Tuesday, 1 October 2013

Giving up

Not everyone makes it.  Not everyone who gets to me makes it back out alive.  A few people come to me in the midst of dying, and they finish their journey shortly after arrival.  One of the most difficult things in medicine is determining who is lost, who has traveled too far down the path to eternity to bring back.  I don't like giving up, but sometimes I have to give in.

I had just such a patient recently.  I'll call her Bertha.  She looked every bit of her 80+ years, and those years had not been kind to her.  Decades of smoking cigarettes had ravaged her lungs to the point where she required oxygen at home. There were numerous other medical problems as well, but that didn't stop her from driving.

I wish it had, and so did the tree she hit.

It seems Bertha passed out while she was driving, probably because her oxygen level had dropped too low.  She woke up as the medics were extracting her from her car (the tree was fine), and she immediately started complaining of difficulty breathing.  Her breathing was so difficult that she didn't even feel the broken bones of her lower leg poking through her skin.  When she got to me, it was clear that she was in very bad shape, and I got that sinking feeling that never seems to end well.  She had severe pain in her chest (I suspected rib fractures), and she had a very nasty open fracture/dislocation of her ankle.  For her own protection she needed to be placed on a ventilator immediately, because she looked like she was going to go into respiratory arrest any second.

Unfortunately Bertha wasn't my typical car accident patient (young and healthy).  When older people suffer massive chest trauma, a contusion to their heart can be life-threatening (or even life ending).  When that older person also has lungs that have been destroyed by cigarettes, it's usually game over.  Bertha got her breathing tube, and just a few minutes later, my worst fears came true: her heart stopped.  We started CPR and gave her medications to try to restart her heart.  After a few minutes, it restarted, but I was afraid the damage to her heart and brain was too much for her system to bear.  I was also afraid that when those medications wore off, her heart would stop again.

And just 5 minutes later, it did.  We did CPR again and got it restarted, but then it stopped once more.  As my team continued doing CPR for the third time, I ran to talk to Bertha's daughter.  I told her exactly what was going on, and that it was probably time to give in.  I didn't think Bertha was going to make it.  Her trauma was too severe, and she had no physiologic reserve to tolerate it. 

"Please don't give up, Doc," she said.  "Please."

I decided to respect her wishes and keep going despite my grave doubts. 

I ran back to the trauma bay, and we got Bertha's heart restarted for the third time.   I waited for it to stop again...and waited...and waited... but this time, it didn't stop.  She required two medications to keep her blood pressure elevated, but her heart kept on going.  The next day the orthopaedic surgeon fixed her ankle and she no longer required those medications to keep her heart pumping.  The next day she woke up.  Two days later her breathing tube was removed and she started breathing on her own.

Bertha's daughter hugged me a few days later as I told her that her mother tried really hard to die.  And I admitted that I had been ready to give in.  Bertha just smiled, coughed weakly, and said, "But I wasn't ready."

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