Echoes

Mr. O is dead.

Yesterday, about 8:30 in the morning, they called a Code Blue (pulseless or not breathing).  The call goes out throughout the hospital on the overhead system – and it was, “Code Blue, ICU, fourth floor; Code Blue, ICU, fourth floor.”  Initially, we all thought this was extremely funny, since WE are on the fourth floor, and there certainly wasn’t a Code Blue going on.  The security guy, who reads the announcement, just got the floor wrong.  ICU is on the seventh floor.  He made a corrected announcement a few moments later.

Regardless.  I was with one of my patients, who was sitting in bed with a non-rebreather mask on, getting 15L of oxygen and some IV Lasix to help her congestive heart failure.  She heard the overhead page and said, “That’s not a good thing, is it?”

“No,” I replied.  “That’s not a good thing.  We don’t wish that for anyone here at the hospital.”

A few moments later, I suddenly realized that it was probably Mr. O who was being coded.  Nicki, our charge nurse, called up to ICU and confirmed it.

~~~~~

I had been off the unit for two days — we were desperately short-staffed on Wednesday night, so I worked a double, went home, slept for about twelve hours, and enjoyed time off until Saturday morning.  But, for a week prior to that, I’d worked with Mr. O fairly intensively.  Mr. O presented at our ER two weeks ago with shortness of breath and a fever.  He’d had a cold a month ago that he couldn’t shake, that turned into a sinus infection, that turned into what they thought was pneumonia.  But when they did a chest x-ray, they realized that this left lung was almost absolutely full of fluid.  No wonder the guy couldn’t breathe.

They took him emergently to IR (interventional radiology) and placed a chest tube into his lower left lung…..and nothing came out.  No fluid drained at all.  They scanned him again, and this time they realized that it wasn’t fluid — it was pus.  To be specific, it was crystallized pus — thick and honeycombed-shaped, stuck throughout his lung.  He had empyema.

The first day I worked with him, I thought he was a complete asshole.  He was rude and abrupt, unfriendly, and unkind to the nursing student I was working with.  He weighed about 400 pounds — he was a very large guy, about 6′ 2″ and built like a linebacker, but still obese.

However, as the day progressed, I realized two things.  One, my nursing student was a complete spaz.  Sigh.  Even I got annoyed with her.  Two, this guy was really sick, and he knew it.  And he was scared.  He was trying to gain control of his life by controlling his nurses.  Once this clicked with me, our relationship completely changed.  By the end of my 12-hour shift, I liked the guy.  And he was OK with me.

Over the next few days, we started tPA therapy — the same stuff you give to someone who has just suffered an ischemic stroke — clot-busting drugs.  I would inject a big syringe of tPA into his chest tube, into his lung, and clamp the tube off for an hour.  After an hour, we would open the tube, and suddenly, all this bloody gunk would start to empty into the atrium (drainage container) of the chest tube.  It felt like victory — I cheered every time the atrium filled up.  We were getting the crap out of his lungs.  He could breathe again.

Until suddenly he couldn’t.  And he had severe left-sided chest pain.  I called a rapid response team in, and we evaluated him for a possible heart attack — no signs of that on the EKG, so we sent him back to x-ray.  And it was a WEIRD looking x-ray.  The bottom part of his lung was now more open, but the top part of the lung, above the chest tube, was completely closed off by pus.  Because Mr. O was so large, he couldn’t breathe if he lay down in bed.  And part of the recommended tPA therapy is to lay down in bed, and roll around every fifteen minutes for an hour.  This distributes the tPA evenly throughout the lung, and drains all of it.  Because he couldn’t lay down, and spent all his time sitting up in his chair, gravity worked its magic, and only the lower lung drained.

He went back to IR and had a second chest tube placed, right under his armpit.  And we started more tPA therapy.  And again, it worked — crud drained out, and by the second treatment his color improved and his breathing got easier.  We cheered again.  His lovely, beautiful wife visited every evening, and we all cheered together.  I said, “It’s working again!”  And with a peaceful calm, she said, “He is in God’s hands.  We are gratefully leaving him in God’s hands.”

This kind of comment usually bugs the shit out of me.  But I have never seen someone so serene in the face of such illness.  They were deeply involved in their church.  And it sustained them.  I never resented them for that.

By Wednesday night, he had had the lower chest tube removed, and was pushing the doctors HARD to get the upper chest tube removed.  He wanted the tube OUT.  And he wanted to go home.  The doctors warned him that if his chest x-ray the following morning showed more stuff in his lungs, he would need to go to the OR, to have a thoracic surgeon cut open his entire left chest and manually debride the infection.  He was adamantly against that.  He did NOT want surgery.  And the doctors really didn’t want to do surgery on him — he was what’s known as a “poor candidate” — he was obese, diabetic, hypertensive, and had respiratory impairment.  He was at high risk to die on the operating table.

The last time I ever heard his voice was early in the morning on Thursday.  He called into the nurses station.  Barb, who also loved him, answered the call light over the intercom.

“Yes, darling, can we help you?”
“Can I have some coffee?”  He was an addict.
“How do you take it?”
“Black, please.”
“Do you know who this is, my love?”
“Yes indeed I do, Miss Barb.”
“I’m bringing in your coffee for you.  Make sure your wife isn’t around.”

And he laughed.

I left the hospital, exhausted, at 6 a.m on Thursday.

At nurses report on Saturday, around 7:30 a.m., Barb told me what had happened while I was gone.  The chest x-ray had looked marginally improved, so Mr. O was absolutely adamant that the chest tube come out.  The doctors were extremely hesitant, but he refused to have the tube in any longer.  He wanted to go home.  They removed the chest tube.

By mid-afternoon, he couldn’t breathe.  They rushed him to radiology,  His lung had filled with blood.  The repeated tPA treatments had been too much for him — the blood vessels in his lungs were leaking.  He was drowning.  He lost consciousness, and they ran him into the OR, and performed an emergency thoracotomy to re-open his lung.  He was cut open from his sternum, around his side, to his spine, so they could get to his lung.  On a ventilator after surgery, he was transferred to the ICU.  Barb went up to ICU in the early morning on Saturday to see him.  He didn’t recognize her, and could barely respond.

