He demonstrated his indomitable will to live in many ways. When the initial staging tests revealed the cancer was much more widespread than originally expected, his response was, “Well, we’ll just have to work a bit harder to get rid of it, that’s all.” When his first chemotherapy cocktail failed miserably he moved on to the next line of treatment without so much as a backward glance. Plan B was followed by plans C, D, E… . One day the cancer disappeared. Extensive testing failed to show any trace of malignancy within his body. Rick was in remission. He was thrilled, but he wasn’t surprised – he had fully expected to conquer his foe.
A year later the cancer recurred. At first Rick was despondent, but before long his unflagging optimism returned. Conventional chemotherapy proved to be completely ineffective this time, so he signed up for oncology trials involving experimental drugs. If he was quoted a mere five percent chance of success for a given regimen he’d say, “That’s all right – I’m going to be in the lucky five percent.” When the drug proved to be a failure he’d shrug and say, “Let’s hope the information they got from studying me will help the next guy beat his cancer.”
Once in a while a treatment regimen would look promising in the early stages – Rick’s tumours would shrink, his blood counts would improve and he’d start to feel better. He would predict with unshakeable confidence that it wouldn’t be long before he was rid of his disease. Within a few months, though, the cancer would invariably regroup and resurge, stronger and more resilient than ever. Eventually it became apparent to everyone but Rick that he was not going to win the war.
The attendants hit the door running. “He was awake and talking the whole way here, but when we pulled into the ambulance bay he slumped over and became unresponsive!”
Rick looked sepulchral. He was propped up in the stretcher and leaning heavily to the left. His eyes were vacant and he was barely breathing. I put two fingers to his neck. His carotid pulse was weak. I cupped my hand to his ear and said, “Rick, can you hear me?” He didn’t respond. I put my hand in his. “Rick, squeeze my fingers.” His hand remained limp. I was reaching for the blood pressure cuff when I noticed his left eye glistening. I stood transfixed as a solitary tear broke free and tracked down his cheek. A tear from a dying man. Endgame. I felt someone walk over my grave. Turning to one of the attendants, I whispered, “What’s his code status?”
“I’m not sure, but you can ask his wife – she’s right next door in the triage room.”
Tammy was distraught. I explained that Rick was moribund and asked if he had ever given any indication as to whether he wanted aggressive interventions in the event his heart stopped beating. She said he had requested no heroic measures be undertaken. We went back to the treatment room together. His blood pressure was hovering around 60 systolic and he was nearly unconscious. It didn’t look as though he was going to last long. She held his hand and stroked his thinning hair. The rest of us stood by and waited.
Impossibly, several minutes later he opened his eyes and looked around. He was too weak to talk, but he seemed to recognize Tammy. He obviously wasn’t yet ready to relinquish his fragile hold on life. I sequestered his family in the triage room for an impromptu conference and asked if they were in favour of giving him a rapid infusion of intravenous fluids in an attempt to boost his blood pressure. I explained any improvement would likely only be temporary, but that it might give him a few more hours of consciousness. After deliberating for a short time they decided to give it a try.
Halfway through the third litre of saline he arose like Lazarus, asked for a drink of water, and held court with his family. When I asked him what his wishes were regarding end-of-life care, he confirmed he didn’t want CPR, defibrillation, intubation or mechanical ventilation. Intravenous fluids were fine, though; he was hoping to keep body and soul together long enough to participate in an exciting new chemo trial scheduled to commence in a couple of weeks.
“You do your job, and I’ll do mine,” he said to me with a mischievous twinkle in his eye.
Over the course of the next two hours Rick slipped in and out of consciousness. During lucid intervals he would reminisce with his family about happier times. Sometimes he spoke wistfully about up-and-coming treatments he had read about. Not once did he speak of death. Shortly after midnight he lapsed into a coma. I wrote admission orders and transferred him to the medical floor for palliative care. By 3:00 a.m. the emergency department’s waiting room was empty. I hung up my lab coat and drove home.
