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I hope when I find out what it's like, I'll be able to handle it, or have someone there looking out for me if I can't D:
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I work as a Tech on an extremely busy cardiac floor. I was assigned to the code team the other day at work. Being a tech means you are the first to respond and begin compressions. The poor guy was literally dead cold. It was probably the most difficult thing I have ever done. I always thought I could keep my composure but I was wrong. I had to run to the bathroom and cry. I never cry. Like ever. One moment your patient is alive and well, laughing with the staff and the next thing I hear "stat rhythm check" and my heart sinks. I can't wrap my head around how the docs feel when making such dire calls for their patients. Well, at least for now.
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Maybe if my profession did more central lines. I think I would be as comfortable with an EJ IV as the nurse. Anyway if you're at that point, why not just get an IO?
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Because if you're upping the game, you're probably better off just sinking a central.
We always switch away from using the IO as soon as something else is up and running (whereas we switch to the centrals), so I can't see why they'd put one in specifically for the hospital course.
I always see, for adults,
'tough IV stick + critical -> central'
'tough IV stick + noncritical -> EJ'
Very rarely do our ED docs jump to an IO - maybe a few times/year? We don't even have the kits readily available other than peds sizes (despite asking central supply 80x), so if we put one in we usually make EMS run out to their rigs for theirs.
EMS seems to like them more, they'll throw them in sometimes. Honestly, they stick out, so they're kind of inconvenient when you're trying to do clothes, blankets, bed changes, or move the patient around.
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You know, one of my most memorable experiences has been when a patient died. And I am glad I got to experience it.
She was in the ICU and was not improving. She was able to hold on for a few hours and see her family, but then things started to go downhill. Previously, she had a clot and had to be on blood thinners but then she developed an internal bleed that couldn't be operated on. Literally, she was bleeding to death in her room, abdomen swelling up as we saw her. We called a surgical consult and they said they couldn't do anything saying, that putting a scalpel to her would relieve the only pressure keeping the bleed from being worse. Her BP was dropping, organs were shutting down, ventilations becoming shorter and shallower, skin becoming less pliable and colder.
So we went to the family and told them the news. We told them we thought pallative care measures were best. We would remove all drugs and IVs, quit taking BPs, etc. The only drugs she would be given would be pain meds and drugs for anxiety in case she had any. And if she coded, we would not do anything. Of course this made them all start to cry, some got angry, but all accepted the inevitability of the situation.
Something amazing happened at that moment. We quit being the doctors of the patient and transitioned to being the doctors of the family. We helped them through the grieving process. We made sure there was a chaplain that visited them multiple times. We brought them quilts and encouraged them to bring whatever she would have wanted. We even used the overhead speakers in the room to play a Pandora station of her favorite music (Taylor Swift if I remember correctly). We stopped recording vitals to not interrupt the time the family needed. We only went there to offer food to the relatives to see how they were doing.
Anyways. We still had a few pieces of data that were coming to us, like the pH of her blood and her ventilation rate. We were using them to predict when she would pass. It's tough to be in the place of the physician in this scenario because we could not tell if she was going to pass in an hour or a day. At some point, the family started to become frustrated because they had said their goodbyes and she still hadn't passed. But we used this time to help them more.
She ended up passing away during the night. The family came to us to thank us for helping them through the tough time and doing everything we could. I left there shortly after she passed and I felt odd. I never thought I would feel like I did a good job if a patient died. However, here I was feeling good about myself and thinking I made a difference.
What I took away from it all is that death doesn't have to be a bad experience. You don't have to have a feeling that you could have done more. I am sure there was something else we could have done, but I don't want to think about it. I want to focus on the positive differences I made that day and remember how this woman made me different. She is actually the reason why I am considering becoming a pulmonary/critical care doctor.
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Ah. We don't have residents, just the attendings, and ER docs respond to and run all codes unless it's the ICU and the intensivist happened to be at the bedside when it all went down.
(Also, in the OR, the anesthesiologists do their thing and if anyone calls a code, they cancel it and run things themselves.)
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More of a philosophical question from a mere pre-med who has never experienced a human death:
Does the numbness and disconnect you feel towards the death of a patient affect the way you think about your own death? Is it the same numbness, or is it different because it is a personal thing?