~~~~~

After the code was called, I checked on my patients to make sure they were OK, and then headed up to ICU.  The whole code team was there — the ICU nurses, the respiratory therapists, two pharmacists, the ICU physician, lab techs, one of our security guards.  Mr. O was hooked up to the crash cart, the defibrillator patches already attached to his chest.  The RT was manually bagging him, breathing for him.  His oxygen saturation was in the 70’s.  One of the ICU nurses was adjusting six or seven IV bags of vasoactive drugs, trying to get his blood pressure up — his diastolic pressure was also in the 70’s.  His heart rate was over 150.  The noise was incredible.

One of the ICU nurses called out to the secretary.  “Did you call his family?”
This is a bad sign.
“Yes, they’re on their way.”

I had to leave after about five minutes — I had a patient who had to go for a gallium scan to take a look at his infected hip replacement.  I went back to the fourth floor, checked on my patients, called report, picked up my patient, took him down the first floor, helped transfer him onto the scan bed, talked with the tech for a few minutes.

Then, on the overhead pager system.  “Code Blue, all clear.  Code Blue, all clear.”

I headed back to the elevator.  The doors opened, and the security guard stepped out.  He recognized me from my stop in the ICU.

“Did he make it?”  I asked.

“No.”

~~~

I took the elevator straight back up to the seventh floor.  I walked into the ICU, and heard the screaming.  His family had arrived — two daughters, a son, his wife, someone else I didn’t recognize.  His daughters were at his bedside, their hands grabbing and clutching their dead father, resting their foreheads on his body, hysterical.  “Daddy!  No no no!  Daddy, no, daddy no!  Oh God, Daddy no no no!”  They wailed and choked and screamed again and again.

His wife stood on the far side of the bed, her arms wrapped around her son, tears streaming down their faces.  I walked into the room, and she looked up and recognized me.  And I walked straight into her arms and began to cry.

“I’m so sorry.  I’m so so sorry.  God, I’m so sorry,” I repeated over and over again.  We hugged each other tightly.  I could hardly breathe.

“It’s OK, Martha.  You did everything you could for him.  It’s OK.  He’s with God now.”

“They tried so hard to save him.  They tried so hard,” I said.

“I know,” she replied.  We stepped away a little bit, still holding on, looking at him.  “He’s sitting with the Lord right now.  He’s in a better place,” she said. She smiled a little, and looked at me.  “He’s with God.”

I am glad she had her faith.  I went up to the ICU to comfort her, but couldn’t, because my grief was so deep.  I didn’t have any comfort to offer.  Her faith did.

~

I went over to his body, and touched his head lightly.  And I left the ICU, and took the elevator back down to the fourth floor.  I walked off the elevator and into the nurses station.  The secretary saw me, and stopped what she was doing.  Nicki was on the phone.  She looked up at me.

“Oh, god,” said Nicki.

“He’s dead,” I said.

Nicki hung up on the staffing office, and grabbed me.  And I sobbed.

~

I remember every time I knocked on his door, I would say, “It’s Martha,” so he would know it wasn’t someone else coming in to bug him.  He was hungry but had no taste for food, but liked yogurt, so I would take trips to the vending machine at 10 pm to get yogurt for him, and we were happy when it was strawberry yogurt because he liked that best.  The chest tube pain caused him to sweat profusely, and I kept him in a good supply of dry towels and dry blankets to keep him comfortable.  I knew his pain medication schedule by heart, and had it available for him right on time, and on the day he didn’t need as much of it anymore we were happy.  I would bring him a wheelchair, and he would walk around the unit, pushing the chair, his chest tube atrium perched on the seat (he called it his “carry-on luggage”), and make frequent rounds to the coffee machine in the lounge.  We would troubleshoot chest tube problems together, and work to keep the drainage tubes untangled when he had two of them.  He knew exactly what he needed, and I made sure he had it.  His was always the first call light I responded to.

And I can see his body, pale and yellow-tinged, the tube still in his throat, his torso disfigured from the huge surgical scar, lying perfectly still, his eyes closed.

They tried to save his life for 55 minutes.  He was 51 years old.

And the screams of his daughters are still echoing in my ears.

No, no, no, no, no……..