The Monitor

by Robert J. Lanz, LCSW

Everybody has seen the scene a thousand times on TV.  A group of concerned doctors and nurses are trying feverishly to save a dying patient. CPR is in progress, the patient is poked full of IV lines and a large tube sticks out of the mouth and goes to a machine that gives oxygen to the small amount of blood being circulated with the chest compressions.  The nurses give medicine in the IV line, stand back for a minute, hold the CPR and then everyone checks the monitor that is attached to the patient in several places.  They get results of tests, look worried, look at each other, appear more worried and check the monitor again.  CPR starts again and the residents and the doctors stand back and hold their chins, look at each other and then look at the monitor and then at each other again.
This isn’t on TV, but live tonight and what everyone else gets to watch on TV we are doing in person. We have tried everything that will normally resuscitate a resuscitatable patient and it isn’t working.  The medical staff starts to get desperate and they grab the defib paddles and the patient is practically tossed off the bed by the shock then flops back down into the lifeless form she is becoming.  There is a moment of hope, of anticipation and then the monitor is checked for signs of a heart rhythm that will sustain life.  When all else fails and there is nothing left to do it does get like a scene from the TV series “ER” every Thursday night.  It’s either “She’s gone” or “flatline, time out 2135”, or “that’s it, we won’t get her back”. Nobody ever just says, “she’s dead” or “he’s dead.” Maybe it’s too obvious, I don’t know.  Anyway, somebody makes a copy of the final rhythm strip, attaches it to the patient’s chart and turns the monitor off.  The patient is cleaned up, tubes removed, IV’s taken out and then covered with a fresh blanket to be made ready for viewing.

Tonight, this very feeble old lady had been trying to die for about half an hour.  She had just enough of a heartbeat that it would have been illegal and unethical to stop trying to save her although from the way she looked, she couldn’t have wanted to go on living.  No matter, it’s not her decision; that is left to the doctor and in the absence of an official Do Not Resuscitate form, every effort will be made to save just about anyone.  I say just about because everybody has just a slightly different take on the rules.  My experience has been that we never let someone die too soon even though we realize that the quality of the patient’s life was terrible before the cardiac arrest and will probably only get worse. We know our best techniques may even cause a coma, rarely save a life, let alone improve the quality of one.

No, more likely we will pursue every possibility, try every trick and even give one last shock for good measure.  Not the way I would want to end my life.  Not the way most people would want to end theirs and I’d guess, probably not the way Mrs. G. wanted to go to meet her maker.

Mrs. G. was one of those people who should have died a long time before she did.  She had the bad luck to have inherited a tendency for several painful maladies, all of which put such drastic limitations on her life she couldn’t move without some sort of medication.  Sometimes the agony was so disabling someone else had to open her pain pill bottle for her. It was on her nightstand, her son told me, next to seventeen other medications, and he didn’t even know what most of them were and he said that his mother didn’t either.  She just took them like the instructions said to.  Mrs. G. had even worse luck when it came to her heart.  It was as healthy as a horse and no matter how ravaged all the other organ systems of her body became she continued to have remarkable cardiac resiliency.  Until today.  At seventy-nine, with all other systems in failure, her heart started to have a rhythm that wouldn’t sustain it.  Of course, we couldn’t let that be and so we gave her drugs, calcium, shocks and thumped on her chest until, if it were me I would have jumped up out of bed, and screamed, “Let me be, can’t you guys see I finally get to die?”  But of course, it wasn’t me. I, fortunately, was only a bystander to this vigorous medical intervention although I do admit I was close to yelling out myself  “Let her be, can’t you guys see she’s trying to die.” But I didn’t. That’s the kind of thing you get fired for and it wasn’t that big of a deal. Not yet at least.

