This month’s Passionate Geek and Power of Art are a little different – they are tied together. When Rosemary offered to write this for me I wasn’t sure where they’d fit, but now that she’s written them I know they belong in these features. It is a fair amount longer than what I normally post, and it is quite a bit different from the other Passionate Geek and Power of Art posts we’ve had, but they fit my vision of both of these features perfectly. Please take the time to read this (and the installation that will come next Wednesday), even if you skim through some of the medical talk (a lot of it went over my head) it is a powerful read.
In the internet world Rosemary can be found sharing about books at earthscorners, but by day (or, until recently, by night) she is a nurse practitioner at a mid-sized hospital in a mid-sized state. The only things she loves as much as medicine are theology and literature.
Midwife to the dying
I’ve caught one baby in the crook of my arm, and I’ve birthed another myself. Two births, and I remember both clearly. But I’ve midwived more deaths than I can count. My closest friend once told me that I had — I will not be able to reconstruct his words exactly — a compulsion to stand on the border between life and death, like a gatekeeper, turning some aside and helping others pass.
I remember balking at the word compulsion (or maybe he said ‘obsessive desire’), but he’s not wrong. Dying is inevitable, and inexorable, and it can be done well or at can be done badly. Dying is an experience. It is the last experience anyone ever gets to have, and it deeply, deeply upsets me when it goes badly.
In medicine it often seems that preserving life is beyond us. There are miracles, yes, but they are few and far between and seem almost drowned by the tragedies. What is almost never beyond us — when patients, families, and providers are all on the same page — is to ease suffering at the end of life.
I want to tell a story of one of the worst deaths I’ve witnessed, and then one of the best. Both will be heavily fictionalized composites because, obviously, I can’t discuss patients on the internet. From these stories, I want to talk about how we can make bad deaths into better ones. I want to talk about death as a part of life, one of the only parts we all share, one of the underpinnings of our common humanity.
Part One: The bad death
Marian was dying. She had been dying for years of congestive heart failure, but she was dying now more acutely. Her dementia had advanced so far that she could no longer eat. I met her post-op of a feeding tube placement. I wasn’t sure how on earth her husband had convinced a surgeon to place one.
She was a thin elderly woman and her white hair had been carefully combed. Her right hand, manicured, lay on top of the bedspread; her left hand had been placed in a soft restraint — tied to the bedrail with a cloth — because it was the only way anyone had been able to stop her from pulling out her feeding tube.
She wasn’t pulling now, though. She was ninety and very frail. She was listed in the computer as a “full code:” her family had said that they wanted everything possible done to keep her alive. I had been called because “everything possible” was about to start unfolding.
The first thing I noticed upon walking into the room was that her eyes were half closed and she was breathing shallowly, rapidly, in a pattern that was immediately and ominously familiar to me. The nurses had noticed, too, and that’s why I’d been called. They’d already placed a nasal cannula for oxygen on her, one of the high-flow cannulas that can provide up to ten or so liters a minute.
Before arriving I’d ordered a stat portable chest x-ray; the tech had just finished as I walked up. I looked over the tech’s shoulder and she enlarged the image for me. I never, ever, get tired of the magic of a portable x-ray machine. There, on the rolling machine’s big screen, was a picture of my patient’s chest. It’d be crisper if I called it up on one of the radiology workstations scattered around the floor, but for this, I didn’t need crisp. I winced and then tried not to wince; the patient’s family was sitting in front of me.
Air is black on an x-ray, and lung space should look very black indeed, allowing for the delicate tissue of the lungs themselves and the lovely branching pattern of the pulmonary vasculature. Fluid in the lungs — whether infectious or from other sorts of fluid overload — shows up white. Her entire right lower lobe was white — consolidated is how I’d describe it to a colleague. I was guessing pneumonia, from the pattern of it, but she did have that history of congestive heart failure so I wouldn’t entirely rule out CHF exacerbation, either.
I nodded to the family and briefly introduced myself — I’m Rosemary, I’m from the medicine service, the nurses called me because they were worried about M.’s breathing. Then I listened to Marian’s heart and lungs, untying her wrist and rolling her from side to side so I could listen to her lungs more clearly by placing my stethoscope on her back.