Three hours later my telephone rang. It was a nurse from the medical floor.
“Sorry to wake you, Dr. Gray, but Rick just died.”
“I’ll be there in a few minutes.”
I got out of bed, dressed and returned to the hospital.
Pronouncing someone dead is a strange ritual. It’s equal parts medicine, religion and magic. Like falling snowflakes, no two pronouncements are ever the same. Sometimes the body is alone in the room; shrouded in darkness, isolated and abandoned. Other times the room is well lit and packed with family members and friends. Sometimes the dominant mood is sadness. Other times it’s relief. No matter how many mourners are present, though, a palpable stillness descends when I enter the room. I become a shaman. My gift is closure.
On this occasion there were seven people clustered around the bed. When I walked in, they all turned towards me expectantly. My fingers gripped the stethoscope in my pocket. For a moment it felt like a string of rosary beads. I approached Tammy and squeezed her shoulder in sympathy.
“Thank you for looking after him earlier,” she said.
“You’re very welcome,” I replied. “I only wish we could have done more. Was he in any pain at the end?”
“No, he looked like he was comfortable.”
“Did he ever regain consciousness after he left the emergency department?”
“Yes, a few times. The last time was about half an hour ago. He opened his eyes and spoke to me. I think he must have realized he was about to die.”
“What did he say?”
“The fire’s gone out.”
Rick was recumbent on the bed with his eyes closed. Although it was clear that his life-thread had finally been severed, I could sense his family needed me to confirm it. I lifted his cooling wrist and felt for a radial pulse. There was none. I assessed his carotids. Nothing. I placed the diaphragm of my stethoscope directly in front of his bluish lips and listened for breath sounds. Silence. I auscultated his chest for a heartbeat. Once again there was no sign of life. The last thing I usually do is check for a pupillary reflex. I put my right thumb on his left eyelid and gently opened his eye. A solitary tear broke free and tracked down his cheek.
Parenting 101
My next three patients are a young family with mild gastro symptoms. While I obtain a history from the parents their toddler Billy pokes around the room, happy as a clam. I examine the father. I examine the mother. Now it’s Billy’s turn.
I ask his parents to put him on the stretcher. When his mother leans over to pick him up, Billy goes bonkers. He windmills his arms and screeches, “No!” He then runs behind the stretcher and stares up at us defiantly.
“I don’t think he’s going to let you look at him,” his mother concludes.
“How old is Billy?” I ask.
“He just turned two.”
“I think we’re in charge here, don’t you? Please put him up on the stretcher so I can check him.”
She approaches Billy cautiously. He bares his teeth at her like he’s some kind of rabid ferret. When she lifts him up, he arches his back, kicks his feet and uncorks a blood-curdling, “No! No! No! NOOOOOO!!!!” Damned if she doesn’t put him back down.
“Billy doesn’t like doctors,” she reiterates.
I’m running out of patience.
“Look, this isn’t a democracy – his vote doesn’t count. It doesn’t really matter if he says no. Just put him on the stretcher anyway.”
At this juncture a tiny light bulb appears ab
ove her head. Aha! A brand new concept! This time she and her husband pick up Billy and deposit him on the stretcher like they mean business.
“Now you sit still, Billy,” she says firmly. After putting up a token show of resistance he settles down nicely. I begin my examination.
Adventures in Paralysis (The Ventilator Blues)
Every now and then we ER docs supplement our armamentarium with techniques borrowed from other specialties. Rapid sequence intubation (RSI) is one such purloined procedure. It involves using induction and paralytic agents to facilitate emergency endotracheal intubation. In plain English, this means we sometimes give patients who are struggling to breathe drugs that render them comatose and paralyzed. We then move their tongue out of the way with a device called a laryngoscope and quickly advance a hollow 12-inch plastic endotracheal tube (ET tube) past the back of the throat, through the vocal cords and into the trachea (windpipe). When the tube is in place we attach it to an Ambu bag. Squeezing the bag rhythmically results in 100 percent oxygen being delivered to the patient’s lungs. Depending on the situation, the ET tube can subsequently be attached to a ventilator.
