Out of Time

Difficulty breathing at the nursing home. The officer who arrives on scene tells us to keep coming lights and sirens.

The room in the nursing home is sparse. The patient, a large man in a hospital johnny, is pale and diaphoretic with a low grade fever and edema in his abdomen and extremities. His eyes follow me slowly as I assess him. His lungs are full of rhonci and probably some rales mixed in. It all sounds crappy. I ask him if he is in any pain and he says his back hurts. He says the bed is uncomfortable, and he is too weak to position himself better. With a nonrebreather on he is only SATing at 90%. His heart rate is in the 130’s. The nurse comes in with the W10 and I ask what kind of respiratory history he has. None, she says. He has metastasized cancer into his bones. He just came back from radiation. He’s only been here a few days. He just started breathing poorly an hour ago, although he has been edematous since he got here. Also, he hasn’t peed for a while. And he’s a DNR.

Whenever I hear the DNR status, I admit, I feel a small, if sad relief. I won’t have to work as hard on this one as I thought, I think. I check quickly through the paperwork, verify the DNR order, and then slip the papers in my pocket. “We’ll get you over to my stretcher now,” I say, “and try to get you comfortable.” The police officer helps us move the man who is quite heavy. I try to get his head under the pillow comfortably, but as it is, his feet are hanging off one end of the stretcher and his head the other. I sit him up to aid his breathing.

When we put him in the back off the ambulance, I look up at him and think for a moment that he has coded. His head is still and cocked slightly back with his mouth open. I see no chest rise. “Stimulate him,” I call to our third partner, who rubs his shoulder and he lifts his head slightly and looks at her.

I tell my other partner to just head to the hospital. He is a DNR, but I don’t want him to die on us, so I tell him to go lights and sirens, but easy.

And dying is what this man is doing. His breathing is becoming agonal. The light is leaving his eyes. His lungs are slowly filling with more fluid. I can’t hear a blood pressure and he only rouses if we stimulate him. I think for a moment about calling the hospital and requesting permission to use some aggression in my treatment, but I can’t figure out quite how to ask, plus I know once I mention he is a DNR, they will likely say no because what he needs is to be intubated. He is too lethargic for CPAP, doesn’t have the pressure for nitro. My only option is probably dopamine. I use the electronic cuff and it comes back with a BP of 120/90, which I do not believe. I do it again and it reads 80/40. I try a manual again and hear nothing. After I pop in an IV, I look up at the man and his eyes are completely glazed. His mouth is moving in the classic fish out of water manner. I shake his shoulder and ask how he is. He looks at me and just nods.

When I call the hospital, they ask to verify if the man in indeed a DNR. Yes, I say. Very good, they respond and I can tell they are feeling the same as I did initially. Okay, he’s really sick, but we don’t have to devote full resources to him.

It’s awful watching somebody die like this. Wheeling him down the hall, I see nurses and other EMS people looking at the patient. I can see they are thinking. He’s not doing too well. One EMT looks at me and gives an expression as if to say, how come I’m not assisting his breathing. “D-N-R,” I mouth and he nods.

They assign us a room and I relay the story to the nurse and show her the paperwork. She goes to get a doctor. My partners and I try to get the man comfortable sitting up on the bed. I rub his shoulder and again he opens his now blank eyes. “You all right?”

He nods, gives a small tired grunt and closes his eyes.

The doctor comes in and I haven’t gotten thirty seconds into my report when the man’s daughter is led into the room by a registrar. The doctor turns to her and she is crying already. He asks what her wishes are and she says she doesn’t know. She wants to know how he is, and the doctor says, he is not doing well. The doctor sees that the DNR is only a week old and tells her it represents her father’s wishes and that this is probably what they should honor. I’m standing in the corner watching. It is a heartbreaking scene and an urgent discussion, but at the same time I am aware of something else going on. The man is passing. I don’t know if he will be dead in the next minute, but I think his ability to respond is slipping away rapidly. I don’t want to interrupt the doctor and the man’s daughter, while they decide, but I feel I should speak up. The doctor is staring at the woman as she sobs and shakes her head. “I don’t know. I don’t know,” she says.

I wait. I wait.

Finally, I break in. “Excuse me, I hate to interrupt,” I say. “Come, take your Dad’s hand,” I say. “Tell him you’re here. Talk to him. He can probably hear you.”

