My patient died 45 minutes after he left the ER. His death was beautiful and awful. I remember snapshot moments that will last to eternity: the sylphlike granddaughter wrapping her delicate arms tightly around my patient's quivering body, the weary sister resting her gnarly hand over her brother's trembling fingers, the soldier son standing to attention, listening to his father's wishes. I thought, he's fragile and wasting away, but their bond remains radiant and strong.
No beauty in my patient's final hour. A devoted grandfather of seven, a skilled classical composer with cobalt blue eyes and the fine fingers of a pianist, he died with a belly full of air and funky yellow contrast dye. He spent his last hour listening to the dissonant lament of the CT scanner as it took cross sectional pictures of his abdomen and pelvis. Images of death's approach ordered as a final request. My patient's last wish: he had wanted to know his diagnosis, his prognosis; how much time he had?
Not long: 5 hours, 300 minutes, 36,000 beats; a fast tempo. An easy post mortem calculation. Did he die with the click of the metronome in his head? My patient was 84 years old. He had presented with abdominal pain. One of the nurses brought him to my attention early on his final evening.
7 pm. "Alexandra, would you see the man in room 43? He is in pain and looks sick."
I respond immediately to the nurse's request. She rarely asks for much. I walk into room 43. I see an elderly man lying curled up, a sheet entwining his upper body, just covering his midriff. The man's contracted and atrophied legs are exposed. A sore festers on his left heel, and a long, ragged scar bisects his right knee. Age comes at a price. The man writhes with pain. His movements stop only when he pauses to vomit. He tries to speak, but his tongue sticks like a burr to the roof of his mouth. The telemetry alarm beeps constantly. His heart rate is too fast.
I introduce myself, then straighten the man's pillow and tuck it under his head. I rinse a washcloth in cold water and wipe the man's dry, cracked lips. He puts out his tongue, trying to catch the water trickling from the cloth. I ask the man to tell me more about his pain. He says it started at 3 am, waking him from sleep. He describes it as diffuse and colicky. He had oatmeal for breakfast but started vomiting shortly after. He has not kept anything down since. Around noon, he had an episode of bloody diarrhea: bright red blood, enough to color the toilet water, not enough to worry him. This happened twice more during the afternoon. He called his neighbor at 5 pm when he could stand the pain no longer. She dropped him here, and his family is coming.
When I examine his abdomen, he is minimally tender all quadrants with hyperactive bowel sounds; no guarding, rigidity, or rebound. I order fluids, pain meds, abdominal labs, cardiac enzymes, and plain films of the abdomen. The patient's ECG done in triage shows atrial fibrillation, but his current strip is NSR. No history of anticoagulants.
An hour later, the man's test results show his lactate level is elevated at 3.9. He has a WBC count of 13.2 and a normal H&H. The radiologist calls me. The man appears to have free air under his right diaphragm consistent with a perforation, but the x-ray is not definitive given some abnormal lung findings. He suggests CT to clarify. I call the surgery resident, who promptly reviews the films, also questions a perforated bowel, and states he will come to see my patient.
I return to my patient. His family is at his bedside, watching over him with gentle concern. I discuss the test findings with them. My patient listens to me, then to the resident. He recommends prompt admission to the SICU and a CT scan. He warns an emergency operation may be needed. The patient interrupts: he does not want surgery, he cannot stand the thought of it, an operation will surely kill him. He moves his hands rapidly and precisely as he speaks: crescendo, diminuendo, release. Silence descends. The clock ticks. Is this the end? The resident places a hand softly on my patient's arm, letting him know that we will respect his wishes.
I talk with my patient and his family. They understand that without an operation he may die. My patient is DNR. He declines surgery, but he wants to know his life expectancy. He wants a CT. I explain the process to him: the drinking of contrast; the risk of vomiting; the futility, perhaps. My patient and his family, however, want a clear diagnosis and prognosis. They insist. I order the scan, but my heart aches. The patient's family remains with him until he leaves the ER.
The floor nurse discovers his still body 20 minutes after he returns from CT; 5 hours after we met. I read the CT report post mortem. I hope in his last moments, my patient forgot the mechanical whirr of the CT scanner and instead remembered the music of the spheres, the sound of his son's heels clicking to attention, the tender embrace of his granddaughter, and the rough but loving touch of his sister's worn skin. Expiration date: is this beyond medicine's reach? JAAPA
Alexandra Godfrey practices emergency medicine at St. Joseph's Mercy Hospital, Ypsilanti, Michigan.