by Atul Kumar
About one month ago Duane had again met with his lawyer and changed himself to DNR/DNI status. This meant that if he was to have an acute life threatening event, he did not want any resuscitation or artificial respiration measures, including intubation, to be undertaken in an effort to save his life.
Social work notes provided even more insight into Duane’s plight. After he’d removed his now ex-wife from his will, she completely stopped visiting him; her last visit was just over two months ago. She was in a relationship with an airline pilot who himself was divorced with one child, a boy similar in age to Duane’s daughter. His wife was in hospice care due to end-stage breast cancer. The two met during group counseling for individuals with terminally ill spouses. They started living together shortly before her last visit to see Duane.
Duane didn’t take well to his wife’s moving on with him still being alive, but who can blame him?
Numerous psychiatry notes revealed that after the divorce Duane had given up on actively participating in his rehabilitation exercises, had become increasingly withdrawn, and on numerous occasions stated that death would be better than his current state of senscience.
Again, who could blame him? The guy had gone from having the American dream: gorgeous wife, beautiful daughter, great job, and excellent health to a miserable existence in which he was eighty percent paralyzed, disfigured, blind, bed-ridden, and alone. Perhaps the worst thing was that his mental faculties were intact.
The only thing left to do was actually ‘talk’ to Duane. Given he’d stopped writing, conversations were now carried out by Duane grunting twice if the letter of a word was between A to M and once if it was between N to Z. Then the letters were recited until he grunted once to indicate that was the desired letter.
Notepad in hand, I entered Duane’s room. The sight of him caught me by surprise. He was barely a hundred pounds and had no muscle mass. His face was gaunt, his cheeks sunken in, and his eyes almost completely white due to the severe scarring of his corneas.
There were 2 IV poles with numerous bags of various liquids being infused into him through a catheter in his neck. I recognized some of the hanging IV bags: two were antibiotics, one was a blood transfusion, another contained TPN, one I presumed was just fluid, and I didn’t recognize the last two.
I walked up to his right side and nudged him. His eyes fluttered open, but he made no effort to turn his head. He wasn’t being rude, it was just that for Duane facing a visitor was no longer required, as he received no useful visual input. And based on the Psych evaluations, he didn’t care for company any longer.
“Hi Duane, it’s me, Rajen Mok. The medical student that was on your team a few months ago.”
Numerous vigorous grunts.
“I presume that means you remember me?”
More grunts.
“Is it ok if we talk? I know the way you communicate and I have a notepad here.”
One grunt.
And we were underway.
LIAR.
“I assume that is in reference to me?”
One grunt.
“I know, there’s nothing I can do to make your situation right, it’s not fair; it sucks.”
Silence.
I figured I might as well continue. “I know what happened with your wife, your DNR status, and your will.”
Silence.
“I’ll cut to the chase. If you want, I’ll help you end it, tomorrow will be your last day. I’ll stay true to my offer, just in a very belated fashion. Better late than never I suppose. What’s the verdict?”
One grunt. Pause. One grunt. Pause. A barely audible, “Yes.”
“WAIT! You can talk?!”
His voice was very raspy and hoarse, but it was definitely present, and in English. “Yes.”
He turned his head to face me, opened his scarred and opaque eyes, and just stared, unblinking. It was creepy. Many cultures believe eyes are a window to the soul; well in this case the soul was nowhere to be found. Perhaps it had already left the building. Finally a tear slid down his cheek and towards his neck where it was absorbed by the dressing around his neck catheter. Duane broke the silence, “Please … help me …”
“Help you die?”
One grunt.
“Ok, I’ll be back tomorrow, late in the afternoon when the nurses are changing shifts. I promise it’ll end then.”
Numerous grunts. He started thrashing in his bed, well, his right side anyhow. More grunts and more thrashing.
When he finally calmed down I asked, “Is there something you want to say?”
One grunt. The activity must had worn him out.
“Ok, if you don’t want to talk, I have the notepad ready.”
THAT … WAS … ME … DANCING … FOR … JOY … And then he smiled, probably for the first time since I last saw him.
