J and the Wilderness

A 68-year-old man came into my ED complaining of sudden abdominal pain. It had started suddenly during lunch with his kids while his wife was out of town. They were all so nice. Uh, oh.

I dug deeper and found that he also had some new numbness on one side of his face, and his arm also felt “funny.” The abdominal pain started at his xiphoid and radiated to his back. No history of anything except high blood pressure.

You probably know where this is going. The CT of the chest and abdomen showed a dissection. It started at the ascending aorta and continued to his iliac arteries, including both of his carotid and renal arteries. Bad, bad, bad.

I had never had a patient with a dissection of the ... everything, but I knew one thing, his chances for any sort of positive outcome were bleak.

I explained the results to the family.

He was going to die.

To be honest, I had no idea how he looked as good as he did, but that quickly changed.

His vitals started the expected trend toward the inevitable.

The patient and the family had one request.

“I want to see my wife one more time before I die,” he said.

Now I am not sure what the world record is for going through the five steps of dying, but I'm relatively sure he shattered the previous record. He jumped over the first four and went straight to acceptance.

His wife had been informed, and she was in transit. She had two hours to drive.

“How long does he have?” his son asked me.

I said the words that all emergency physicians hate to say, “I have no idea.”

His family never left his side over the next hour and a half. We kept him as comfortable as possible and monitored his gradually declining vital signs.

Then, the expected happened. His blood pressure tanked, and he went into ventricular tachycardia. We resuscitated him and shocked him, and much to my surprise, we got him back.

He had a tenuous grasp on consciousness, but would grip his son's and daughters' hands. It was two hours, but his wife still had not arrived. I warned his family that he had little time.

His vitals plummeted a second time. Again, we started resuscitating him, but my expectations remained low. He was out of time.

Five rounds of CPR later, we got him back again. To this day, I still do not understand how.

His motionless body was ashen. The only inclination of life was the slow breaths and the cardiac monitor.

Two hours and 20 minutes after his diagnosis, his frantic wife arrived. She had been informed by her children of his condition. She sat at his side. She held his hand. Somehow his hand gripped hers when he heard her voice. She stayed by his side.

Less than ten minutes passed. Then he died.

I remember being told that I would never forget any death. This has not been my experience as an emergency physician. We know well that death is a part of life. I do not remember every patient I have pronounced; there simply have been too many.

Some, however, will stay with me forever.

A week later, after I had time to digest everything that happened I had a conversation with a colleague. We discussed futile care. Why even try to bring him back when I knew the inevitable? What if the wife did not make it back? What if his vitals never came back?

I could have simply pronounced him after he lost his vitals the first time and no one would have faulted me. In fact, some faulted me for even attempting CPR on someone who had no chance for long-term return of function.

It came down to one thing: my word. I told the family I would try my best to let him see his wife one last time. Somehow, this time, it worked out. We have all had numerous times when it simply does not.

This happened years ago. A few months ago, I took care of a middle-aged man with a sprained ankle.

Everything went fine, but he stopped me after he had been discharged.

“You know, I never really got a chance to thank you for what you did for my dad,” he said.

I had not recognized him as the son, but somehow he remember what I looked like years later.

“You have no idea how much it meant to my mom and to her children that she got to say goodbye. We really appreciated it,” he said.

Put yourself in your patient's situation.

What you would want?

Even if your patient dies, it matters.

What you do matters.

What you say matters.

The choices you make matter.