A man died in the ER the other day. This is hardly news, it is an everyday event for us. He had pneumonia.
Previous generations of physicians called pneumonia the old man’s friend. He comes in the quiet hours, when older friends have long since ceased to visit, coming to lift the burdens that old age and infirmity bring.
Other generations, no less respectfully, called pneumonia the Captain, captain among the men of death.
The current generations of physicians see pneumonia as a clinical challenge to be fought at every turn, and mostly we are successful with our powerful antibiotics and sophisticated life support systems. The respect is diminished but not completely gone.
My patient spanned the gap between the generations. Pneumonia had come for him in its age-old way, in its timely fashion, but we would fight with modern weapons and high- tech solutions.
He was in his late eighties. Multiple strokes had left him unable to speak, unable to move and unable to feed himself. His arms had frozen in flexion, fists tightly clenched, chin resolutely tucked down and he looked like a fighter, forever refusing to surrender. His breath rattled in his chest, the death rattle all seasoned physicians have heard. Time and again he chased after his breath, faster and faster, only to catch it and, so exhausted, rest without breathing at all.
“Cheyne stokes respirations,” the resident reported.
“A perimortem finding,” he explained to the medical student as the patient’s labored rapid respirations began the losing race again.
“We should intubate him Doctor Reiser, he is a full code.”
“I wonder if that’s what he would really want?” I questioned out loud.
The patient’s eyes flew open and his startlingly clear blue eyes fixed on mine. He turned his contracted fist upwards, thumb foremost and jabbed it at the ceiling. Thumbs up? What did he mean? Opinions were mixed.
The nurses who had been working closely with him since he arrived explained that he could indicate yes or no by waggling his left fist sideways for yes and up and down flexion for no. But this was a different motion altogether almost a combination of the two.
I tested his understanding.
“Are you in any pain?”
“Are you short of breath?”
“Do you want us to put you on a breathing machine?”
Thumb jabbed up.
“Do you want us to put a tube in your throat to help you breath?”
Clear eye contact, then the thumb up.
We contacted the family in California who had medical power of attorney. They were indecisive but thought for now do everything, all heroic measures possible.
We tried broad spectrum antibiotics, IV fluids and non-invasive methods of ventilatory support. From our computers we ordered it all and more and at the bedside the nurses worked with the patient for hours.
Finally, we could wait no longer. I told the old man we would need to put in a tube to help him breathe. His eyes seemed alert and unafraid. He gave me a thumb up. We put him to sleep.
His flexed neck presented a problem and we used a fiber optic video camera to successfully navigate the extreme curves into his airway. Very slick. Placed on a ventilator he lasted less than 5 minutes before going into cardiac arrest. We were unable to resuscitate him. I pressed the team to stop the efforts. By custom the entire team was surveyed.
“Anyone have any objections to stopping?”
The old man’s primary nurse spoke up.
“I think it is too soon. I think we should keep trying.”
In my twenty years of asking this question I have never heard anyone ever object. In hushed respect we resumed our work.
Later, after we finally let him go I found two of his nurses in the locker room with moist eyes, hugging and consoling each other.
Sheepishly one explained it to me.
“We see lots of patients die. But it’s different when they come in talking to you.”
I looked at her quizzically.
“I know he couldn’t really talk, but you know, he was talking to us.”
“And besides, Dr. Reiser, the way I see it, when nothing in this job can make you cry then it is probably time for you to retire and do something else.”
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