Her heart was regular but very quick — tachycardic. She’s taching away in the 120s, I might say to a nurse. I did not hear a “gallop,” an extra heart sound that sometimes can be heard in heart failure. Her left lung was clear in the uppers. A “clear” lung, listened to with a stethoscope, makes a pleasant rushing noise as air moves in and out of it, like the noise in your ears as you coast downhill on a bicycle. That lung was, however, diminished in the base. She was breathing too shallowly to effectively move air in and out of it. Her right lung was even more quiet in the bases. Here and there I heard faint crackles — that really is the technical term — that suggested fluid in the airspace, bubbling as her breath moved through it. I hadn’t heard any crackles on the left.
Marian’s primary nurse handed me a brown paper towel that she’d scribbled some vital signs on. BP 86/40 RR 40 HR 116 O2 84% RA, up to 92% 6L/NC. T 38.5. Those were not reassuring numbers, though granted the heart rate was slightly less rapid than I’d guesstimated by auscultation. Slightly.
“Thanks,” I told the nurse, who was named Kris and with whom I got along particularly well. “I’d like to hang a liter bolus, LR to gravity. If you could ask a tech to draw some labs for me, please? I want a CBC with diff and a lactate on ice. Oh, and two sets of blood cultures. And page respiratory for a stat ABG?”
“Sure,” she said, and went looking for the tech. Once she had left the room everyone turned and started at me. Everyone besides the patient, that is. Marian was still gasping for breath, her nasal cannula probably doing very little as she breathed through her mouth. But her husband was there, and someone who looked like a daughter, very red-eyed in the corner. A younger woman was present, too. A grand-daughter, I guessed.
“I think she has pneumonia,” I told the room at large. I more than thought; I was almost certain. But I tend to hedge with these things because it is always possible to be wrong. “I’m getting a few labs to check.”
“How could she get pneumonia?” her husband asked, almost angrily. “No one here has been sick.” Apparently he was the spokesman. There’s usually one. I addressed the rest of my comments to him.
“Well,” I said. “She has a feeding tube. That’s an awfully common complication of feeding tubes. The formula sometimes bubbles back up the esophagus and into the lung, and it breeds bacteria there and causes an aspiration pneumonia.”
“Aren’t you going to give her antibiotics?” he asked.
“Yes,” I said. I would probably prescribe two, in fact; pneumonias picked up in a hospital are generally nastier than those picked up outpatient. Everyone has prescribing habits, and for an HCAP — in medicine there are acronyms for everything, and HCAP is healthcare associated pneumonia — I would typically write for piperacillin-tazobactam and ciprofloxacin, both IV. If she had any history of methicillin resistant bacteria documented in her chart, I’d add vancomycin, too. “Yes,” I said again, “but I want to let you know, she looks really very sick.”
“Do something, then!” he demanded.
“I will,” I said. “But I’m worried about her. I think . . . you know, she’s ninety, and I think there’s a good chance that despite everything we can do, she won’t pull through.”
“A chance is still a chance,” he said. “Are you just going to let her die?” The granddaughter was sobbing openly at this point; her mother had an arm around her shoulders and a tissue clenched in one fist.
“No,” I said. I looked for a chair but there was nowhere to sit. I got scabies once by sitting on a patient’s bed. I sat on the radiator, instead. “No, I won’t just let her die. But this infection looks pretty bad. I’ll know better once I see the labs, but this morning she was breathing normally and her vital signs were all stable. Now she is breathing very, very quickly, her blood pressure is dangerously low, and she has a temp. I’m going to give her a whole lot of fluid through her IV to bring her blood pressure up and her heart rate down.”
I had no choice but to give her fluid; a dropping blood pressure can kill someone pretty fast. Her heart failure complicated this decision, though. Giving her that much fluid all at once could overwhelm her failing heart until her lungs flooded with the extra fluid, further worsening her breathing. That would kill her too, though more slowly, which is why I was choosing to give the fluid. If her lungs became fluid overloaded, I could try to diurese her — remove some fluid by giving her a medication to make her pee it out. But that medication would also drop her blood pressure again. I did not try to explain all of this to her husband. I didn’t know how to start.
“I’ll also give her antibiotics,” I went on, “and when respiratory therapy comes, they can tell me more about what her breathing is doing.” Respiratory would do that by inserting a small needle into the radial artery and drawing off a specimen of bright-red arterial blood. Arterial blood, unlike venous blood, can tell us exactly how well-oxygenated a person is, among other things.
