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Christmas in the Emergency Department
A little bit of this, a little bit of that; someone dies, someone brings carrot cake
You never know what you’ll get for Christmas in the emergency department, but there’s a good chance it will involve someone’s death.
People die in America, every day, all day long, and many of them do it here. Sometimes it’s a terrible tragedy, sometimes a peaceful release. If a death seems particularly tragic — as it often does when it’s a holiday, or falls on a patient’s wedding anniversary or birthday — we will shake our heads ruefully. “That’s so terrible! And on Christmas!”
This Christmas, before dawn, I took over from a night shift colleague who had caught a teenager in cardiac arrest. She was far gone, but he had revived her. Christmas saved!
He signed his unfinished cases over to me and fled for home and family.
Day staff were trickling in to take over from the night crew. Many were wearing Christmas sweaters or hats. Christmas food was piling up in the break room — baked cookies, Chinese take-out, fresh-brewed coffee. Far from everyone this day was an observer of Christmas, and there were some cheerful acknowledgments of Hanukkah and Festivus, some good-natured debates about the appropriateness of just singing out “Merry Christmas” or sticking with the safer “Happy Holidays.”
A second physician colleague arrived. The two of us were sharing the high-acuity side of the department. It was moderately busy, and soon my colleague caught the second cardiac arrest, a man in his 70s. The case was somewhat bizarre, and my colleague was tied up with it for awhile, but he eventually revived this man, for our second Christmas save.
Patients kept arriving. Many had influenza A or COVID-19. Some were intoxicated, some depressed, some had slipped and fallen, still others had cut their hands in their kitchens making Christmas dinner. I saw one man with a blood clot to his lungs, grunting in pain with each breath, and another who would need his first-ever dialysis for kidney failure, and in between I addressed three separate kitchen-related hand lacerations.
When the paramedics called about our third cardiac arrest, it sounded like our winning streak was about to be over. A woman in her nineties had just collapsed in front of her husband. He had performed CPR and called 911. Paramedics found her in asystole — a flat line, the cardiac rhythm with the worst associated outcomes — but they were working to bring her back. They had drilled an intraosseous needle into her shin for fast vascular access, had given epinephrine, had put a tube in her airway and were ventilating her with a hand-squeezed oxygen bag. But nothing had changed, she was still flat-lining. They were five minutes or so out by ambulance.
All of our big resuscitation rooms were full by now. The charge nurse told me we’d use room 10, a smaller space without much equipment — not a preferred option, but I didn’t protest. We both knew this would probably be a very brief resuscitation, since it sounded so futile.
A team of three paramedics arrived. We watched from room 10 as they expertly guided their ambulance stretcher towards us, walking briskly alongside it, while also performing compressions on the patient, squeezing her oxygen delivery bag, and managing a heavy cardiac monitor, an oxygen tank, and other bulky gear.
The lead paramedic delivered a formal report, while everyone else in the room worked together to get the patient moved smoothly over from their stretcher to ours, and for our staff to take over from EMS to provide the compressions and the oxygen bag ventilation. The only new information in the paramedic report was that, according to her husband, the patient had always wanted to die at home, and had planned to obtain a Do Not Resuscitate order — had even printed out the DNR form (a magical document that instantly stops CPR) — but had never filled it out or signed it.
This was incomplete information but it provided support for what I’d already decided from my first look at this woman: We needed to let her go.
She was a thin, frail woman, obviously a person with little physiological reserve. She’d had a solid resuscitative effort by the paramedics, and it had failed. She wasn’t coming back — certainly not to any kind of meaningful neurological recovery. My main concern now was making her passing this Christmas morning as easy as possible on her, and on everyone else touched by her death.
That meant we needed to stop our efforts as soon as reasonable. We would be doing no one any favors if, at this late stage, we somehow clawed this poor person back from death. If she recovered a pulse, she would still never come off of a ventilator, and almost certainly would re-arrest multiple times and die anyway before the day was out.
But if we stopped our efforts too abruptly, how would it feel to the paramedics, who had just worked so hard for about an hour to find her, treat her, carry her to the ambulance, bring her in to us? (I’ve been a paramedic and remember feeling deflated and vaguely foolish when a bored-seeming doctor had instantly pronounced dead someone I’d worked for an hour to save). How would it feel to our emergency department staff, including nurses and techs?
Most importantly, how would the way this was handled impact family? The husband had after all given some mixed messages: calling 911 and performing CPR, while also reporting that perhaps she wouldn’t have wanted any of that. (There’s nothing surprising about that sort of inconsistency, it in fact is the rule. It’s a rare family that is composed and rational when a loved one is dying.)
I stopped our resuscitation after just a few more minutes. I verbalized my thinking, and everyone seemed comfortable with it. I looked at my watch and, per the time-honored ritual, pronounced her dead as of 11:09 a.m. We wouldn’t be contacting the medical examiner for this obviously natural death, so I asked that the patient be cleaned up prior to family arrival.
I returned to my computer to survey the department. My colleague was still in his cardiac arrest case. The day-time pediatrician had arrived, and the opening of the pediatric wing of the department was already helping to decompress the waiting room. A third physician colleague was fully in the game, marching through patient after patient on the lower-acuity side. Two more patients had arrived to our higher-acuity side — one with COVID-19 and one with influenza A, for symmetry. I clicked in the computer to sign up for both, and allowed myself the frosty thought that I had better not catch COVID or flu, just days before I’d be off to visit my own parents. I’d been diligent about wearing an N95 mask all shift; I was honestly most worried about influenza A, which seemed to be everywhere this week.