As the name implies, RSI allows us to rapidly take control of a patient’s breathing. Anaesthetists have long used coma-inducing and paralyzing drugs in the OR, but it wasn’t until relatively recently that it was recognized there was a role for these medications in the ER as well. RSI is an invaluable adjunct, and it has bailed me out of a number of airway crises. Usually it goes off without a hitch, but once in a while things can get a little hairy. Here are three cases from my Yikes! file.
Are You Sure This Stuff Is Going to Help Me Relax?
Several years ago I was working in the ER when we got word an ambulance was on its way in with someone who had been trapped in the basement of a burning building. Before long the paramedics arrived with an uncooperative man in his early 20s. His clothing was badly charred and he was covered in soot. Inspection of his throat revealed a raw, beet-red palate, and his sputum was speckled with carbonaceous material. It was obvious he had suffered significant thermal damage to his upper airway. It is generally recommended that patients with this type of injury be intubated early. If you wait too long, late attempts at securing the airway may prove to be impossible due to massive soft tissue swelling in the throat. In situations where multiple intubation attempts have failed, oftentimes the only remaining airway management option is emergency cricothyroidotomy, i.e., cutting the front of the neck open to directly access the trachea. Rumour has it that incising the neck of a confused, combative burn victim isn’t much fun. Intubate early and save yourself a world of grief.
As we stripped off the patient’s smouldering clothes and started IVs I advised him of my concerns regarding his airway. When I told him I thought he needed to be intubated he said: “Are you saying you want to stick a tube down my throat and put me on a breathing machine?”
“In a nutshell, yes.”
“Yeah, right! Like that’s ever going to happen! No way, man. I’m out of here.” He sat up and pulled out one of his IVs.
“Mr. Cotard, I think you’re making a big mistake. Any minute now your throat might begin to swell. If it does, you could suffocate.”
“I already told you, there’s nothing wrong with me. I’m going home.” He started tugging on his remaining IV.
“Hang on,” I parried. “What’s the big rush? Why don’t you stay a little while and let us keep an eye on you? If nothing happens, we’ll let you go.”
“Okay,” he agreed grudgingly. “I’ll stay for 10 minutes, max.”
With each passing minute he grew more restless and agitated. We had to continually remind him to leave his oxygen mask on. Eventually his oxygen sats began to drop.
“If we wait much longer to intubate you, it may be too late.”
“Not a chance!”
Moments later his voice started getting raspy. The ER nurses and I exchanged worried glances. Vocal cord swelling. Not long after that he developed stridor, a high-pitched inspiratory wheeze indicative of a precariously narrow upper airway.
“That noise you’re making each time you inhale tells us we’re running out of time. We have to intubate you now before your airway becomes completely obstructed.”
“No way!” he squeaked. “Stay away from me!”
“All right then, at least let me give you something to help you relax a bit.”
“Okay.”
I drew up four syringes of RSI drugs: thiopental, succinylcholine, pancuronium and diazepam. My patient eyed the syringes suspiciously.
“Are you sure this stuff is going to help me relax?”
“I guarantee it.”
I injected the thiopental and succinylcholine into his IV port. Within a minute he was unconscious and paralyzed. I then squeezed a pediatric-sized ET tube through his flambéed vocal cords, hooked him up to a ventilator and shipped him off to the closest burn centre.
We were later advised his inhalation injuries were so severe he required mechanical ventilation for more than a week. His subsequent convalescence was uneventful.
As you can see, occasionally we're forced to override an irrational patient decision in order to save someone from themselves. These situations have the potential to ignite ethical and medicolegal firestorms. Whenever I'm caught in this type of quandary my guiding principle is to do whatever I feel is morally imperative and save the worrying about potential repercussions for later. In other words, do the right thing! So far this axiom has not let me down.
How Come She’s Not Breathing Anymore?