“Then,” I went on, “After respiratory sees her, depending what her labs look like, I might put her on a BiPap. That’s a breathing machine — it’s not a ventilator, more like a mask, like what people wear for sleep apnea?” I waited for his nod. Most people are used to what a CPap machine looks like, these days. A BiPap is very similiar.
“The BiPap can help breathing a lot. But if all this doesn’t work, we’d be looking at going to the intensive care unit, and I have to ask — are you sure that’s what she would want? She’d be hooked up to tubes and they’d put a tube down her throat, too.”
Her husband stood up, turning red. “Of course that’s what we want. You just want to kill her! You doctors are all the same! You don’t want to take care of old people; you just want our money….” he sat down again, abruptly, and started to sob. I crossed to him to sit on the bed, scabies and all, and I took his hand. He let me.
“I’m a nurse practitioner,” I said irrelevantly but reflexively. I don’t like being confused for a doctor, though I always am. “I want only what’s best for your wife. If you want us to do everything, we’ll do everything, I promise. But I just — I don’t want to lie to you. She looks really, really sick.”
He sniffed and patted my hand. “All right,” he said. “I trust you. But please do everything.” I nodded and left the room.
An hour later, the critical care physician was not best pleased with my phone call. I enjoy our working relationship, but Dr. Lupescu is an irascible man. He’s worked straight nights — 1900 to 0700 — for as long as I’ve worked here, and he’s legendary for pulling 21 shifts a month. That’d make anyone a bit cranky.
“Rosemary, she is dying,” he told me over the phone.
I had all of Marian’s labs back at this point, which confirmed not only that she had an infection, but that she had a truly devastating, overwhelming infection. Her family was huddled in the waiting room with a cardboard box of coffee one of the nurses _ probably Kris — had ordered up from the cafeteria. The cafeteria is closed overnight, and we were closing in on one in the morning, but there are always “comfort trays” for moments like this one. Coffee and a plate of cookies. I have never seen a family member eat a cookie, but the coffee is often poured around. People clutch hot cups in cold fingers, and cry.
I’d paged the hospital chaplain — happily for my own peace of mind, the chaplain on tonight was a personal friend of mine — and he was in there with them, along with Kris, who had asked another nurse to watch over the rest of her patients so she could give all her attention to this one. I could see them vaguely through the wired glass of the waiting room doors. I thought they were praying.
“I know,” I said into the phone.
“What do you think I can do for her?” he asked rhetorically. “Her lactate is five! Her CO2 is seventy! Her pH is 7.1! She has a white count of twenty-five! She is in septic shock!”
Those were all very bad numbers. The lactate, very high indeed, told us that her body was no longer perfusing properly — no longer getting vital oxygen to all her organs. The carbon dioxide (too high) and the pH (too low) told us that she was in respiratory acidosis — essentially, that her breathing was failing. The very high number of white blood cells she had circulating suggested that the cause of all this was an overwhelming infection. Which I had already known, based only off my exam and the chest x-ray. If I hadn’t had the x-ray, I was sure I could have made the diagnosis of pneumonia by her story and the exam alone. But the lab values and the imaging helped us think it through, helped a lot.
“I know,” I repeated. “I know. And we’re three liters of fluid in, and her pressure is still dropping. It’s 80/40 now. Her family insists they want everything done. She has to go to the unit.”
“She’s ninety. She is not going to recover from this.”
“I know,” I said. “Look, will you try to talk to her family? I can’t get through to them.”
He sighed. I deeply respect this man, and affectionately call Dr. Lupescu the “code whisperer” behind his back. I do love watching him in action during a cardiac arrest; he choreographs the chaos like a ballet. But the real reason I call him the code whisperer is that when a case is looking hopeless, he is better than anyone at speaking with the family and convincing them that further measures will be futile and will only hurt their loved one. He complains about doing it, but when I ask nicely, he almost always helps me out on this. Also, I’d done him a favor earlier in the evening, checking in on one of his patients while he’d been tied up in a procedure. He owed me.
“I’ll come up,” he said.
“Thank you,” I said.
He appeared perhaps fifteen minutes later and I waved at him as he ducked into the patient’s room. I was doing other work while waiting for him; I cover up to a hundred and twenty patients overnight, and I was looking at someone else’s EKG. He stopped by my computer as he left the room.