Since I was at the computer I also signed up for the cardiac arrest patient I had just pronounced dead. I quickly reviewed her medical history — heck, she’d just been here a few days ago, and her decision to immediately enter hospice care for end-stage congestive heart failure was beautifully documented. I changed her disposition in the computer to “expired”. I filled out her death certificate, printed it, signed it, and gave it to the ED secretary. I typed up the beginning of a brief care note. Could I document the minimum 35 minutes of critical care time, for such a short case? I’d make a couple of hundred dollars more if I did. And if I did not document that time, I was sure the hospital billing office would hound me about it, because the hospital also gets paid for this. I left it be for now.
And the patients kept coming. One woman in her 70s arrived from a local nursing home with a new diagnosis that morning of COVID-19. She seemed fine. But it was a huge drama, because apparently, the nursing home staff were upset by the offered ETA for a routine private ambulance and so they had called 911 — which could have been reasonable — but then they had also apparently reported her case to the dispatcher as “cardiac arrest, CPR in progress” (!), when it was just a pleasant old lady doing perfectly fine with COVID-19. The nursing home received police, fire and ambulance all racing to the scene to help, and everyone was quite indignant about it.
The husband of my deceased patient arrived. The charge nurse couldn’t put him in the room we usually use for family meetings — it was occupied, by family from the other cardiac arrest — so she’d put him in an empty patient care room in our fast-track area. She told me this, but then I got side-tracked by the drama around the newly arrived, “Just-COVID-not-CPR” case, and I had to be reminded he was still waiting. Guiltily I hurried back to that part of the department.
I introduced myself, told him I’d heard how she’d collapsed in front of him, how he’d done CPR, and how the paramedics arrived and had taken over. He confirmed it. I told him I was sorry to say that despite CPR and medicines, we could not bring her back to life.
“So she’s gone?”
“Yes, she’s passed away, she’s died.”
“Well, she always said she wanted to die at home,” he said, with a sigh and a grim look.
He wanted to see her. He wanted to take her jewelry home. He’d also have to figure out how to pay for a funeral now. He wanted to see her. She’d loved her earrings in particular. “Will you escort me to her?” he asked.
We walked through the long halls of the ED, past multiple hallway patients, past incoming EMS stretchers with patients, and he wondered aloud how to organize the funeral arrangements, and noted he wanted to take her jewelry home, because she’d loved her jewelry. I had him wait in the hall near her room, explaining I wanted to make sure everything was ready for him — I didn’t want to pull back the curtain on a shocking murder scene, which is often what things look like immediately after a critical resuscitation. I needn’t have worried. I’d only pronounced her dead maybe 20 minutes ago, but she was tidied up, in a gown, the breathing tube and IO needle out, all of the pads and stickers gone. The ED techs had lain her flat, put a blanket over her up to her chest, and had folded her hands neatly on her chest. Her dentures were out, in a clear plastic bag on the counter. I think they’d even fixed her hair.
I ushered him in to her bedside. He made a vague, approving remark about her dentures being bagged up. I brought him a chair to sit in. He sat down next to her, and said again, “Well, she always said she wanted to die at home.”
And then he started sobbing, and put his head down on his folded arms on the bed next to her. I patted him awkwardly on the shoulder, and then I too was overwhelmed by the horribleness of it, of a man who had lost his wife after decades together, lost her on Christmas morning, and I started to cry. It lasted for about 3 seconds and then I swallowed it and it was gone, just a little burning in the eyes. I turned and left to go find another clear plastic lab bag, for her jewelry, and to ask the ED secretaries to call a social worker for the patient. I returned to the room and he was still sitting there, with his head down on his folded arms on the bed, still sobbing.
I gave him a box of tissues, and the plastic bag. I offered to take off her jewelry for him, or to have one of the nurses do it if he’d rather. He said no, he wanted to do it himself. For the first time I noticed she had on such nice jewelry — earrings, a necklace, rings, all of it gold — and even a little lipstick.
“Well, she always said she wanted to die at home,” he said, and this time I agreed, and said that I guessed she’d gotten what she wanted, and there were many worse ways to die than to die peacefully, quickly, at home, with a loved one there. He began to cry again. I had no business starting to cry myself, so I told him I’d go find someone to come talk to him about funeral arrangements and such.
Back at my computer, I reviewed the list of patients I was signed up for. One of the nurses told me we had all sorts of good new food in the break room, including a fresh pot of coffee and an excellent carrot cake. I promised to check it out. From the computer I learned that a transvaginal ultrasound had come back on a pregnant patient; she’d been seen overnight for vaginal bleeding, signed out to me in the morning with the ultrasound pending. I hadn’t met her yet, but on the ultrasound the pregnancy looked fine. A six-week pregnancy. I asked the ED secretary to call the Spanish interpreter for me, so I could tell her and her husband the good news. While I was waiting for the interpreter, I documented 35 minutes of critical care time on my deceased patient, and finished and signed her care note, and crossed her name off of my running paper list (my backup for the computer list). It wasn’t even noon yet, but according to my handwritten list I’d seen 17 patients and I was already starving. The social worker was in with my deceased patient’s husband; for the moment the Spanish interpreter was busy elsewhere; it was as good a time as any to snatch a Christmas morning coffee break.