90 Seconds in Heaven?

Today was another eventful day in the Grady ER:

An elderly lady with a possible stroke, a middle-aged man who overdosed on tylenol in a suicide attempt, a young man in diabetic ketoacidosis because he can't afford his medicine for his diabetes, and lastly, the miracle patient who came back from the dead.

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We got a call from EMS, "We're about 5 minutes away with a patient that is unresponsive and losing a lot of blood through the oropharynx(throat). We can't intubate him because he's clamped up." The physicians hurried into the CPR room to prepare the intubation equipment along with airway drugs (to paralyze and anesthetize the airway for intubation). As EMS wheels the patient into the room, the paramedic reports the patient lost about 2L of blood in the ambulance and went into ventricular fibrillation (vfibb) and they tried to shock him, but he was still in vfibb.

There about 10 people in the room at this time (interns, residents, attendings, nurses, medical students). Everyone got busy working on the patient. Someone cut off his shorts, the resident started a central line in his femoral vein, an intern started chest compressions, another resident worked on intubating him, another resident was getting an ultrasound of the heart, another resident was giving epinephrine injections, a nurse was standing by ready to shock when needed. People kept switching turns doing chest compressions. Every two minutes, they would stop compressions and check for a pulse. Every 6 or so minutes they would give a shock. After 20 minutes of working on the patient, the resident in charge of the code asked if anyone else thought that they could do anything to bring this patient back. No one said anything, and time of death was declared.

A chill ran down my spine. Through this whole process, I had been standing in the corner, trying to stay out of the way, watching everyone trying to desperately to bring this man back to life. I felt like crying (but I didn't). He was a stranger, yes, but the loss of another human life is hard.

As people were leaving the room, the resident I had been shadowing came over and asked me if I had any questions. As we were discussing the patient, we hear someone say, "He has a pulse!" With this, the activity in the room picked up again as the patient was ventilated and given more blood and fluids.

After having no pulse for about 20 minutes, the patient's heart had started to beat again on its own...a few minutes after he was declared dead.

Patient Autonomy

When I was in clinic today, my preceptor (Dr. M) told me about a patient he saw last week. An 86 year old man came into the office with his son and daughter because of altered mental status. His children reported he has been getting progressively more confused and the patient could barely stay alert during the office visit. At one point, they had given him coffee to try and help him stay awake, and he felt asleep holding the coffee, ending up spilling it on himself.

Altered mental status in an older patient is never a good sign, so Dr. M discussed going to the emergency room with the family. The patient was insistent that he didn't want anything done to him and he certainly didn't want to go to the emergency room. Dr. M and the family compromised and decided to do blood work in the office that day and set up an appointment to get a CT scan the next morning (to rule out stroke, etc...)

The blood work came back the next morning with HUGELY elevated liver enzymes and some other minor elevated electrolytes. Dr. M immediately called the daughter to advise them once again to go the hospital. He even arranged for a hospitalist to admit them directly, so they wouldn't have to wait in the ER. The daughter said the previous night had not gone well, so she would discuss it with her brother and father. She later called Dr. M back that day to tell him her father had passed away, not wanting to go to the hospital.

This story bothered me. At the core of it, lies the issue of medical ethics. One of the four pillars of medical ethics is patient autonomy -- you can't make a patient do something they don't want to do, but as their doctor, you feel a certain level of responsibility for their well being. So what do you do? Can you force someone to go the ER? If someone has resigned themselves to death, but you know there is an easy way to save them, do you just let them die? I think it's one of the bigger lessons in medicine that I'll have to learn -- to accept that you can't control everything, sometimes it's the disease and other times it's the patient's will.