“She is dying, Rosemary,” he repeated.
“Yes,” I agreed, and then added rather tartly, “that’s why I called you.”
Most cranky doctors become irritated if you crank back at them, but not Lupescu, which is one of the reasons I liked him so much. He cracked a very, very faint smile.
“Why wasn’t this caught on days?” he asked, irritably.
Night shift always blames day shift for this sort of disaster, and days will blame nights, but the truth is that infections can develop quickly, and it is not always possible to catch everything immediately. Her vital signs had all been normal as of 1600, except for a slight bump in her respiratory rate that was ominous only in retrospect. “They probably saw her early in the day,” I said diplomatically. “I bet she decompensated fast.”
“I saw the antibiotics were running and you put her on BiPap. How many liters of fluid have you given her?”
“The third of LR is running in right now.”
“She will need to be tubed and on pressors next. I’ll talk to the family.”
I nodded. Almost always I go in with him for these conversations, but my pager was too steady at the moment. There were not one, not two, but three drunks with the DTs on the floor above me, and their nurses were getting a bit desperate. One of them had paged me three times in ten minutes. “I have to answer these pages,” I said. “I’ll be here when you get out. Sorry.”
“I remember how it is to manage the floors,” he said, and went into the family waiting room.
I knew by his expression as he walked out that the conversation had not gone well. He walked up to me quickly, and started issuing orders before he was even up at the desk.
“We’re tubing her,” he said, grim-faced. “And I’ll need to place a central line. You get the meds pulled up for me; I’ll go down to the unit for the cart. I want to do it here and then move her. She’s too sick.”
“All right,” I said.
Things began to move quickly, with that peculiar frenetic calm that is unique, I have found, to this sort of critical medical situation. Lupescu would intubate her first. Her breathing was just not working well enough, even with the assist of the BiPap. After that, he’d place a central line — a catheter that can drip fluid and medication directly into either the superior vena cava or the right atrium of the heart. A line placed there can give more medication, more quickly, than any other line. And a central line also allows certain very potent medications to be given that cannot be administered in any other way. Like the pressors she’d need to keep her blood pressure up.
Lupescu and I had worked together often enough that I knew exactly what medications he’d want to use for the intubation. First 5 milligrams of midazolam for the induction — to put her under, a fast bedside anaesthesia. And then 150 milligrams of “succ,” pronounced “sux” — succinylcholine, to paralyze her. The paralytic would stop her breathing entirely, which was always the most nerve-wracking part of the endeavor; there are always a few tense minutes when the patient is not breathing at all on their own but the ventilator is not yet breathing for them. The thing is, it’s almost overwhelmingly difficult to put a plastic tube down someone’s throat and into the lungs — specifically, down a couple of centimeters above the carina, the branch of the mainstem bronchi — if they are not paralyzed. They try to bite you no matter how much midazolam you’ve given them, and their vocal cords are flopping all over the place. Don’t try it at home, trust me.
Anyway, after checking Marian’s renal function (we’d use a different paralytic if it was poor, like vecuronium) I ordered the meds in the computer and Kris pulled them from the Pyxis, the special locked cabinet associated with the computer system. The elevator dinged and Dr. Lupescu stepped off, rolling his central line cart and with a respiratory therapist, Deb, in tow. We all trooped into the room.
Intubations are always ugly. This one went more smoothly than most, really. Kris didn’t feel comfortable pushing the midazolam and the succ, so I pushed the meds on Lupescu’s cues. There’s a certain way that critical meds are given. I always find it to be a little like rock-climbing. Lupescu and I had often done this together, and it went smoothly.
“Versed,” he said, using the shorter trade name for midazolam. I attached the needleless syringe to Marian’s IV line and pushed the med. “Versed in,” I replied, flushing it through with a second syringe of saline. We waited until Marian had deeply relaxed. She’d been comatose before, but now she was also anaesthetized.
“Succ,” he said after a minute. I repeated my movements, attaching the syringe, pushing the med, flushing it through with another syringe of plain saline. “Succ in,” I said, and this time I lifted the blanket so we could all stare at Marian’s bare feet. Paralytics cause tiny convulsions, called fasciculations, as they take effect. We were waiting for them to come on, then to pass. The respiratory therapist wasn’t waiting, though; she had already started ‘bagging’ Marian, breathing for her with a mask pressed against her face and a bag full of oxygen forcing the air in.
