Sitting by the bed: The final task in emergency medicine

For those who work in emergency medicine, the focus is almost always on the hard work of preserving life. Some of the hardest tasks, though, require the least action.

When my mother died without warning, just a year after I started medical school, she died in the night. I was 200 miles away. The rheumatic fever she had as a child apparently had taken its toll on her heart, and she died much too young.

I didn't get to say goodbye. Life is supposed to have a predictable, natural course of events to it, or so we wish it did. One of those wishes is that we outlive our parents after they've lived to a ripe old age, and that our children outlive us after we live a full life, and so on goes the cycle.

Losing a loved one is always difficult, even when it does follow this natural life cycle. Being able to say goodbye to a parent when the inevitable end of life comes is perhaps, in a way, a small gift to help ease the transition.

I read something once that suggested there are five tasks we need to complete, and express, to a loved one who is dying, whether death is a prolonged affair or imminent. The five things that need to be said are "Please forgive me"; "I forgive you"; "Thank you"; "I love you", and finally...."Goodbye".

It is about the last task, saying goodbye, that I wish to write today, and how we, as health care professionals, can help facilitate its completion.

But first, the clinical picture.

An elderly woman of 85+ was brought into the ED recently by her daughter because of ongoing abdominal pain. This had started a few days ago, and she felt "bloated." Her doctor, an excellent Internist, had examined her, and performed blood tests and x-rays, and felt she was constipated. This often happens in the elderly, so it was a reasonable diagnosis. The family tried enemas, but to no avail. Her symptoms worsened and her doctor ordered a CT scan but, again, it wasn't re-ally diagnostic.

After a few days of struggling with no improvement, her daughter brought her to the ED one evening. When I first examined her she was awake, cooperative, and complaining of abdominal pain. She had a distended belly. To inject some humor, I asked her if she could possibly be pregnant, to which she smiled broadly and said "No."

It was clear to me that she was stoic, and was trying to hide her pain.

My differential
There are obviously many causes of abdominal pain. In the elderly it can even be an MI. Her distended belly, the nature of the pain, and the history did not suggest that however, although just to cover my bases, I ordered an EKG and cardiac biomarkers, which were all negative.

The exam revealed she was hypotensive at 85/54, mildly tachycardic and slightly clammy. She had no fever nor any respiratory distress, although her breathing seemed heavy.

If it wasn't an MI, what else could it be?

  • Aneurysm/dissecting aorta? Her previous negative CT scan made this unlikely
  • Ischemic bowel? Which could be the etiology of a ruptured bowel
  • Diverticultis/appendicitis?
  • Cholecystitis with peritonitis?
  • Pyelonephritis? Her urinalysis under microscopic exam was negative for infection. Pyelonephritis would most likely cause more fever and sepsis and not bloating and distention

Other hints with the exam and testing included:

  • An x-ray pointing toward air under the diaphragm. A good x-ray that shows air under the diaphragm can be extremely helpful and accurate, but this was a technically difficult film. Surgeons often like a CT scan as it can be very helpful in pointing toward the specific site of pathology
  • Rectal exam -guiac positive
  • Absent bowel sounds and abdominal bloating -suggesting this was an intestinal problem
  • Abdomen had diffuse tenderness to tapping -another clue this was perhaps intestinal in origin
  • History -this was an indolent process and did not have a sudden onset like I would sus-pect with an aneurysm or dissection

Experience and my fuzzy logic made me consider this was an infective pro-cess. Another CT scan was reasonable, so a CT without contrast was ordered.

I chose a CT without contrast due to my suspicion of an intestinal problem. The contrast in the CT can be delivered in one of two ways: oral or IV. If this was an intestinal problem (she had no bowel sounds), an oral route would be of no use. An IV contrast can sometimes compromise renal function, and since she had slightly impaired renal function (a previous creatinine was slightly elevated), that did not seem a good choice either. A non-contrast CT would give me the information I needed to clinch the diagnosis and would be the safest for the patient.

For the reasons stated above, I suspected a perforated intestine. The non-contrast CT confirmed my fears, showing an extensive amount of free air. This meant some part of her intestines had ruptured and was spilling the contents into the peritoneal cavity. Such a problem would be life-threatening at any age, and would require emergency surgery, in addition to antibiotics, fluids, and some divine intervention. At her age, realistically, her ultimate and imminent demise would be the only outcome. The next steps would not be easy.

After I got the report, I went back and sat down beside her, and held her hand. This is what I told her, "I'm afraid I have some bad news for you. The tests show that a part of your intestines have broken open and are leaking. That's what is causing your pain."

We sat in silence while I gave her a moment to absorb this. Then I proceeded, "I think we are at a choice point here. One way we can go is to rush you off to emergency surgery, where the sur-geon will fix the leaking hole in your intestines. But this is major surgery, and the recovery won't be easy, or quick. I can't even guarantee you could make it through surgery."

"The second choice is that we don't do surgery," I continued, "but rather we keep you comforta-ble, pain free with medication, and warm. And even though we are giving you antibiotics and fluids in your the end the infection will win, and you won't live past the next day or so."

In an adjacent bed was a pleasant patient who had her own problems with SVT and a rapid heart rate in the 170's, however she was alert and without distress. When I looked over to her to observe my nurse's activities and give some orders, she nodded to me and said, "Take good care of her." I promised I would.

Her daughter was holding back her tears at hearing this news, but nodding her head in agree-ment. The decision was made to avoid surgery and keep her comfortable while she and her daughter spent their last few hours together.

Rather than admit her, and since I knew she most likely wouldn't live through the night, it seemed prudent to keep her in the ED since she was a DNR. Fortunately, the ED was not too busy, and as the evening progressed, I was able to go to her bedside frequently. Additional aliquots of morphine kept her pain well controlled. Her daughter remained at her bedside. Finally, after a few hours, I could see a change coming. When I would hold her hand, it was very cold, and her breathing seemed more shallow, but she would open her eyes and even smiled once or twice, when I spoke to her.

Finally, at 10:23pm, her heart finally stopped. I reached over, closed her eyelids, and I looked over to her daughter. She smiled, and with tears glistening in her eyes, she silently mouthed the words "thank you." Her mother was gone. She had been able to say "goodbye," and just possibly complete some of the other tasks in the private moments they spent together in those last few hours.

For some inexplicable reason, my eyes grew watery for a second or two. I often wonder why that happens to me in these situations. It is not that I have known my patient for years, and am grieving my personal loss. I think it's just because, for a moment, I have shared and felt a stranger's pain. Maybe I live vicariously through them, and in an indirect way I'm saying goodbye to my mother, by helping create the environment for others to do just that.

A few more minutes pass, and I get up to leave. As I dry my eyes, I smile at my nurses, and walk back to the nursing station to pick up the chart for my next patient. As we all know, the rhythm of the ED doesn't stop for any reason and we tuck away our emotions as we move on to the next challenge. I pray that when I finally leave this earth, there will be someone there to keep me comfortable and hold my hand, and possibly shed a tear or two.

If you've read some of my articles, you've no doubt heard me express: "Don't just do something, stand there!"

This is another example where less is more and doing "nothing" was the greatest and most powerful thing to do.

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