Posts Tagged ‘death’

Saving a life?

Posted: August 11, 2011 in medicine
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This story begins with me in a rotation in the medical ICU as an intern, which is the first year of residency. I feel more prepared than others because I have experience as an EMT on a 911 ambulance service and I also have had quite a few rotations before this one, including pediatrics, 2 family medicine hospital rotations, and a rotation in the cardiac ICU.

As settle myself in I see the fast paced action going around and I decide in about the second week to tell the senior residents that I want to “run” the next code. Running a code basically means you tell when to give the drugs, when to stop CPR to check the EKG rhythm, and when to stop the “rescue effort” all together. As fate would have it, the next patient who “coded”, aka whose heart stops mechanically pumping, is one of the patients I have been managing.

She is an african american in her 50s who looks like she’s in her 80s because of her severe blood infection (sepsis). I have never interacted with her when she was awake, as all my visits have been while she was in this coma like state. Despite our efforts to save her, including tons of IV fluids, which are making her swell like a marshmallow, and 10 drugs hanging from IV poles, she is still dying. Even though everyone sees what is happening, her health care proxy, her son, wants us to do everything possible.

The blue light begins flashing, “CODE BLUE MICU, CODE BLUE MICU”, indicating a patient in cardiac arrest. I run to my patients room knowing that it is probably her. I am one of the first ones there and begin assuming command of the code. As I am keeping track of time and the drugs that have been given, I am disgusted as I watch the medical staff slip off her chest as they do CPR. Sadly, she is so far into sepsis that any contact with her is literally tearing off her skin. The area where chest compressions are done is just bare raw flesh, even her wrist where the nurse is checking for a pulse has turned into red flesh absent of any skin. The staff put a towel on her chest so their hands stop sliding while doing CPR. We continue the code….5 minutes…10 minutes… I call out “2 more minutes and I am calling the end of the code!” 1 minute passes… Then a nurse yells out “I have a pulse!”, I reply in a monotone voice “Confirm”, which another nurse does.  We end the code and I have “saved” a person. A person who is twice their normal weight from all the fluids that are needed to keep her blood pressure up, a body that’s skin falls off at the slightest of touch, a person who has no interactions with the outside world.

At the end of the code, when everyone else has left , I straightly stand over the “living” person. I stare down at her corpse-like body thinking “What have I done?” Have I really “saved” a person to experience more suffering and hardship? Tears begin forming in my eyes as I am having trouble accepting if I have done as what Hippocrates said, “Do no harm”.

I go off to lunch for about 10 minutes, when I come back a bedsheet is over her body. Her heart stopped again during the short period I was gone and the staff made the son watch the resuscitation process. He last only few minutes before he pleaded for the workers to stop and let his mother go.

Thus ended one of the most horrible experiences I have had when I did what is medically right, but felt so wrong inside.

 

I stand in the hallway with my dress shirt and pants accompanied by an oddly matched tie wearing a long white coat which is slightly dirty and has pockets overflowing with papers and notes.  Next to me is a small red-haired medical student, this is her first rotation but she is a former hospice volunteer so she is use to these emotionally stressful situations.

Across from me is a young black woman with tears in her eyes even before I say a word. But her eyes speak of something else, they speak of an intense need for someone to give them hope, but I am about to do the opposite. I am very blunt with her, I use the word “Death” and “Dead” repeatedly. Odd thing is, I feel myself when speaking like this, I drop all my filters which parallel tact and just “Shoot from the hip”. I crush her hopes, re-affirm again and again that palliative is not curative, and her loved one is in the hospital to die, not be treated.

While I am explaining this I am burning a lot of energy actively scanning for non-verbal communication. This of course is a problem with people with autism, we lack the ability (severity varies) to read non-verbal signs. To overcome this I run what I call “computer scripts”. I watch water from eyes forming tears, I look at the angles of the mouth to see if they change from resting state, I look at the facial muscles to see if they twitch, and I watch the hands to see if they jitter about or make fists.

The worst part for me, and sometimes most telling, is eye contact. Making eye contact, especially prolonged, causes what feels like physical pain to me. A searing feeling in my head that causes my mind to shout at me “LOOK DOWN LOOK DOWN”, I start to feel anxiety flood my body and my muscles tense, then I break eye contact and start again. But the problem is I know normal people thrive off eye contact. They NEED the ‘other’ to look at them in the eye and maintain eye contact in such a very stressful situation. So I run another script, I stare at their pupils for 20 seconds, break eye contact and look down for 1-2 seconds, re-engage. During this I examine their own eye contact, do they avoid my eyes? Do they burn with intensity and anger? Do they look beyond me? Are they dim-witted, like they aren’t absorbing the information I am giving?

It’s amazing how comfortable I am in these encounters, it almost feels like I am in “the zone” despite my lack of natural communication skills. I have an objective and multiple strategies to get to achieve that. I adjust my plan based on my scanning of non-verbal communication. And when the patient has a peaceful passing that is void of suffering, when I have reduced whatever mental suffering and questions the family has, that is when I feel a sense of accomplishment.

Its kind of funny though, if you asked me in undergrad or medical school if I was interested at all in palliative/hospice care I would’ve given a definite no. But this year I have had many, many encounters with it and it is one of the most satisfying interactions I have hd. Even when I spend a large amount of time fighting with a family on the behalf of a patient suffering horrible pain, when that patient passes in no pain because of me, I feel like I made a difference.

Does grief affect someone with autism differently than neurotypicals (those without autism)?

I went to assess a pt who was in end of life and met the pt’s daughter in the hall. She was shaking and saying her mother hadn’t breathed in over a minute. While the nurse tried to calm her down I listened for breath and lung sounds, which there were none. I informed the daughter and she started crying. I started feeling the strong sense of composure and cold detached logic, which I pride myself on, collapse. The wall around my emotions I had been building since my grandmother’s death 3 years ago just gave way and I felt the daughter’s grief affect me on a personal level. As I saw the daughter cry I began identifying with her pain and knowing how deep it runs which tore me apart inside. I felt tears start to well up in my eyes, I tried to say my condolences, hugged her (which I did even though it causes me physical pain because I know neurotypicals need it in times of grief) and quickly escaped the room.

It all seems odd to end up this way as I have spent countless hours focusing on my death, planning it, trying to predict it’s after effects. I looked at death in a logical way, as in an event that is expected end point of any life. Yet I was not prepared for my grandmother’s death and it ended up changing me forever. After the event I didn’t really talk and I started sleeping the days away. I had typical grieving reactions such as thinking I heard her voice or seeing her out of the corner of my eye. I cried for months and found it very hard to not wake up thinking of her. I couldn’t even watch TV shows or commercials that contained grieving people or I would become very upset.

Fast forward 3 years later, and things have become like what Johnny Cash said regarding his brother’s death “I kept talking but everyone stopped listening, so I stopped talking about him”. In this time period, it feels like I have built a wall, a defense system against tragic events effecting me personally. While this may seem cold, it is required if you are a doctor in a field with death being a normal expected event, for example: In my ICU rotation we had someone die around once a day and if I had opened myself up to the experiences of the family because I would have not made it thru. I thought the barriers I had formed over the years were near complete as I had gone thru patient deaths unscathed. Yet, when this patient’s daughter, who I have known only for 6 months, started grieving my defenses completely failed.

I suppose I should have predicted this, for the wall itself is in part a charade. If I was completely healed from my loved one’s death, couldn’t I bring myself to visit her grave? Couldn’t I think of her and things we did without crying? Would I avoid talking about her for fear of the emotional response it will bring?

So I would say yes, in this case an autistic man grieves like any other man.