A copy of the woman’s final recording was taken from the monitor and the room was cleared.  The flatline strip was put on the patient’s chart, and her life officially ended and there was only the matter of the living to tend to. So the doctor asked me to go find the family and get them ready to hear some bad news.  The rest of the staff, including the paramedics, gathered their things from the room and in just a few minutes there were no signs of the brutality the poor woman experienced while dying.  It looked like she just decided to come to our facility, lay down in one of our pristine beds and slowly and peacefully fade away.  It was the kind of impression we didn’t mind making despite the obvious falseness to it.  If families had a sense of what really went on they would probably be content with a nice peaceful death at home, but at times like this, reality was a separate issue and nobody wanted to get into it.

The attending physician, Dr. S, went to talk to the patient’s son and daughter in law and told them Mrs. G. had died. They took it pretty hard.  About as hard as I took it while watching the patient dragged back from the brink on at least three occasions while she was trying to get over to the other side and finally find some peace. But we didn’t talk about that.

There was a sharp rap on the little window that looks into my office and one of the nurses was beckoning Dr. S to the door.  “How rude” I thought. She must have known that we were in the middle of a death scene and the family was obviously grieving.  Her timing couldn’t have been worse and I made a mental note to talk do her about this. Anything short of another dying patient wouldn’t be an acceptable excuse for an interruption at this solemn time.

I stepped out into the hall with Dr. S to see what the big deal could possibly be.  If it was worth an interruption under those circumstances it was probably something else I would have to get involved in. I would just as soon know about these things as soon as possible to make the time and energy adjustments I have to make to save myself from ending up needing my own round of CPR and medications.

“Dr. S, one of the paramedics was in room three getting his stretcher when he noticed the monitor,” the nurse said.  “No one turned it off after the patient died. It was showing some intermittent heart beats.”

“In room three?  Can’t be. I pronounced her almost ten minutes ago.”

“You better look,” she insisted.

Me too, I thought.

We walked down to room three and looked at the monitor. Sure enough, there were some faint beats, widely spaced but definite beats.  We watched for about thirty seconds to be sure we were really seeing what we were seeing, that it wasn’t some artifact electrical activity that sometimes occurs after a patient’s death.

“She’s back,” Dr. S stated simply, as if it was commonplace for dead people to return to life after we said they were dead. “Call a Code Blue and get the medical resident back down here.”

Poor Mrs. G.  She had enough strength in her heart to last another eight hours. The son watched all night while she had repetitive seizures nearly shaking herself off the bed on several occasions.  The medical resident was up all night giving phenobarbital to try and control them.  It was torture for everybody and the patient finally died for good about dawn.

I found out about the torturous death when I came back to work the next day and saw the young doctor in training who had had the misfortune of being on call the previous night. He looked exhausted and obviously wasn’t happy about the way he spent his shift. I’d guess everyone eventually felt that way, especially Mrs. G. who had about forty seizures before her body finally gave up.

I hate to start my day with bad news, anguish and frustration. As common as bad food and stand up meals on a busy night, anguish and frustration would come soon enough anyway.  I couldn’t figure out what to do about this auspicious beginning of my shift and just sat at my desk staring into space.  What would I have wanted if it had been me? What if it was my mother? Or my wife? It was a terrible thing to lose the luxury of denial, to not be able to dream up some blissful release from life, some peaceful passing into that big tunnel of light that gets mentioned so frequently.  It was one of those times when I had knowledge that I needed to have but really didn’t want to.  Knowledge that would allow me to take care of everyone else but leave no room for me to hide when I needed it.  It didn’t feel good.

I gave it a lot of thought before I finally picked up the phone and dialed the firehouse and spoke to the paramedic who was there the night before and discovered our dead patient had returned for a final round of brutality.

“Hey, Jim,” I said. “Can you do me a favor?”

“Sure, what is it?” he asked.

“If you ever go into a room again and find a dead person with a heartbeat please turn the monitor off and don’t say anything,” I told him.

“Uh, OK,” he answered and he hung up.

I sat there for a moment and listened to what I had just said I realized I was more upset about the torture of Mrs. G. than I thought.  And I realized when health care workers joke about having “No Code” tattooed on their chests, it really isn’t a joke. It’s a wish. A wish that became all too clear as I gave thought again to the only tattoo I ever considered…