“I don’t need to ask you if you are sure about going through with this do I?”
Two grunts.
“I’ll see you tomorrow.”
His grunts and thrashing were so vigorous that an alarm went off and his nurse rushed into the room.
She saw him and looked at me, and back to Duane. “I’m going to page the attending, I think he’s seizing.”
“No, no, I don’t think that’s necessary. I think he might like some music actually.”
“Are you kidding me, he hasn’t listened to music in months. They tried everything in rehabilitation, music, audio books, massage therapy, animals, air mattresses, mood lighting, white noise, nature sounds, you name it.”
“Duane, would you like some music?”
One grunt.
“I’ll be damned!” Exclaimed his nurse, and took off to get her iPOD. Hospital rooms are now fully wired with music docking stations and surround sound.
When she got back she asked, “What do you think he wants to listen to?”
“Oh, I think some dance beats would be just great.”
“You got it.” And she put on some hip hop.
“I’ll see you tomorrow, Duane.”
He was thrashing away as I left his room. I think that was the happiest dance I’d ever seen.
I headed down to the operating rooms. Most were up and running, but I saw a couple that were not in use at present because the cases were not scheduled until later in the day.
I was already in scrubs, so I just removed my nametag and put on a hat and face mask. Now I fit right in as any number of scrub clad worker bees. I saw a mop at the end of the hallway, and a plan formulated in my head.
Grabbing the mop and cleaning cart, I moved it to OR 17 which was currently not in use and pretended that I was mopping the room. I nonchalantly made my way over to the anesthesia cart where all the medications are kept.
Damn it! It was locked. There was a combination lock. I figured tons of Docs must use this cart, thus, the code must be easy. I tried the usual 1234 and 9876 combinations to no avail. Then I figured the four corners might work and BINGO, I was in.
The cart unlocked and the whole slew of anesthetic medications was at my disposal. I grabbed several vials and stuffed them in my scrub pockets, closed the cart, and meandered back to where I found the cleaning cart. I left it where I had found it and went straight to the locker room where I’d dropped off my bag.
Nobody so much as glanced at me.
Entering a toilet stall I placed all the drugs I’d procured into my bag and did a quick inventory of what I’d accumulated: Propofol, Atropine, Vecuronium, Epinephrine, and SoluMedrol. Any of those first four would be enough to do the trick.
My heart was racing; this was just too easy. I threw my bag over my shoulder and left the OR. I walked to one of the regular patient floors and into a general supply room, where I procured a 50 cc syringe and a few eighteen gauge needles.
I found a private bathroom and again found myself in a toilet stall. I quickly opened up all my vials and drew up all the contents into the 50 cc syringe. The medications filled the syringe to exactly the 50 cc mark. The lethal cocktail
milky white in color … scary, it could easily be confused for an infant’s formula.
I flushed the empty glass vials into the toilet one at a time and fortunately they all went down the drain without any complication, as did the needles.
Placing the filled syringe back into my bag I headed again to Duane’s room. I was now acting on auto-pilot, my feet were moving, but my brain wasn’t telling them were to go. There was a strange peace that had settled in. My heart rate was normal and my mind completely clear. I had no second thoughts about what I was going to do; I just didn’t want to wait until tomorrow.
I found myself outside Duane’s room, watching him mildly thrashing about with the music bumping. Dancing, in his own seizure-like way.
“Hey, Buddy, I’m baaaack!”
A few grunts.
“I moved things up. I got the goods and I figured it might be better to do it today; if I think about it too much, I might back out again.”
Two staccato grunts.
“OK, here’s how we’ll do it. I have a syringe with enough chemicals to put away several people. I’m using some of the same stuff that did Michael Jackson in. I’ll just silence you monitors, turn up the music, and slam the concoction into your TPN line. They’re both the same off white color, so it won’t even be noticed. You’ll just go off into a sleep in a few seconds, and the medications will paralyze all your muscles and increase your BP to well over 300.
