Why we persevere despite a poor prognosis

Last night, I responded to a code blue while working the night float at the hospital. The patient was a relatively young female who had just completed a coronary artery bypass procedure. Per training, I began compressing her chest to induce blood flow to the rest of her body.

As I pushed, the incision reopened and blood began spewing everywhere. I could feel her ribs giving and cracking from the force of my weight, yet she still remained asystolic for approximately 15 minutes. From the look in the eyes of the cardiothoracic surgeon running the code, her prognosis was not good.

After a fourth set of compressions, the team and I were able to shock her back into ventricular tachycardia and she produced pulses bilaterally. We continued to follow the ACLS protocols and stabilized the patient. As things looked better, I quickly signed off from the code and left to continue my other duties, barely stopping to think about what I had just done. As I left the ICU, a resident pulled me aside and told me that the patient’s son and daughter were in the room for the entire code.

My insides felt queasy and my heart seemed to fall into my stomach.

“How were they reacting?” I asked.

“Okay,” the resident responded.

After completing evening rounds, I went back to checkup on the patient.  Her family was huddled around her bedside and holding her hand. But something didn’t look right on her monitor. I pulled the ICU nurse aside and asked how the patient was doing. She told me that despite all our efforts to save her life, the patient’s family decided to withdraw care.

A second uneasy feeling overcame me.

“My scrubs and watch were covered in blood and I sweated like I just ran a mile!  The team spent at least 45 minutes coding this patient, and yet all the family wanted to do was withdraw care?” I thought to myself. “But her heart is pumping blood again!”

Dumbfounded, I looked away from the nurse and gazed back into the patient’s room.

In medicine, we say that there is always a silver lining that families and loved ones search for to help them cope with each loss. For some, it is organ donation. For others, it is knowledge that the patient passed peacefully. As the patient’s family peered out the door back towards us, her daughter mouthed the words, “thank you.”

And then it hit me. For this family, it was the chance to say one final goodbye.

In life, we are taught to carry on when all seems lost.  We might not be able to save every patient, but we always persevere despite a poor prognosis.  This is why we play the game.

Andrew Ho is a medical student. 

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  • doc99

    In Super Bowl XLII the unbeaten Patriots were overwhelming favorites to beat the Giants. The Giants won. In Game 6 of the 1986 World Series, the Mets were one out away from yielding the World Series crown to the Boston Red Sox. The Mets won. History is replete with tales of those who overcame overwhelming odds to triumph. That’s why we play the game.

  • Ron Smith

    Hi, Andrew.

    In the first 6 1/2 years out of Pediatric residency some 30 years ago, I was doing level 3 NICU care as a solo practitioner in a town of about 25,000 that was 2 hours from every referral center. The hisital there had been doing a fair amount of level 3 stuff when came there. The smallest baby I took care of was 1 lb 13 ounces ( about 870 gms) and about 24 weeks.

    Because we were participating in the Exosurf investigation studies (later phase) this child got lung surfactant, and did well. There was exceedingly minimal vent time and the baby fed and grew for some 3 months before discharge. I still have the chart that was never picked up when I later moved.

    That was a great success. But not all were so great.

    Somewhere in that time there was a 21 weeker delivered. The eyes were fused, there was a very faint, slow heartbeat, and no respiratory effort. The skin was very gelatinous.

    I made the call not to pursue resuscitation. As you can tell this is something that I still think about, because the nurses, fresh off newfound NICU victories, wanted to jump in with guns blazing.

    I still think that I did the right thing. We could have done a lot of things without actually doing anything for that child. Sometimes it just takes enough experience to know when to say yes and when to say no.

    When my daughter Laura suffered a large brainstem bleed in 2012, the neurosurgeon (a very good friend and colleague of mine) knew without hesitation that we had lost the battle and the war to save my little girl. He didn’t have to convince me though. I knew it even before he told us.

    I can understand wanting to say goodbye. Because Laura was on a ventilator already from the surgery two days before, we had that time. With her family around her we were able to hold her in our hearts and peacefully let her pass on to her Maker.

    I’ve walked a number of other children to that same door in my career. It will never get easy especially with kids. I empathize with your situation.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • Shirie Leng, MD

    You bring up a very interesting and controversial point; that of having family members in the room when you are coding a patient. I tend to dislike it, but it does do two very important things. 1. It shows the family that we really are doing all we can. 2. It demonstrates to the family in a visceral way the seriousness of the patient’s condition. In the case you presented, the family were able to be grateful for the care that was given, which gave them time to say goodbye as it became clear to them that they must. All in all a good outcome.

  • Rob Burnside

    A career in medicine is a forty year wrestling match with the Grim Reaper, the outcome predetermined. By demonstrating courage in the first half, we acquire the courage necessary to endure the second half.

    In the end, if the win-lose columns are fairly equal, that’s a draw, and a draw is a victory for the home team. The home team is us.

  • Rob Burnside

    Thanks. It’s actually re-tooled Native American mythology.