Does the numbness and disconnect you feel towards the death of a patient affect the way you think about your own death? Is it the same numbness, or is it different because it is a personal thing?
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I wouldn't call it a numbness, but I am now a great believer in DNR/DNI. I spent several days on palliative medicine during my FM rotation, and many of those deaths are neither pretty nor peaceful. Not that death should be "pretty" but a lot of the terminal ICU patients are in bad shape, so much that I wouldn't want my family to see me like that.
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A lot of times there isn't something else you could've done short of a miracle. Most of the people I've taken care of are terminally ill or chronically ill/have so many comorbidities + so old that they'd be better off having as close to a peaceful death they can get. I'm a firm believer in hospice and being able to die at home.
Instead the end of a lot of peoples years are spent being shipped back and forth from nursing homes to hospitals developing pressure ulcers/skin breakdown bc there's not enough staff to properly take care of them, worsening dementia, falling out of bed, developing hospital acquired infections, being poked in the arm day or night sometimes screaming bloody murder, having tubes stuck in you, choking on your food and developing pneumonia and so on. Then we wind up breaking your chest at 90 years old. Not a good quality of life imo and not how I'd want my body handled even after I'm gone. But if that's something you fully understand and want at an old age then that's your right as well. But people should really get their affairs in order. As mentioned above a lot more people should be DNR's than actually are.
Just the other day one of my coworkers was taking care of a man who must've been at least 85 years old but he looked 110. Pressure ulcers everywhere, contracted into a little ball, dementia and she had to stick an iv in him. Why torture the man anymore. What quality of life does he have. This man served in WWII and now he has to go through hell again. That was a kind of sad one. But most of the time I think of it as a relief. They're at peace.
Now when a patient does die who was young or it was something easily preventable, that's a whole different story. That'll always hit you in some way and feeling that is a part of coping.
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My past two rotations have been a month of palliative care and I'm not into 2 weeks of medical ICU at a very large referral hospital that sees the sickest patients in the area.
I go home almost every single day and have very stern talks with my husband about all of the things he isn't allowed to let be done to me. He has been threatened a lot about the amount of haunting that's going to occur if he ever g-tubes me or codes me when it's pointless or gives me chemo/radiation until my passing day.
PS everyone in this thread should read Atul Gawande's new book, Being Mortal. It's pretty short and an amazing look into end-of-life care in this country. I wish I could give the last half to every single patient & their family that I encounter.
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Patient deaths have changed a lot for me over the 15 years I've been a doc.
In the beginning they were often terrifying and felt like personal failures. Or system failures. There were tears. There was anger. There was horror at what death in the hospital looked like most of the time. The first time I broke an old lady's ribs was not so great.
Since being an attending, I've been physically present for fewer hospital deaths, but have had my share of long time patients die. Most expected, some not.
Keep a record if you can. Some are instructive, all are part of the story.
In the beginning they were often terrifying and felt like personal failures. Or system failures. There were tears. There was anger. There was horror at what death in the hospital looked like most of the time. The first time I broke an old lady's ribs was not so great.
Since being an attending, I've been physically present for fewer hospital deaths, but have had my share of long time patients die. Most expected, some not.
Keep a record if you can. Some are instructive, all are part of the story.
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Early on I used to be able to recall the faces of all the people who had died on my watch.
After a while, there were just too many to remember. Now I forget them after a few weeks.
Emotional numbness I suppose.
Between being an ER resident, ER attending, ER/Trauma attending at a deployed military base, and ICU fellow... I think I've coded hundreds and hundreds and hundreds of people. At some point, you just have to shut it off or it will break you.
After a while, there were just too many to remember. Now I forget them after a few weeks.
Emotional numbness I suppose.
Between being an ER resident, ER attending, ER/Trauma attending at a deployed military base, and ICU fellow... I think I've coded hundreds and hundreds and hundreds of people. At some point, you just have to shut it off or it will break you.
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Glad you got him/her back.
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Just a personal thing for me, but it pisses me off to no end when people (health care workers and even the general public) write off old patients.