“You’ll probably die of apnea, a stroke, a ruptured aneurysm, a heart attack … hell, maybe all of the above.
“I don’t think it will hurt because you’ll be completely asleep first. But then again, I’ve never done this before. You ready?”
One grunt, then silence. This was clearly a man who’d made peace with himself and had been looking forward to this opportunity for months.
I nodded and took out the syringe and hid it under his sheets. I turned up the music. Then I silenced the alarms, buying me 90 seconds of quiet before they’d begin to blare their myriad of warnings. As soon as I did that, I connected the 50 cc syringe and slammed it into his IV over the course of about eight seconds.
Unhooking the syringe, I walked out of his room without looking back and headed straight for the exit and to my car, dumping the empty syringe in one of the random trash cans on my way to the parking structure.
~~~~
I came to work the next day to round at 5:45 am. The ICU was exactly as I remembered it the day before. I logged onto a computer and pulled up my patient list and the only thing I noticed was that Duane was no longer listed as ‘active.’
I clicked on his name and saw that some labs were drawn shortly after I’d left the hospital yesterday. There were several critical lab values. Curiosity overcoming me, I just had to walk by his room.
As I walked by, I saw that his room was empty with a well-made bed ready for its next occupant. I glanced at the patient board at the central nursing station and the only difference was that instead of his name by the number of the room he’d occupied yesterday, it said ‘DECEASED.’
Nobody paid me any attention or questioned my presence on the floor. I was just another medical student going about my day’s duties.
Appendix 1: Acronyms
5150: An involuntary 72 hour psychiatric hold.
A & 0: Alert and Oriented (out of a possible of 4: person, place, time, and event).
ACGME: Accreditation Council for Graduate Medical Education.
AMA: Against Medical Advice.
Ampho: Amphotericin B.
AMS: Altered Mental Status.
ANC: Absolute Neutrophil Count.
BFF: Best Friend Forever.
BMI: Body Mass Index.
BP: Blood Pressure.
BS: BullShit.
CD4: Cluster of Differentiation 4 (a glycoprotein found on the surface of Helper T Cells).
CMV: CytoMegaloVirus.
CNA: Certified Nurse’s Assistant.
CP: Cerebral Palsy.
CPR: Cardio-Pulmonary Respiration.
Crypto: Cryptococcus (a genus of fungus).
CSF: CerebroSpinal Fluid.
C-spine: Cervical Spine.
CT: Computed Tomography.
CYA: Cover Your Ass.
DIC: Disseminated Intravascular Coagulation.
DNA: DeoxyriboNucleic Acid.
DNR: Do Not Resuscitate.
DOA: Dead On Arrival.
ECHO: ECHOcardiogram (ultrasound of heard).
EKG: Electrocardiogram.
EMS: Emergency Medical Services.
ENT: Ear, Nose, and Throat.
ER: Emergency Room.
ET: EndoTracheal.
FACS: Fellow of the American College of Surgeons.
FLK: Funny Looking Kid.
GHB: Gamma HydroxyButyric acid (also, Rohypnol).
GOMER: Get Out of My ER.
H & P: History and Physical.
HAART: Highly Active Anti-Retroviral Therapy.
HIV: Human Immunodeficiency Virus.
ICU: Intensive Care Unit.
IM: Intra-Muscular.
IV: Intra-Venous.
IVIG: Intra-Venous ImmunoGlobulin.
JD: John Doe or Jane Doe.
LP: Lumbar Puncture.
MA: Medical Assistant.
Mg: Milligrams.
MI: Myocardial Infarction.
MIA: Missing In Action.
MILF: Mother I’d Like to Fuck.
MRI: Magnetic Resonance Imaging.
MRSA: Methacillin Resistant Staphylococcus Aureus.
N95: A type of face mask corresponding to NIOSH (National Institute for Occupational Safety and Health) standards.
NPO: Nulla Per Os (nothing by mouth).
NYU: New York University.
OR: Operating Room.
PACU: Post Anesthesia Care Unit.
PC: Politically Correct.
