Death in the cardiac ICU

Death is on our floor. It has been there for far longer than I have.

On my first day in the cardiac surgery ICU, I was running late. I hurried past the dimly-lit rooms, their monitors regularly chiming their final lullabies of the night before the receptionist brightly greets the morning shift nurses and flips on all the fluorescent lights outside the twenty rooms on this floor at 7:00 a.m. sharp.

There is a Korean family who has been on our floor for many months. Every day, they would come see Mr. L. I first saw him from the back as the occupational therapists were helping him move in bed. The thin hospital gown split all the way down the back and revealed his sallow skin with his spine jutting out like a gnarled range. They were turning him in bed. His arms were so slender with a mass of wires and IV lines dangling from them. A white plastic tube connecting to the ventilator emerged from a hole in the midline of his neck from a tracheostomy. His hair was thin, matted and graying. He made faint gasping breaths, his mouth was open and so dried it resembled a bird’s beak from the way the lips were pulled across his teeth.

Every morning we round on Mr. L, the curtains are drawn across the entire entryway so that we step into a sort of sanctuary that had been concocted out of delicate classical music playing in the background and the soft lights emitting from the monitor screens in his room. His wife tries her best to listen and speak English while his daughter wipes her eyes bravely. The conversations about Mr. L are always short by this point in his condition. The doctors can’t do much to adjust his health care. Mr. L’s heart was continuing to fail inexorably and, with it, it was taking the rest of his body.

Out of earshot, the attending shook his head, “He is literally wasting away.”

Death is on our floor.

As a medical student in my final year, I’m no stranger to witnessing death. I’ve participated in several codes for patients who have lost their pulse, taking my place in line to give my two minutes’ worth of hard and fast chest compressions.

Sometimes, the heart reawakens from the compressions alone. Other times, after the administration of additional medicines like epinephrine. Sometimes, though, nothing works.

I remember watching from the doorway of a patient’s room during the very beginning of my clinical clerkships three years ago. Towards the end, the woman’s torso was flopping on the bed like a fish out of water. The force from the chest compressions had broken some of her ribs.

Everyone went back to their stations and regular schedules after the code concluded. We medical students retreated to the workroom. The social worker later dropped by to ask the resident to fill out the time and cause of death on a few papers. Other than that, the patient’s name wasn’t mentioned again.

Death is on our floor.

Mr. G was brought in after he was discovered unconscious from a heart attack. The surgeons performed an emergency coronary artery graft during the night to save his life. In contrast to Mr. L, who was always accompanied by someone at his bedside, Mr. G was alone in his room, eyes closed from the sedation, intubated, the white sheets tucked around his chin, a paper sign with the words, “Caution: Open Chest,” taped to the headboard. The attending wonders aloud whether Mr. G has any paperwork regarding resuscitation. At this point, are we saving lives or staving off death?

Three days later, he finally had a lone visitor a friend from church, who informs the staff that Mr. G does have family in the area. However, it takes another two days to locate his estranged son. This entire time, Mr. G still has not awoken, machines keeping him alive.

In the meantime, Mr. L’s family has spoken with our team and agreed to declare futility and refrain from escalating care. The chaplain assured us that Mrs. L finally felt comfortable coming to terms with her husband’s situation and with her Christian faith. The new ICU attending kindly spoke again with the family, offering to clarify any remaining questions. Mrs. L asked, “Will he feel any pain?” The attending assured her that the team would make certain Mr. L would pass peacefully. At 10:55 a.m., Mr. L passed away surrounded by his loved ones after 256 days on our floor.

In my short month rotating on this ICU floor, I’ve helped take care of some of the sickest patients I have ever seen. They are elderly, who’ve suffered numerous heart attacks, in need of multiple-vessel grafts. They are young with rare diseases, requiring transplants and a lifetime of immunosuppression medication. The first day after their surgeries, they don’t fully awaken from the sedative stupor, or they are frail from the pain and shock of undergoing an open chest operation. They are scared about their condition and their future. But they are brave too, as are their doctors and nurses, who do their best and believe that they can do even better. I’m always amazed and gratified by the technology available in this hospital, the technical abilities of the surgeons, and the patient care by the entire team. There are many lives saved on this floor.

Still, there are many ways of dying, I realized. During the final day of my rotation, I directed a distraught pair of visitors to Mr. G’s room. His room was already filled with the sounds of quiet sobbing and murmurs over the beeping of the monitors. His family made it to say their farewells, though Mr. G would not actually hear or see them. A nurse kindly drew the doorway curtain closed after the new visitors entered.

Hours later, I walked by Mr. G’s room, pushing an ultrasound machine needed for a newly admitted patient down the hall. He was alone again in the room, though now with no machines surrounding his bed. Somehow, it was peaceful. I was glad that his family could say a proper goodbye.

Adela Wu is a medical student.

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