Especially patients who may be outside of the age range to be treated for a stroke or MI... Some think well, they are old, they have lived their life. Sometimes I just want to say NEWS FLASH! THEY ARE STILL ALIVE!!! They just write them off and send them over to hospice.
😡😡😡
🙁
Especially patients who may be outside of the age range to be treated for a stroke or MI... Some think well, they are old, they have lived their life. Sometimes I just want to say NEWS FLASH! THEY ARE STILL ALIVE!!! They just write them off and send them over to hospice.
😡😡😡
🙁
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Exactly this.
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This person is coding 1-2x per day... kind of reaching the limits of medical technology at this point...
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Heard some attendings talking about how xyz patient with substantial mets has only 2-3 months to live. Went to go consent a patient for a tumor study and came face to face with that patient. Healthcare proxy is pushing for surgery. It's on an extremity for a path fracture, but ugh.
There was a patient yesterday who almost died on the OR table before the procedure even began. Had orders not to use chest compressions so the anesthesiologist shot them through the roof with pressors and the case was fine. I saw the patient's son today and he was bringing his parent coffee this afternoon and was overjoyed at how well she was doing. Not bad for having had spine mets and significant cord compression.
There was a patient yesterday who almost died on the OR table before the procedure even began. Had orders not to use chest compressions so the anesthesiologist shot them through the roof with pressors and the case was fine. I saw the patient's son today and he was bringing his parent coffee this afternoon and was overjoyed at how well she was doing. Not bad for having had spine mets and significant cord compression.
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Oh, so not a code that feels like a win. Etiology of their coditis?
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I've never been in a hospital in which one could go to the OR without at least being temporarily full code.
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The patient had scheduled surgery for Metastatic disease causing cord compression.
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The patient had scheduled surgery for Metastatic disease causing cord compression.
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This is a big legal/ethical debate in medicine right now.
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Come on, you're an ICU fellow - you know this is usually the beginning of a long shift
Depending on the circumstances, it may be a good thing, or a bad thing. Do enough codes, save enough people, and care for them post-code in the ICU, and you will understand when sometimes a successful code isn't really a good (or humane) thing for the patient
Sorry to hear that. Long day?
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Bad heart, needs a new one but not a candidate for transplant. Family not understanding the reality of the situation. Finally bridged with ECMO (which has stopped the coditis). Unfortunately it appears to be a bridge to nowhere...
Yea... makes the shift go by faster though.
My opinion of a successful code has definitely evolved as I've moved from the ED to the ICU. And now when I go back to the ED I'm more willing to take the time and talk with the family while compressions are ongoing and try to explain the reality of the situation (I like that phrase btw). As an ED resident I would often see a code as a procedure lab, leaving the psychological/moral/ethical dilemmas to the attending. As long as they said keep going I would maximize the medical impact on the patient even as we all talked around the room about how futile this is...
Hmm... I guess everyone has to grow up eventually.
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Ah, I understand. She was a doctor in a different country and said she didn't want chest compressions.
I'll ask the fellow about what you mentioned though!
I'll ask the fellow about what you mentioned though!
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Just a personal thing for me, but it pisses me off to no end when people (health care workers and even the general public) write off old patients.
Especially patients who may be outside of the age range to be treated for a stroke or MI... Some think well, they are old, they have lived their life. Sometimes I just want to say NEWS FLASH! THEY ARE STILL ALIVE!!! They just write them off and send them over to hospice.
😡😡😡
🙁
Depends on the protoplasm. I've seen CABG on 88-92 y/o patients that did well because they were still living on their own, gardening, driving (hopefully we'll), etc. I was personally glad the surgeon took that into account (and the cardiologist who catheterized beforehand). However, the far more common bedridden, nursing home resident, 20 pills a day taking, demented patient, getting daily dialysis for nonexistent kidneys and heart, etc is the type of patient I completely disagree with you about. There are docs out there that look at more than age (most do) but the majority of the time you aren't seeing these healthy oldest old patients.
And ribs crack on the healthy 80+ y/o patients during codes too. Not saying that alone is a reason not to code, but it feels pretty terrible.
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I do agree with you on this. It is extending a quality of life that is not really a life at all just an existence.
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