Crozet Annals of Medicine: Two Arrivals


This is what happened to me at work today. A 90-year-old guy was brought in to die. An ambulance had been summoned to his nursing home because he was confused. En route to us he took a turn for the worse; he stopped breathing and his pulse became very slow. He was dying, but there was a piece of paper, a copy of another piece of paper actually, that said that he should not be resuscitated at all. This is the well-known DNR form.

Because they were so close to the hospital the medics decided to bag him, that is to assist his breathing for the short ride with an oxygen mask and some puffs from a device (the bag) that breathed for him. Was that resuscitation? Maybe a little.

Anyhow, when he got to us, he was alive again but tenuous. He was placed in a major resuscitation bay and a skilled team of nurses and techs, a pharmacist, a respiratory therapist and of course an Emergency Medicine resident coalesced around his stretcher as he arrived. By custom, the respiratory therapist took over the bagging and the techs quickly established IV access and gave some fluids intravenously. It was only then that the medics produced the DNR order. 

By then he was doing rather well, his pulse had recovered and he seemed to be a little more alert. It was clear though that without the bagging and fluids he would rapidly decline and die. We put him on a machine that did the bagging for us, but stopped short of putting him on a ventilator. 

A social worker tracked down his remaining family, four children who lived in other states and the resident and I conference-called them. They were firmly in support of the DNR order. This is a bit uncommon, for all the family to be in agreement, but they were. We offered to try to support him with the bagging and the fluids until they arrived, but they rejected that approach. It was time and they were ready for it. They would not be coming.

I went back to update the care team and to try to direct this new turn in his care. The nurses were upset and quietly arguing. One nurse thought we had all gone too far and prolonged his suffering, especially with the IV sticks. The other nurses were reluctant to withhold the IV fluids and withdraw the bagging, which was the family’s specific directive. To say the mood in the room was somber was an understatement. My team was depressed and dysfunctional, and the day was only just beginning. 

We honored him with a moment of silence as the bagging ceased and we eased his passage with some IV morphine, in case he felt any pain or anxiety. Time of death was called by the resident, yet nobody left the bedside. They were each processing the events in their separate ways. It is tough to stand by and do nothing as someone dies. They needed time and space. 

I left them, slipping out of the room just in time to see a new team of medics bringing in another dying patient to an adjacent resuscitation bay. Nobody gets time and space in the ER.

I joined the medics for their report. While helping move the patient from their stretcher to our hospital bed, I realized how critically ill the patient was.

I was going to have to get my dispirited team right back into the fray, and I was not looking forward to calling on them for another brush with mortality. 

Just as I lifted my phone to call them in, they arrived, unbidden. Quietly they formed up on either side of the bed. No fuss, no drama, no hint of what went before. They went right to work, needing little direction. I stood by, quietly amazed at their teamwork and choreography. This guy was not a DNR. He was, as we call it, a full code: do everything possible. So, we did. IV’s, bagging, intubation, fluids, meds, X-rays, antibiotics, pressors, ICU. And he lived.

The day went on and the team performed flawlessly and even cheerfully all day. Giving so much of themselves had given them something in return, a deep sense of connection, a purpose, and fulfillment. 

It is days like this that remind me to be grateful for the opportunity to do this work with these people who arrive every day as normal citizens and then rise to every occasion they are needed for. Thank you all. 


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