Crozet Annals of Medicine: Another June in the E.D.

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“So, if May is your favorite month in the hospital what month is your least favorite?” David asked me slyly as we were puttering around in the resuscitation bay. David is a respiratory therapist who likes to kid me about my Crozet Gazette columns.

We were setting up for an incoming cardiac arrest, making sure all the airway tools we would need were close at hand. I had mentioned in last month’s column that May was my favorite month in the hospital due to the high experience level the residents and interns all had.

Now it was June. My most experienced residents were gone, the new interns hadn’t started yet, and a critically ill patient was about to arrive.

“My least favorite month?”

I glanced at the nervous residents milling about outside the resuscitation bay. They were avoiding eye contact, hoping to avoid getting picked to run the code.

“I like them all,” I said diplomatically.

The nurses rolled their eyes.

I picked a resident to run the code, but he politely declined, citing obligations elsewhere. I picked a second resident who also had compelling reasons why a more senior person should be picked this early in the year. The senior pointed out that he was now too senior to run it and what a good learning opportunity it was for the juniors. I began to daydream about my upcoming vacation.

Well, things flow downhill and eventually someone was found who couldn’t decline and we were in business.

The patient arrived in full cardiac arrest, no pulse, no cardiac activity. Now that we had a resident on the hook for running the show we had no shortage of extra hands to help and the other residents jumped in to assist with procedures. Big IVs, central lines, were placed to reach directly into the heart. Arteries were threaded with transducers to record blood pressures, although there was no blood pressure absent the chest compressions the medical students were energetically performing. Ultrasounds were done to look for oddball diagnoses that might be amenable to therapy. Every drug in the Advanced Cardiac Life Support textbook was pushed and there was absolutely no response.

It was obvious to me after 30 seconds that this effort was futile. I had done this a thousand times or more. But this was the first time for the resident running the code and I did not have the heart to call it off. It was too early in his career to reveal the reality of the odds we face in this work.  And really, from a medical standpoint it was a rather compelling problem and exercise for the team to work through. You see, this patient had arrived from the field with no identification. We did not know who she was, how old she was, what her medical problems might have been or what medicines she was taking. We did not know the circumstances leading up to her cardiac arrest. Was there an occult traumatic injury we had missed? Was this an overdose? Heat stroke? Infection?

This scenario is surprisingly common in the ER, treating John and Jane Does, unidentified patients. In fact we have registration and medical record keeping systems worked out for just these events. Most importantly we have dedicated social workers assigned to the ER who track down family and friends, working through the police, EMS, bystanders and anyone else who can help. We usually figure out who they are or were.

As I was contemplating all this and watching the increasingly confident resident team run all of the possible solutions, our social worker informed me who the patient was. Her husband had been located and was in the “quiet room.”

Every ER has a quiet room. No one wants to go there. Quiet. Dim lights. Chairs arranged in a semi-circle. Tissue boxes close by. Security is close by as well. Sometimes these things don’t go too well.

I gathered up the social worker and the chaplain. Best not to go alone.

I knew what to expect. An elderly man, alone, hunched tightly, clenching the arms of the chair in nervous dread. His face worriedly scanned mine looking for clues, wanting to ask, not wanting to know. He waited.

I explained to this man what we had done so far, the lack of response, the grim prognosis. I told him the team was still working on her.

“We’ve been married for 41 years,” he offered. The chaplain offered tissues and a touch on the shoulder.

Eventually we go to see her together, the husband to say goodbye, me to pronounce her dead.

Arriving at the resuscitation room, I was surprised to find the room quiet. The medical students looked tired and sweaty, but they were no longer doing compressions. The residents had lost the frantic energy they had when I left. They appeared much more confident and competent. Their patient had regained her pulses while I was gone. Never underestimate the optimistic energy of young doctors. Of course I knew that they had really only bought her a little time, but sometimes that is a great gift.

Her husband moved to her, grasped her hand and bent over to whisper into her ear. She looked peaceful. They would be together for a little while longer.

I guess June has its moments. But I am going on vacation anyway.

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