain is 10 out of 10 and immediately falls asleep. It is the warmest and quietest place he will sleep until he comes back next week.

He is 20 and he overdosed on heroin. He was not breathing when the ambulance arrived. They gave him medication and resuscitated him and now his heart is racing and he looks bewildered as if he is on fire with anger. He says he knows it is dangerous. He has seen his friend dead in a car from a heroin overdose with the needle still in his arm. Maybe this is his rock bottom. I ask him if he is ready for me to help him get help so he doesn’t die too. He was really close this time. He says he understands what I am saying and he appreciates it. He says he is ready to stop, but he just doesn’t need help today.

These were four people I met on my evening shift last night. There are endless more stories like theirs. I don’t know where they were before they got to here, but I know life has not handed them anything. Their days are constant, steep uphill climbs. It may be addiction. It may be mental illness. It may be violence. It may be homelessness. It clasps its grip around them and won’t let them go. Day to day it swallows them and pulls them back down deep. There is little voice that advocates for and represents them. There is endless judgment that looks down upon them.

Friends and family will ask me how my shift went. I often don’t know what to say. Sometimes I feel I can help and do great things. Sometimes it is a vat of endless hopeless stories in a system with limited resources that continually seems to fail in one way or another. We will keep showing up and keep doing what we can, but it certainly is not enough.

A Love Story

Most love stories we see in the movies begin with a young man, a young woman, a chance encounter, or these days—maybe a swipe right on an online profile. But the greatest love stories are those that go untold. And this love story—this is one of the greatest I have had the honor to witness, if only for a few hours of their story.

She started with her confusion four months ago. Initially, it started as small things that most would not have noticed. A misplaced purse. Forgetting where the car was parked. Forgetting to mix the eggs into the cake she was baking. Nothing any ordinary person hadn’t done. But soon it turned into something more, he explained.  Getting lost in their apartment. Realizing she had opened the closet door instead of the bathroom door and the shame that followed that he couldn’t shoulder for her. The full out heaves of tears he couldn’t calm when she couldn’t find the bathroom after all. The heart ache of watching her grab armfuls of clothes from the closet and place them on the floor with such purpose, knowing there was only a mass jumble of thoughts and hysteria behind her frantic actions. It was a test of stamina to care for her, to look after her, to help her find the way in this narrowing, dark tunnel of her mind. It tired her too. And she slept. She slept after breakfast, she slept after lunch, she slept after dinner. Her waking hours became so sparse, but when she was awake, it was so filled with hyperactive conviction and activities that were seemingly purposeless. He would spend her sleeping hours placing all her shirts, pants, and dresses back in the closet. Washing stains off her clothes that she had spilled soup on. Salvaging what he could out of the trash of the oranges he bought yesterday that she had thrown away.

And soon, she lost her ability to dress herself. And it angered her. With such frustration, she would pick a dress, throw it on the floor, not knowing how to put it on. She would pick something else out of the closet, throw it on the floor, acting as if it wasn’t that she didn’t know how to put it on, but that she no longer wanted to wear it. Yesterday, she settled after picking a towel, laying it neatly on the ground, and with a satisfied content look, declared that this towel was in fact the dress she had decided to wear that day. He told me this, then fell into silence; keeping his eyes locked on my reaction, as if he couldn’t believe his own words, as if he wanted me to tell him they were not true.

He shared most of these things with me in rapid succession, with the same low, quiet, monotonous voice. His eyes tired but gentle; he spoke with such tenderness and love for his wife. This was a love that had grown over 51 years of marriage. Four months of hardship was worthwhile so long as he still had her.

She lay in the hospital bed with her eyes closed. I talked to her softly as I examined her. He chuckled at me, “you know she is probably stone cold asleep, don’t you?” She awoke when I sat her up to listen to her lungs. “Marty?” She said, startled by my presence. “Yes, May? It’s okay. It’s just the doctor. She is just taking care of you.” “Hm.” she grunted as her shoulders relaxed.

Last night had frightened him. “It scared me the way she was acting.” For the first time, he had seemed to slip from her mind. It had been different when it was the location of her purse, the location of the bathroom, or even how to put on her pants. Last night, she couldn’t remember him. She had asked for her pain medication, and when he gave her only one tablet as prescribed, she had become upset. Looking straight at him, she had said, “I don’t know why Marty wouldn’t give me the whole bottle so I could take what I want. He would only give me one tablet! ONE tablet! Can you believe him?” she had shouted at Marty. She proceeded to ask him to call the police, as there was a man in their home. She tried to leave the apartment without her shoes on with the car keys in hand. “And she doesn’t drive. She’s never been like this. It scared me.”

