Time of Death: 1503

When I have a really bad day at work, someone usually dies. Yesterday was a really bad day.

Mr. H was standing at home talking to his wife, and mid-sentence he just fell over backwards and hit the floor. When a 74-year-old with a history of coronary artery bypass graft and an upcoming appointment for defibrillator placement does that, it's never a good thing. Mrs. H called 911 and then, instead of doing CPR, sat and waited 10 minutes for them to arrive.

By the time he got to me he had gotten multiple rounds of code drugs and had been shocked a dozen times or more. His heart was still fighting, but his after the 10 minutes without oxygen before EMS got to him, his pupils were fixed and dilated -- a very poor neurologic prognosis. This is why everyone should know CPR. Hell, I'm even thinking of getting an AED (automatic external defibrillator) for home as Dan starts going more and more gray. (Yes, I do want to keep him around!)

Even though Mr. H's brain was probably gone, I started coding him to try to get return of spontaneous circulation, because that is what we do. Mr. H's heart was stubborn. He had remained in ventricular fibrillation (where the heart muscles beat independently and the heart is a quivering lump that can't get all it's muscles to work together to make a beat and actually pump blood) no matter what EMS tried, and I couldn't get him out of v fib no matter what I did either. I'd shock him and we'd get a few beats of something and he'd slip right back. I got a few minutes of accelerated ventricular rhythm at one point and actually had a pulse with it, but as soon as I got the cardiologist on the phone to tell him I had thought I had something to work with, of course... v fib again. We saw some Torsades and some pulseless ventricular tachycardia (neither of which are compatible with life) briefly, but by and large, the man remained in v fib for almost 2 hours. He was like my science project... We cracked open countless epinephrine doses, atropine, amiodarone, magnesium, bicarb, lidocaine, calcium and even the now-out-dated procainamide ("I can't remember the last time I gave this," commented one of the older nurses). We even had him on normal saline and amiodarone drips. But his damn heart was just too stubborn. It was supposed to either stop fibrillating and go to asystole (flat line) or start beating again. After 2 hours of CPR, 20 shocks, a consult with the other ER doc on duty, analysis of his chest x-ray & labs, a conversation with his primary care doctor and a bedside visit from the cardiologist on call, he was STILL fibrillating. None of us could do anything to get him out of it. So we had to stop CPR.

I was drained and frustrated because V fib is something we're supposed to be able to fix. I think Mr. H's heart and I would have been battling all night if it weren't for (1) both the cardiologist and the more experienced ER doc telling me that there was nothing else left for me to do and (2) the fact that I knew Mr. H would likely never wake up anyway, even if I could get circulation back, because of his devastated neurologic state. I did feel better when one of the nurses working the code with me told me that she hopes I'm on duty if she ever presents in cardiac arrest, because she doesn't want anyone giving up on her too early. She also told me she can't remember the last time she saw a list of code medications given as long as the one I'd just compiled. I honestly can't think of anything else I could have done, but I always wonder, "Could I have done better?"

There is one episode of Grey's Anatomy (one of my favorite shows) in which the resident tells her intern that the reason docs go through such valiant efforts at the end of life, even if deep down we know it's futile is "So we can tell the family we did everything we could." Amen to that. Giving families news like I had to give the H family is the worst part of my job. I tried to prepare them by telling them when he first got tot he ER that I was trying to get his heart going but there was a good possibility I wouldn't be successful. Mrs. H was a sweetheart and grabbed my hand and whispered "It is in God's hands. Try your best." I let her come into the code for a few minutes and explained to her everything that was going on so she could see that we really were doing everything we could. Then I ushered her back out so I could focus. There is a new trend in Emergency Medicine to let families be present for as much of the end of life resuscitation efforts as possible, so when we finally decided to call it, I let Mrs. H and family come in the trauma room for the final minutes of CPR. I explained that there was nothing further we could do, and then we called it, right in front of them. "Time of death -- 15:03." The drama that ensued overwhelmed the whole ER. There must have been 6 family members present; half of them fell on the floor, and half of them threw themselves on Mr. H's body. The wailing and shrieking and "Oh Lordie"s could be heard in the ambulance bay. Not that I blame them. I just question whether it really is better to have family right in there at the bedside for such traumatic moments. It definitely wasn't better for me. Maybe in a few weeks they'll have more closure and feel more at peace (the way research suggests) from having been there with him for the final minutes, but it was rough for all involved yesterday at 15:03 and made me again wonder "Could I have done better?" in terms of easing the family through it.

When I finally emerged from the room, a Nurse told me "You're bright red... even your ears." My face always seems to find a way to express everything I try to bottle up inside, and yesterday the redness was a neon sign to everyone -- "Watch out, I've had a really bad day."