EPTIt's been one hell of a long time.
First of all, apologies for the long absence. I've had a massive workload lately and I haven't been able to write in my blog or play as much SC2/cast games as much as I wanted. Now that my voice is all screwed up, I can't cast either :C...
Buuut... Since I'm sick with laryngitis and my doctor put me on sick leave for 10 days, since, as he said "you're a doctor and your main tool is not your brain, it's your voice, and if your voice isn't good, you're worthless, so you're hereby forbidden to talk until further notice, and thus, TAKE A FUCKING SICK LEAVE, FFS!"... So I'm now home with a speech ban upon me, hence I'm boring sick, so I've been playing a lot of ladder games, checked the HoTS beta, and thought to write about my last ER case, as I usually do.
This was yesterday, on my last shift. I had been sick for over 10 days, and I was refusing to give up my ER shift, so I went to work with the shitty little voice I had left.
An uneventful morning was going on. I had seen about 40 patients when we had a phone call from the EMT dispatch centre.
We've got a call for an elderly woman who's unresponsive at her home; next of kin is providing CPR. EMTs arriving to scene.
I then preppared everything at the reanimation box in the ER for what seemed to be a cardiac arrest. My gut call was confirmed a couple minutes later by the EMTs calling on the radio.
Doctor, be advised: Were inbound with a 92 years old female, hypertensive, BP 180/110, pulse slow but steady at 40 bpm's, saturating at 95% with 2 litres per minute of oxygen, who collapsed at her home; recieved CPR from relatives for reported missing pulse upon first attention: patient currently with good vitals.
So, patient was sort of stable...
She enters the ER 2 minutes later. When I saw her, my heart sort of shrunk.
She was a little old lady, looking very, very frail... A little pale, with white hair; very thin, in an odd sort of lateralized possition... Seconds later, her family arrives. I send a nurse to gather some data.
As soon as she leaves the room, we connect the patient to the vital signs monitor. Nothing weird so far...
Her physical examination had a few things to note.
Upon examining her chest, she had noises in her lungs that suggested fluid was being gathered in them. I ordered to push an amp of Furosemide, a medication which helps the kidneys get rid of excess fluid in the body. Her extremities had oedema, which is basically swelling due to retained excess fluid. And last but not least, when I examined her heart, I heard a murmur at the mitral valve. You see, the heart has 4 cavities: Left atrium, right atrium, left ventricle and right ventricle; there are 4 valves, acting as gateways between atriums and ventricles, and ventricles and major blood vessels: The tricuspid valve, the gateway from the right atrium to the right ventricle; the pulmonary valve, from the right ventricle to the pulmonary artery; the mitral valve, from the left atrium to the left ventricle, and the aortic valve, from the left ventricle to the aorta.
The mitral valve recieves that name because it resembles a bishop's mitre...
![[image loading]](http://cdn.aquinasandmore.com/images/items/damascene-bishops-mitre9121lg.jpg)
A bishop's mitre.
This particular murmur is called the "mitral regurgitation" murmur, since it sounds like blood is being pushed back to the ventricle. It usually means one of the valve's leaflets has dropped, being leaky. In a patient like this, I had to think of a very particular reason: One of the muscles which control the leaf had been damaged, most likely from a myocardial infarction.
![[image loading]](http://www.heart-valve-surgery.com/Images/mitral-valve-anatomy-1.jpg)
TL; DR the last paragraph: The old lady had THIS in her heart.
I then ordered an EKG and some blood tests.
Her EKG was taken in a minute. I inmediately took the paper strip from the machine. It looked like this:
![[image loading]](http://www.portalesmedicos.com/imagenes/publicaciones_2/0909_ECG_IAM_IMA/supradesnivel_ST_infarto.jpg)
Oh, fuuuuuuuuuuuuuck...
Upon seeing the EKG strip, I looked like this:
![[image loading]](http://illblogthereforyoublog.files.wordpress.com/2012/03/carter.jpg?w=523)
Yeah, I was not amused.
Note: Any likelihood between Dr. Carter and myself is a coincidence.
Grim. She had a MASSIVE heart infarction.
I went outside to speak to her family to break out the bad news...
Both her daughters were there. I knew one of them, which happened to be an EMT at my hospital: she retired 3 years ago. She was the one who gave her mother CPR.
So I told them what her mom had.
Then the former EMT asked for a while alone to discuss the subject with her sister. I went back inside the reanimation box to attend my patient and told them I'd be back in a couple minutes.
I then ordered 3 miligrams of morphine to be pushed IV, a drip of labetalole to be installed and to up her oxygen a little while we waited for the blood tests, and asked for a bed to be prepared for admission.
A few minutes later, the nurse comes back in... Tells me the old lady's daughters wanted a word with me.
They basically told me this:
Doctor, we're very grateful for everything you're doing for her... But she's so old. Her heart is giving in, and we'd like to respectfully refuse any treatment you want to prescribe for her right now. She's lived her life and we don't want her to die in a hospital, visitors restricted, maybe alone and without her family and without her things... We'd like to take her home, and we understand what it means to refuse treatment, but we don't want her to be admitted and to die here...
I was so moved I had a hard time handling my emotions. But I understood. I thought of my own mother, if she were that old... And I totally got in their shoes.
If you truly understand what taking her home means, I have no objections... You'll have to sign a release authorization, a do not resucitate order and a do not treat order... I understand what you're thinking and I fully support your call...
Then, the former EMT said 9 words that have been ringing in my head ever since.
"Doctor, thank you for letting my mother die well."
After signing a few forms, they took their mother home.
I broke upon seeing them leave. A colleague of mine who was leaving the residency saw me on the hallway, hands on my face, crying...
"What happened, man?"
I told him this story. With my almost non-existing voice.
He told me this:
"Look man, I know letting go is very emotional, but they have been strong enough to face death with a grin... You should too... And get yourself home, damnit, you can't even speak and you still want to work here... You must really love the ER, but you've got to look after yourself, too... Go home, get some rest, call an Otorhinolaryngologist and get your throat checked, man... I'll handle your shift.
I then went home... And have been thinking of those words.
We truly don't value the dignity of death. We sometimes don't see how important it is for people to be surrounded by their family, to be within their home, in their bed, during their final moments. Hospitals should be a place for people to get better... Not for them to go dying. The bravery with which the family of this patient faced death was admirable.
I wish to have that strength the day one of my folks goes away.
I want my kids to have that strength when I go, too.
Thank you for reading.