One night I was paged to the Special Care Unit to evaluate a teenage girl in respiratory distress. The nurse caring for her informed me the patient had presented to the emergency department earlier in the day after having ingested a large quantity of unknown pills. She had been treated with activated charcoal and observed closely in the ER. Nothing untoward had happened, so after a few hours she had been transferred to the unit for further monitoring. Her breathing had started to become laboured a few minutes prior to my being contacted.
The patient’s breathing was rapid and shallow. Despite maximal supplemental oxygen, her sats were only 80 percent. Examination, bloodwork and a portable chest x-ray failed to reveal any obvious cause for her abrupt deterioration. I wondered about the possibility of a pulmonary blood clot. Before I could pursue that line of thought any further, her respiratory status took a turn for the worse. I decided to intubate.
I selected my airway tools and calculated the appropriate RSI drug dosages. While the nurse got the medications ready I studied the patient’s mouth and neck in an attempt to gauge how difficult it was going to be to intubate her. Her receding chin, small mouth and big tongue all suggested the procedure would be technically challenging. If I paralyzed her and then found myself unable to get the tube in I’d be up the proverbial creek. Like the saying goes, bad breath is better than no breath. I therefore decided to do an awake intubation, meaning I would numb her throat and upper airway with the topical anaesthetic Xylocaine and then gingerly advance the ET tube into place. Once the tube was in, I’d quickly sedate and paralyze her in order to eliminate the possibility of her inadvertently yanking it out. I went over the plan with her in detail. She said she’d try her best to cooperate.
First I flattened her tongue with a tongue depressor and sprayed the back of her throat with Xylocaine. A minute later I instructed her to lie down. I then slid the laryngoscope blade to the back of her throat and sprayed the zone between the posterior throat and the voice box. This caused her to cough and splutter so much I had to withdraw the scope and give her a minute to recover. On the next attempt I was able to get the blade a bit further down, but when I began spraying she reached up and tried to grab my hand. Not good. I removed the scope again.
“Are you okay?” I inquired.
“Yes. Sorry about that – it was just a reflex,” she panted.
I turned to the nurse and whispered: “This looks like it’ll be a tough intub
ation. I’m going to want to give her the thiopental and sux to sedate and paralyze her as soon as the tube’s in place so she doesn’t pull it out.”
“Okay, I’ll have them both ready.”
I went in again. This time I saw a sliver of the epiglottis, which is the lid of the voice box. The vocal cords lie directly beneath it. When I squirted the epiglottis with Xylocaine she started coughing violently. She then began twisting and rolling around on the bed. I withdrew the scope and waited for her to settle. When she calmed down I asked, “Are you okay?” No answer. “Miss Pickwick?” Silence. Something was wack. Was it just my imagination, or did she appear to be unnaturally still?
“Hey, wait a minute – how come she’s not breathing anymore?”
The nurse checked the patient’s IV line and gasped.
“I inserted the loaded syringes of thiopental and succinylcholine into her IV port and left them there so we’d be able to inject as soon as you got the tube in! Both syringes are completely empty – she must have self-injected just now when she rolled over!” Yikes!
Her oxygen sats entered free fall. I asked the nurse to apply firm pressure to the patient’s cricoid cartilage to reduce her risk of aspirating stomach contents. In the meantime I attempted to ventilate her lungs with the Ambu bag. Even using both hands I couldn’t get a good seal with the mask. Her sats hit 70 percent. I put the laryngoscope back down her throat and hunted for her vocal cords. I could barely see the epiglottis, never mind the cords.
“O2 sat 60 percent!” shouted the nurse. A multitude of monitor alarms started beeping simultaneously. I went into Hulk mode and pulled on the laryngoscope so hard, it’s a wonder the patient’s entire body didn’t lift off the bed. Miraculously, her vocal cords popped into view. I vaguely recall my hands trembling a little as I guided the ET tube home.
Miss Pickwick went on to a complete recovery.
Dude, Where's My Stethoscope? Page 9