PCA: Patient Controlled Analgesia.
PCP: Phencyclidine (Angel Dust).
PET: Positron Emission Tomography.
PICC: Peripherally Inserted Central Catheter.
PO: Per Os (by mouth).
RBC: Red Blood Cell.
RNA: RiboNucleic Acid.
SAT: Standardized Achievement Test.
SIRS: Systemic Inflammatory Response Syndrome.
STAT: STATim (Latin for immediately).
STD: Sexually Transmitted Disease.
SUV: Sport Utility Vehicle.
TEN: Toxic Epidermal Necrolysis.
Tox: Toxicology.
UCSF: University of California, San Franscisco.
V-Fib: Ventricullar Fibrillation.
VIP: Very Important Person.
Appendix 2: Definitions
Amphotericin B: An extremely toxic antifungal agent used to treat only the most severe human fungal infections.
Anemia: Low blood counts or concentration (measured as hemoglobin or hematocrit).
Atropine: A neurotransmitter that decreases parasympathetic activity, dilates pupils, and in high doses causes severe abnormal cardiac rhythms which can be fatal.
Autoimmune Hemolytic Aanemia: When a person’s body attacks its own red blood cells.
Bacteremia: Systemic infection by a foreign bacteria, usually severe and in the circulatory system.
Bactrim: A sulfa containing antibiotic, commonly used.
Bell's Reflex: A primitive reflex in which eyes roll upwards to keep the corneas covered and hydrated (often making eye examinations very difficult).
Bicarbonate: HCO3-, used to buffer pH in biologic systems.
Boba: Tapioca balls used in ‘pearl milk teas.’
Bolused: To administer a large amount of fluid rapidly (in medicine usually one liter IV given within a few minutes counts as a bolus).
Cachexia: Severe malnourishment, loss of body mass that cannot be reversed nutritionally.
Calculi: Mineral deposits that can form a blockage in the urinary system.
Cannula: A tube for insertion into a vessel, duct, or cavity (vein, eye, nos
e, stomach, etc …).
Catheterization: A tube inserted someplace it doesn’t belong (heart, bladder, etc …).
Central Nervous System: Brain and spinal cord.
Cerebral: Brain.
Code Blue (a.k.a—code): Called when a non-DNR patients either stops breathing or beating his/her heart (extreme emergency).
Code White: An acute heart attack in which intervention, usually by cardiac catheterization and stenting is required with the hour.
Colic: Severe pain or other symptoms of distress (occurs in babies and with kidney stones).
Colostomy: A procedure in which the intestine is sutured to the abdominal wall creating an opening known as a stoma (yes, fecal matter is collected into a bag taped around this opening).
Cricothyroid: A joint in the neck connecting the cricoid cartilage and the thyroid cartilage, placing pressure here can make the view of intubation easier.
Cryptococcal meningitis: Fungal infection of the membranes covering the brain and spinal cord.
Cryptococcus: These fungi grow in culture as yeasts and are usually aerosolized from dirt, infection in non-HIV individuals is rare.
Cyanotic: Blue, usually due to lack of adequate oxygenation.
Decubitus: The most dependent part of a patient when they are lying down, prolonged periods in the same position can cause ulcers in these dependent positions which are difficult to treat.
Diaphoresis: Sweat.
Diaphragm: Primary muscle of inspiration, separating the chest from the abdominal cavity.
Diazepam: Valium.
Doppler Effect: The frequency of sound of an approaching object is higher than when the same object recedes (very common as an ambulance approaches and passes).
Dyscrasias: Nonspecific term that refers to any disease or disorder, but it usually refers to blood diseases.
Ecstasy: MDMA (3,4-methylenedioxymethamphetamine) party drug that makes people more sexual, high doses can cause severe hyperpyrexia.
Emboli: Any detached, traveling intravascular mass (can cause a stroke).
Emesis: Vomiting.
Endotracheal: Inside the trachea, a tube here is used for artificial ventilation during anesthesia.
Epidermal: Outermost layers of the skin.
Erythema: Redness.