The fasciculations came and went. Dr. Lupescu picked up her arm, let it drop back on the covers. Thud. He nodded to Deb. “Hyperventilate her,” he said, and we all watched the monitor as her oxygen saturation climbed from 92 to 95 and then to 100 as Deb bagged. “Stop,” he said. Deb stepped away, and Lupescu came in with the scope, handing me the ET tube to hold at the ready.
I’ve done this a time or two myself and it is definitely nerve wracking for me, even though I’ve only ever done it with Dr. Lupescu behind my shoulder, ready to catch me (and the patient) if and when I fail. Lupescu himself, though, is an old hand, and he moved quickly with the laryngoscope, pressing back her tongue, tilting her head back, looking down her throat at the vocal cords. “Tube,” he said, and I handed it to him. He slipped it down her throat in one smooth gesture, and Deb attached a syringe full of air to inflate the balloon at the end of the tube, which would make an air lock in her throat. While Deb did that, I attached the same BVM to the end of the tube and started to bag again, breathing for Marian by hand until the tube could be attached to the ventilator. Lupescu attached the tube to Marian’s face with a special dressing and silk tape. Deb began setting up the ventilator, Lupescu calling out the settings for her. Kris stepped out of the room to grab the central line cart, the next stage of operations, and also to page for another portable chest x-ray, to check for proper placement of the tube.
And that’s when Marian’s heart stopped.
“Shit,” said Dr. Lupescu succinctly, as the monitors started beeping. It wasn’t an alarmed shit, it was an exhausted, weary sort of shit. Shit, he really did not want what was coming next. Neither did I.
“Call the code,” I said to Kris, who was already in the hallway. She nodded and ran.
Deb and I rolled Marian to the side so we could shove a backboard under her. CPR doesn’t work if it’s done on a squishy surface like a bed. Something hard needs to go underneath the patient. All hospital beds are built so that their headboard can come off and be used for exactly this purpose. We did so now.
Deb and I glanced at each other, and I shrugged, and climbed up on the bed, and started CPR.
The first compression always cracks. God, I hate that. I’d yanked up Marian’s gown so that I could see the anatomical landmarks — the compressions have to be done in the right place, or they’re useless. It was going to be useless anyway; resucitation at such an advanced age is almost always futile. But we were going to do this right.
So Marian was naked, and her breasts bounced as I leaned on her and cracked her ribs. Hers cracked quickly, snapping like sticks. She was very osteoporotic. It generally takes a few minutes for ribs to stop cracking. After that, the chest usually sort of caves in, and there is a soft hollow in the center where hand after hand has pressed.
It’s exhausting work. The chest needs to be compressed by about a third of its depth for the heart to move any blood. I turn red, and I sweat. Everyone does. If you’re not exhausting yourself, you’re not doing it right. It was easier to perform compressions on Marian, because she was so tiny, but it was also harder, because she was so frail and we hated every moment of doing this.
Lupescu had pushed the defibrillator over, and we took Marian’s gown entirely off to pop the pads onto her — they’re giant stickers, these days, not paddles like in the movies — and we paused to look at the rhythm. M herself, the center of this hideous entertainment, stared at the ceiling. She had dentures, and they were yellow, badly fitting, and locked in a grimace around the endotracheal tube. Her chest had indeed collapsed in, and the purpling bruise between her breasts looked like a hideous flower. Her skin, pale before her heart stopped, now had that waxy character that is common in all deaths. There’s a greenish cast to a dead face, a blue around the lips and a yellow in the cheeks. She had it now.
On the monitor, we saw a waveform that looked like a heartbeat. No one smiled.
“Does she have a pulse?” Lupescu asked, putting his hand over her femoral artery and feeling for one. I felt at her carotid.
“No,” I said. I hadn’t been expecting one. Pulseless electrical activity — PEA, each letter pronounced individually — is one of the most common patterns in a cardiac arrest. The electrical system of the heart is still working, but it’s not pumping any blood. PEA is not a shockable rhythm, unlike V-Tach or V-Fib. And it’s almost always fatal.
He nodded agreement. “Resume CPR,” he said. “Give an amp of epi.”