They met 60 years ago in fifth grade. They spent much of their adolescent years getting to know one another, and at the age of 20, they married. They spent the next 51 years married, 20 of those years married with multiple sclerosis grabbing a hold of her and settling into their marriage with them—an unwanted, dreaded third wheel. There have been good days and bad days, early on the good days outnumbering the bad days and making them tolerable.   These days, the bad days like a storm cloud ravaging all their days. There are days with falls. There are days with anger. There are days with forgetfulness. And every day that slides by, he tenderly holds onto the girl he met all those years ago. His one love.

I walked into room 14 of our emergency department, 4 hours into their visit. I found him sitting still next to her bed holding her hand in silence. The TV off, her eyes closed, the lights dimmed. Her presence—even in these dark days that have consumed them, even when he is losing his ability to care for her in the way he has for 51 years—her presence still his greatest comfort.

Where they go outside of the doors of our emergency department will be a new chapter in their lives. Their story is one of the great love stories that deserves to be told. A love that knows no end.

Beyond The Final Breath

Republished at:  https://www.washingtonpost.com/national/health-science/we-didnt-save-his-life-but-we-didnt-disrespect-him-either/2017/02/03/74612afe-d1f6-11e6-9cb0-54ab630851e8_story.html?utm_term=.9e665c02ec43

Republished at:  http://www.kevinmd.com/blog/2016/12/didnt-save-life-better.html

“Well?  Did you save him?” “No. We did better than that.”

He came in pulseless. The machine performing chest compressions with the rhythmic thud, thwack, thump. His ribs heaving under the force of the compressor, keeping his heart artificially beating. The plastic tube secured in his airway forcing puffs of air to inflate his lungs.  His skin slightly purple-gray, on that narrow brink between life and death. His eyes like speckled round pieces of glass, with fixed pupils, staring nowhere.

Our team was assembled, prepared, ready. We worked deftly with experienced hands, our focus and determination fueled by adrenaline, a synchronized team, we worked side by side; this was our life to save and we were going to do everything.

But his glassy, fixed eyes spoke to me. As we regained a heartbeat, and we halted the chest compressions, and our adrenaline settled–here he lay, not out of the woods, but heart back from a standstill. His glassy eyes told me his heart was back, but his life of living was gone. The life that laughed, that smiled, that held his wife’s hand–there was no amount of life saving measures that could bring that part of him back.  We didn’t know how long ago he had stopped breathing. But it was long enough to have robbed him of his mind, his memory, of everything that made him that man his family loved.

His wife and only daughter arrived. I left him in my able teams’ hands and sat down with them. I looked them in the eyes. I told them the story of his final hour of life, from the perspective of his fighting, beating heart.

His heart was here with us, but his  brain had gone too long without oxygen before we could reach him. He would never walk out of this hospital. They listened to my words.  Words spinning and exploding beyond comprehension. They nodded their heads, as if to ask me to keep talking.  So long as I was talking, we didn’t have to move.  Tears were inevitable. It was so sudden. How could they be asked to make a decision of whether to continue with the resuscitation or to just let life walk its final march.

Yes, this was about them, but this was ultimately about him. What would he want? It is true it was sudden. It is true it is the toughest decision anyone will make.  But with the return of his heartbeat, the decision to continue resuscitation is as big, as active a decision as it is to stop all aggressive measures and let him be comfortable. These are both big decisions with big paths for us to travel down.  I needed them to understand that this wasn’t their decision to shoulder. It was their time to respect–in the most selfless of ways–the man they loved.  To step outside themselves, slip into his shoes and honor his wishes in the greatest way possible.  What would he have wanted if he saw himself in this moment?  Representing him in this way is a responsibility no one cares to bear, but this final act is the biggest, most giving way they could love and honor him.

His daughter immediately said, “oh, he would want none of this. He would want you to stop.”

They stood by his bedside. We withdrew all aggressive cares. We turned off the beeping monitors, we stopped artificially putting oxygen in his lungs, we turned off all pumps, we covered him with warm blankets, we let him be comfortable with his wife holding his hand for his final minutes, and his daughter stroking his hair.

And that’s how he left us.

Did we save his life?  No we did not.  Not today.  We did better than that. We upheld our promise to continue to respect his wishes beyond his final breath.