Death isn't new anymore

This is a tough post to write. Doing it with bourbon in hand. I warn you some of the below is a bit more graphic at times, so fair warning from the start. Skip if you're not in the mood.

The last number of days actually haven't been too bad. I haven't seen anyone die, but I've watched as people were dying. And today, as restrictions on visitors for patients at the end of life have been lessened, I still hit major roadblocks in trying to allow families to come say goodbye to their loved ones.

In NY we are starting to allow a visitor for someone who is imminently dying from COVID in the hospitals. For weeks we have had patients die without loved ones around them. Relying on brief phone calls or videochats, never enough. Luckily, as hospitals decompress, we are correcting this issue. However, Elmhurst seems to be lagging in this, probably because the whole hospital is covered in the virus. We recently had two patients in the unit with poor prognosis. Today our Palliative care attendings informed us that visitors may be a possibility. I was almost in tears, so happy at the thought of family members in our unit, breaking up the whooshing sounds of ventilators interrupted by the endless alarms. But, unfortunately, I learned that since our patients were not in individual negative pressure isolation rooms (the whole unit is one large negative pressure room; patient isolation is, no joke, that we put clear plastic bags over patient heads), visitation was not allowed. I was again, almost in tears. It was too unfair, that just by dumb luck these patients were stuck in our unit instead of in a place where family members could visit. I guess that just took me to a darker place where I thought about all of the death I have seen over the last number of weeks.

Prior to this experience, I have seen three deaths. One was as a medical student, actually at Elmhurst. I was working in the Emergency Department and, very sadly, a pregnant woman was brought in in cardiac arrest. (WARNING: graphic line ahead) They performed a slash c-section on her in the trauma bay, and performed cardiac arrest on her and her baby. Neither survived. I was next in line to perform compressions. She died before I got the chance.

The next time was earlier this year while in the operating room. We had a sick patient who had a problem with his tracheostomy. He was awake and interactive when we came into the room. Medically, what happened was complicated, but in short, he too went into cardiac arrest. We performed ACLS/CPR for 45 minutes. I was the first person to perform chest compressions on him during that code. I was an EMT and CPR instructor before I graduated medical school. I taught this a million times, but never did it myself until then. I always told students if they were doing it right, they would feel the ribs crack. As I learned then (and have now experienced multiple times), I was right. That sensation is one of the weirdest things that is now stuck in my brain. No matter how I try, I can't get it out. During this code, I tired myself out on compressions, threw in chest needle decompressions, ran through my H's and T's. With a room full of anesthesiologists, surgeons, and eventually the rapid response team, we finally called the code. My hands were still on his chest when he died. I was the last one to touch him "alive."

The third time, the most difficult, was not in medicine at all. It was with my dear mother-in-law Leslie. I don't want to get too into it. It's too hard. I got to say goodbye. I got to hold her hand. I stayed with her afterwards. I miss her.

But in all of these, I got to process my experience. With Leslie, we had a funeral, we had family. With the ones in the hospital, it was obviously more regimented. When I was a medical student there were debriefing sessions for everyone involved in that code, as it was more emotionally charged than most were used to. For the patient in the OR, the entire team discussed, as a group what went wrong and what went right immediately after the code. The core group of ENT's in the surgery met after to just sit and talk.

I bring this up because in COVID-times, it's all changed. There has been no time to really process. It's part of why I am writing this. Death just came in the beginning. I've mentioned in other posts some of the early deaths I saw. Unceremonious. No long codes. No big teams. Not for lack of caring, but just because of lack of resources and time. We had to save who we could. As a friend and co-resident who has been working in our ICU too said to me, this was more like war than medicine.

Since my time in the ICU, I've now coded more patients. I've felt more chests crack. I've watched more hearts stop. In a horrible horrible way, I've felt like a god. Calling the time of death, calling the end of someone's life--I don't feel like I've earned that responsibility. And I'm no one to that person whose life I "ended."

The other night, me and one of my co-residents sat and watched a woman die. She had an incredibly poor prognosis. The family agreed to not give her chest compressions, but everything else was fair game. I maxed her out on three pressor medications to keep her blood pressure from plummeting, knowing that it did not matter what I was going to do. She was going to pass in a few hours. Those few hours were the longest I've ever experienced. I feel sick thinking about the awful feeling, "just get it over with already", that crossed my head. I felt multiple times like we should just withdraw care instead of watching this happen; not sure if I felt that way because I thought it was more humane or because I wanted it to be over. I watched her cardiac monitor as her heart raced. Then it looked like the monitor shorted out. Her heart stopped, so did her blood pressure tracing. 1, 2, 3, 4, 5. Then it came back. But instead of a racing heart, it now was beating at 50bpm. I just saw part of her heart die.

Despite additional interventions, an hour later, the same short circuit happened. 1, 2, 3, 4, 5. This time her heart was 30bpm. Then crazy rhythms appeared but she still had a pulse. Her heart tracing disappeared multiple times. Small parts of her heart were dying as we just basically watched, knowing that this was it for her. Maybe if I knew more, I could have done some more. Most likely not. Eventually she lost a pulse. I started the "code." We gave her some epinephrine and a "normal" rhythm reappeared, but no pulse. This is called pulseless electrical activity (PEA). It's one of the craziest things in medicine, because basically it looks like heart is functioning but it's just one big fake out as the heart isn't pumping at all. Another round of epi. Still the same rhythm, no pulse. I had to call it. So weird to call the code with a heart rhythm still there. It honestly felt like I was killing her.

Look, there are people in medicine who do this MUCH more regularly. Yes, COVID is different and there has been a lot more death in a very short time period. But there are ED docs and intensivists who do this for a living. Medicine residents take care of far sicker patients than I ever do. I have such an incredible respect for them that I did not before. Maybe you can too now. Your doctors and nurses emergency departments, medicine floors, ICU's, and palliative units (those that really do this for a living) are saints. When 7pm hits, I'm clapping for them, because when I finish my stint in the ICU, they are going to keep going. I don't know how they deal with this death without getting numb. Or how they deal with death without letting the negative emotions take them over. Over the last number of weeks I have been both devastated and numb. I'm trying to find the balance of how to deal so when I face this again, after this is done, I will know how to handle it better.

Sorry for the morbid post. Thanks for reading if you got to this point. We are coming to the end of this COVID ICU and I'm just a bit reflective on the experience, good and bad. This was the bad. Next time, the good.