And now everyone had arrived. The code had been overhead paged, and at least a half-dozen more people were crowded into the room. It doesn’t really take that many people to run a code, but the extra hands on the CPR are nice. And there’s a moral strength in numbers. No one liked what we were doing just now. I stepped away to let a tech take my place, and I was shaking.
Kris was by the emergency med cart, the “code cart,” pulling the epi out on Lupescu’s order. She handed it to one of the ICU nurses who had arrived for the code.
“Epi in,” said the ICU nurse. “Epi in, oh-one-twenty-three,” said the charge nurse, writing down the time on a paper flow sheet.
Marian’s family had arrived, too. I heard her granddaughter’s sobs from the hallway. Her husband pushed in, past the mass of people, past the nurse manager with her clipboard and the ICU nurse with her literal tackle box of backup meds and the second respiratory therapist and the two family practice residents and the cardiology PA and three nurses and four techs.
Marian’s husband stood at the foot of the bed and his face was horrified. His wife was naked on the bed in front of him, and someone was leaning on her chest, and an unidentified fluid — I thought it might have been feces, but I was not entirely sure — was coming out of her mouth, around the ET tube. Deb was trying to suction it with the Yankauer.
“Say that we can stop,” Dr. Lupescu said, looking him full in the face. “We can stop right now. We don’t have to do this.”
“Stop,” her husband said, and closed his eyes. “Please stop.”
We stopped. There was a moment of silence, broken only by the grand-daughter’s sobs.
“Everyone out,” I said, finally. “Out. We’ll clean her up. Kris, help me? And Stacey?” Stacey was one of the techs. They nodded. The chaplain put his hand on Marian’s husband’s shoulder and led him from the room. And we started to clean her.
There was blood everywhere from where M had bitten her lips, and from where one of her IVs had blown. We took the tubes out and washed her face, and we put her gown back on her again, and we drew the covers up over her so she looked peaceful. I tried to close her eyes, but they kept popping open and finally I gave up. Some eyes are like that. I should know; I’ve closed enough of them. We managed to tuck a washcloth under her chin so that her mouth wasn’t hanging open, and we pushed all the medical equipment away to one corner, and then we turned out all the lights except for one, right over her bed, which we aimed towards the ceiling. It wasn’t like a funeral home but it was the best we could do.
We went out to find her family and the first person I saw was my friend, the chaplain. “Are you all right?” he asked gently.
“No,” I told him. “But I will be. Go see to her husband; he needs you more than I do. Also, there are three drunks up on A6 that need more fucking Ativan. My pager went off, literally, sixteen times during that code. Not an exaggeration. I have to return sixteen pages, and I want a damn sandwich. I haven’t eaten since six pm, and now it’s two in the morning. God, I’m hungry.”
I thought I could feel him watching me as I walked away.
I didn’t go up to A6 to see the drunks, not immediately. I called my friend instead, the one who told me I had a compulsion, the only one I can call at almost-two in the morning when someone has just died violently under my hands. His voice was sleepy when he answered the phone, but he listened to me, as he always does.
“You know,” I said, after I’d told him what happened, “There’s this famous passage from George Fox’s journals. The founder of Quakerism, right? I mean, a really famous passage.”
“Mm,” said my friend.
“Yeah. He said . . . he said that he saw an ocean of darkness and death, but also an infinite ocean of light and love, flowing over the ocean of darkness. And in the light he saw the infinite love of God.”
“Okay,” said my friend.
“So, you know, when I explain to people who don’t believe in God about what it’s like to believe in God — well, that’s how I explain it. There’s this infinite pain, this infinite ocean of darkness and loss. No one can argue with that. We all see it every day. So when I say I have faith — I don’t mean that I believe in the virgin birth or whatnot. I mean — I believe there is also light and love. That’s what faith is, believing that there is also good. In the face of all the evidence to the contrary. And most of the time, in my job, I think I skate right between the edges of both those oceans. I can see them both at once. But sometimes it is so damn hard to believe anything but the darkness is real. It’s so hard to believe that love means anything, in the face of all that pain.”
“Hey,” he said softly, after a moment. “I love you.”
“I know,” I said, and started to cry.
He was quiet for a very long time on the other end of the phone, listening to me hiccup from a couple of states away. “Rosemary?” he said at length.
“Go eat a damn sandwich.”
And I did.