condition a

Living well really is the antidote to death.

Cases: Perhaps Death Is Proud; More Reason to Savor Life
By THERESA BROWN
September 9, 2008

At my job, people die.

That’s hardly our intention, but they die nonetheless.

Usually it’s at the end of a long struggle — we have done everything modern medicine can do and then some, but we can’t save them. Some part of their body, usually their lungs or their heart or their liver, has become too frail to function. These are the “good deaths,” the ones where the family is present and knows what to expect. Like all deaths, these deaths are difficult, but they are controlled, unsurprising, anticipated.

And then there are the other deaths: quick and rare, where life leaves a body in minutes. In my hospital these deaths are “Condition A’s.” The “A” stands for arrest, as in cardiac arrest, as in this patient’s heart has all of a sudden stopped beating and we need to try to restart it.

I am a new nurse, and recently I had my first Condition A. My patient, a particularly nice older woman with lung cancer, had been, as we say, “fine,” with no complaints but a low-grade fever she’d had off and on for a couple of days. She had come in because she was coughing up blood, a problem we had resolved, and she was set for discharge that afternoon.

After a routine assessment in the morning, I left her in the care of a nursing student and moved on to other patients, thinking I was going to have a relatively calm day. About half an hour later an aide called me: “Theresa, they need you in 1022.”

I stopped what I was doing and walked over to her room. The nurse leaving the room said, “She’s spitting up blood,” and went to the nurses’ station to call her doctor.

Inside the room I found my patient with blood spilling uncontrollably from her mouth and nose. I remembered to put on gloves, and the aide handed me a face shield. I moved closer; I put my hand on her shoulder. “Are you in any pain?” I asked, as I recall, thinking that an intestinal bleed would be more fixable than whatever this was. She shook her head no.

I looked in her eyes and saw ... what? Panic? Fear? The abandonment of hope? Or sheer desperation? Her own blood was gurgling in her throat and I yelled to the student for a suction tool to clear it out.

The patient tried to stand up so the blood would flow into a nearby trash can, and I told her, “No, don’t stand up.” She sat back down, started shaking and then collapsed backward on the bed.

“Is it condition time?” asked the other nurse.

“Call the code!” I yelled. “Call the code!”

The next few moments I can only describe as surreal. I felt for a pulse and there wasn’t one. I started doing CPR. On the overhead loudspeaker, a voice called out, “Condition A.”

The other nurses from my floor came in with the crash cart, and I got the board. Doing CPR on a soft surface, like a bed, doesn’t accomplish much; you need a hard surface to really compress the patient’s chest, so every crash cart has a two-by-three-foot slab of hard fiberboard for just this purpose. I told one of the doctors to help pick her up so I could put the board under her: she was now dead weight, and heavy.

I kept doing CPR until the condition team arrived, which seemed to happen faster than I could have imagined: the intensivists — the doctors who specialize in intensive care — the I.C.U. nurses, the respiratory therapists and I’m not sure who else, maybe a pulmonologist, maybe a doctor from anesthesia.

Respiratory took over the CPR and I stood back against the wall, bloody and disbelieving. My co-workers did all the grunt work for the condition: put extra channels on her IV pump, recorded what was happening, and every now and again called out, “Patient is in asystole again,” meaning she had no heartbeat.

They worked on her for half an hour. They tried to put a tube down her throat to get her some oxygen, but there was so much blood they couldn’t see. Eventually they “trached” her, put a breathing hole through her neck right into her trachea, but that filled up with blood as well.

They gave her fluids and squeezed bags of epinephrine into her veins to try to get her heart to start moving. They may even have given her adenosine, a dangerous and terrifying drug that can reverse abnormal heart rhythms after briefly stopping the patient’s heart.

The sad truth about a true cardiac arrest is that drugs cannot help because there is no cardiac rhythm for them to stimulate. The doctors tried anyway. They went through so many drugs that the crash cart was emptied out and runners came and went from pharmacy bringing extras.

When George Clooney and Juliana Margulies went through these routines on “E.R.,” it seemed exciting and glamorous. In real life the experience is profoundly sad. In the lay vernacular of Hollywood, asystole is known as “flatlining.” But my patient never had the easy narrative of the normal heartbeat that suddenly turns straight and horizontal. Her heartbeat line was wobbly and unformed, occasionally spiked in a brief run of unsynchronized beats, and at times looked regular, because chest compressions from CPR can create what looks like a real cardiac rhythm even though the patient is dead.

And my patient was dead. She had been dead when she fell back on the bed and she stayed dead through all the effort to save her, while blood and tissue bubbled out of her and the suction clogged with particles spilling from her lungs. Everyone did what she knew how to do to save her. She could not be saved.

The reigning theory was that part of her tumor had broken off and either ruptured her pulmonary artery or created a huge blockage in her heart. Apparently this can happen without warning in lung cancer patients. Only an autopsy could tell for sure, and in terms of the role I played in all this, it doesn’t matter. I did the only thing I could do — all of us did — and you can’t say much more than that.

I am 43. I came to nursing circuitously, following a brief career as an English professor. Often at work in the hospital I hear John Donne in my head:

Death be not proud, though some have called thee

Mighty and dreadful, for thou art not so.

But after my Condition A I find his words empty. My patient died looking like one of the flesh-eating zombies from “28 Weeks Later,” and indeed in real life, even in the world of the hospital, a death like this is unsettling.

What can one do? Go home, love your children, try not to bicker, eat well, walk in the rain, feel the sun on your face and laugh loud and often, as much as possible, and especially at yourself. Because the only antidote to death is not poetry, or drama, or miracle drugs, or a roomful of technical expertise and good intentions. The antidote to death is life.

Theresa Brown is a staff nurse at a hospital in Pennsylvania.