She takes his hand. His eyes are closed. His breathing is shallow, irratic. She kisses his head. “Dad. It’s me. I’m here. Can you squeeze my hand?”

I look down at where she holds his hand. There is no movement.

12 Comments

  • Rutgher Pruijm says:

    wow that was such a moving post

  • AlisonH says:

    Good for you. I do believe she will forever after be grateful for that.I had the experience once of repeating to an intern exactly word-for-word what he’d said while my bp was 63/21 and falling fast and I was utterly unable to respond. He thought therefore that I was out cold. He was very uncomfortable at hearing his own words given back to him out loud by the patient–nicely spoken, (I had teenagers, I could handle him like one of my kids) but to say, dude. You do not treat people like that. So when someone knows and understands and gets it like you did here, I want to exclaim oh, thank you. THANK you.

  • Walt Trachim says:

    Thank you for that post, Peter.It is so hard to watch someone who is struggling and, ultimately, dying. It is harder to take care of the son or daughter or wife or mother or father that is left. You did a good think with his daughter.From one who knows.

  • Erin says:

    Peter- Thank you for doing that and for writing about it. It shows that this job is more than just going through the motions. I had a patient come into the ED by ambulance a few weeks ago. His family had just put him into hospice the day before. He started to rapidly decline and his family called 911. He wasn’t breathing so the medic intubated as there were no DNR orders or paperwork. His heart was still beating-sinus tach on the monitor. After the doctor talked with the wife, it was decided to take the patient off the ventilator. The wife and college aged kids were able to go in and be with him in his last moments. The patient’s wife was standing back crying looking like she didn’t know what to do. I told her to hold his hand and talk to him as he still might able to hear;his heart is still beating but he just isn’t able to breathe on his own. As I walked out of the room to give them privacy- I hoped that it would give her a little bit of comfort and closure to know that she was able to talk to him while he was still alive…No matter the level of consciousness, I always talk to my patients as if they are coherent- even if someone isn’t breathing and we have to tube them. I still explain everything that we are doing and they are in good hands. You never know if your voice is the last they will hear….In the ED or out on the ambulance it is something I will continue to do.Sorry for the long post. I really want to thank you again for the compassion you show to your patients and their families.

  • Michael Morse says:

    Sometimes it seems as if we are the only peope capable of grasping the signifigance of what is happening around us. I try to keep my eyes and heart open and never forget the enornity of what is happening when a patient starts the death process. Another job for us, an entire life summed up in our presence for the dying person and their family.Your actions on this call will be remembered by the daughter for as long as the memory of her father is alive. It is amazing how during the normal course of our day we become part of a family’s history. Again and again.Great job, both on the call and your recounting of it. Thanks.

  • Laura says:

    Peter -Your post was very touching and brought back many memories…I was with my dad when he died of small cell lung cancer (at home, where he wanted to be). I was able to provide for him and ensure he received appropriate care. He had an excellent hospice nurse.I remember the moment when the life began to fade. I remember holding his hand. I remember when he was no longer able to respond to my touch.You did something special and very important by breaking up that discussion so that a daughter could spend those last moments holding her dad’s hand. :o) Laura

  • Ben says:

    Great post. Everyone should have the chance to die with dignity like that, with the family near them.Hopefully, his last though was an happy one, with his daughter near him.

  • e says:

    Awesome post. This is definetly one of the worst parts of the job. This post shows that you defietly have compassion for your patients and that is awesome and more medics need to be like you. I have been a volunteer firefighter/emt for 9 years and a career firefighter/paramedic for around a year and it is amazing to me the number of people that i work with that have lost all compassion for the people that we are supposed to be helping. Keep up the good writing and good work.

  • Damian Rickard says:

    Pete,Thank you. Nothing more needs to be said…

  • Zach says:

    God, I wish more people understood this stuff. I get so tired of the BS that everyone dishes out as if the bureaucratic processes are actually pertinent in light of the big picture. I appreciate your grip on this. It needed to be put into words.

  • Katherine Howell says:

    Peter, you’ve done it again. Beautiful.

  • Rogue Medic says:

    I used to interrupt people much less. I’ve learned that, if I have a patient care related reason for interrupting, it is probably the right thing to do. The times I haven’t interrupted cannot be taken back.

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