"You'll
Never Get Off the Table". |
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By
Tom Janisse, MD
"Doctor,
it's Carla in ER, the Tyler police just called. Medic 3, Tony's rig,
is rolling in Code 2 with a suspected leaking abdominal aortic aneurysm.
That's what Tony said the patient said. They're twenty minutes out."
"A
triple A! Why not Code 3?" said Stewart from the sleep room.
"Patient
said not to. Police don't know any more. Tony's probably hoping he can
go straight to his mortuary."
"Why
are the police calling?"
"You
don't know Tony," she said. "He's always hated this medic
stuff. In the sixties, back before EMTs, he'd just cruise out to the
accident scene in his Cadillac hearse to pick up bodies. Turned on siren
and lights to blast through traffic. Not really legal."
"Does
he always call the police?" asked Stewart.
"They
might have been at the patient's house. Tony calls whoever and whenever
he wants, to avoid taking Medic radio orders. He'd still rather go straight
to his mortuary than the ER. But doctor ... he drives like Mario Andretti!"
"Some
story, Carla," Stewart said.
"I'm
going on a bit to make sure you're awake. Tony wants to go Code 3 speed,
but doesn't want to give Code 3 care. You need to be here when Tony
gets here. No telling the patient's condition."
"What
time is it?"
"It's
3:15." Carla hung up.
"Thanks,"
Stewart said to the dial tone.
Good,
not another drunken 19 year old. Wrecked his car. You wonder, when they
go off the road on a straight stretch, like last night. Switching tapes?
No turns to keep him awake? Unconscious suicide attempt?
Middle-of-the-night
stuff irritated Stewart. A Houston physician, on a research year in
residency, he worked in any ER that needed a doctor on the weekend.
Tyler County Hospital needed one because the hill town doctors were
exhausted seeing patients day and night, in their office, in the hospital,
in the ER, quick questions at the flower shop, consultations in the
hardware. Even home visits for some old folks.
"Doc,
you up? Medic 3 called back. Tony's rounding the corner by the bank.
It's Barry Colton. You don't know him but he's got a history of an abdominal
aneurysm. Half the town knows. He's 84. Tony says they can't hear the
blood pressure
now ... because of road noise."
"Okay,
be there before you can hang up." Stewart slept in his clothes.
Gave him an extra minute. He struggled to drag himself out of the deep
sleep that he'd fallen back into. His black ruffled hair flowed over
his ears and onto his neck. In contrast his mustache was trimmed into
a trapezoid. He had an incessantly twitching left upper eyelid. It made
him nervous because it meant he was nervous.
Only
August ... wish it was 1986 already. Outta residency. Treat a triple
A in Tyler? Ship him to Houston before it blows. Not while I'm standing
next to him. Vascular surgical team would save him ... Tony could take
him. Maybe just a kidney stone. A triple A! ... in the middle of the
night ... in Tyler. What a nightmare! Major pain. Like getting shot.
"Hello,
Mr Barry Colton? I'm Dr Eddie Stewart. Are you all right? Do you hurt?"
Stewart scanned his face and belly for clues. Barry had this eerie look
of painful calm on his round face. His ashen hair curled under his ears,
matted with sweat against his neck.
"Hurt's
here." He points mid-abdomen. "Deep. God, it's intense! I
gotta have something for pain, doc. I'm dying from the pain."
"Okay,
Mr Colton, but let's see what it is first." Stewart started palpating
his belly with his hands one on top of the other, fingers pressed tightly
together creating a blunt instrument. "On a one-to-ten scale, how
much pain now?"
"Eleven.
Christ!"
Tense,
full, yet feeling's distinct. Pulsatile mid-abdominal mass--aneurysm.
Belly and back pain--leaking. Hypotension--near rupture.
"His
blood pressure is 70 over 50," Carla said. "Rate's 130."
She spoke to him across the bed while plunging the puncture end of the
IV line through the soft port in the second bag of saline. As she slid
the top slit in the bag over the metal hook, the pole rattled in its
base. Carla had a square face, traditional stiff nursing cap pinned
on, starched white uniform, nursing pin exactly horizontal on her left
lapel. Always adjusting it to make sure.
"Start
another large bore line," Stewart said, looking straight into Carla's
eyes. "Turn up the oxygen, call EKG, call blood bank
for six units, get labs, call Dr Sovitch, call the OR crew in. Get the
floor supervisor down here. And draw up ten of morphine."
"Done."
Carla turned to Jimmy, the lab tech who had just run into the room,
carrying his basket of color-coded tubes tinkling in little wire cages,
and said to him, "You hear those orders?"
"Got
'em. Know the drill from car wrecks." Jimmy pulled out red top,
purple top, and green top tubes, a syringe, and tourniquet.
"Mr
Colton," said Stewart, "we're drawing up your pain medicine
right now. This looks serious." Stewart, six feet tall, reached
down and touched his shoulder. "You know you have an aortic aneurysm?"
"Yes,
doc. It's it, isn't it? That's what I told Tony."
"Sure
looks like it." Stewart looked up, for the first time noticing
Tony leaning against the supply cabinet. He didn't look 60. He was tall
and lean with his head down writing his ambulance ticket for the transport
down the hill. He wore a navy blue uniform top that zipped up the front.
After replacing his call log into his waist pocket, he clicked his ballpoint,
twirled it to see the "Hill Country Mortuary" logo on it,
then clipped it alongside the log. Tony cured olives every season and
brought jars around to everyone he worked with. He even gave Stewart
a jar of green ones yesterday. Reminded Stewart of his dad who made
little tile trivets and gave them to neighbors. He died last year. Cancer.
Stewart felt he should have helped him at the end, as a doctor.
For
all the olives he cures and eats, smoking must dictate his weight. Did
leave his face with creases ... visible because he's clean-shaven. Reminds
me of a saying, "There are more old lungers than there are old
doctors." After smoking ten years ... wonder how many lung units
I have left? Dad never smoked. Still died.
"Tony,"
said Stewart, now over in the corner close enough to talk to him softly,
"Can Medic 3 take him to Houston? We can't get a chopper in and
outta here in time. They'd have to land up at the airport. Triple transfer."
"Bart's
gassin' 'er up now, doc," said Tony. "But doc ... don't order
CPR in the back. It'd be a flail at high speed. I have two sets of lift
tracks in the back. Bart and Barry need to stay on each side for good
balance. You know what I'm good at. I can get him to Houston faster
than anyone in the county. Cops know the Cad. It's like flyin' a jet
under radar. And doc, he doesn't want us doing anything anyway."
"How
long?"
"Under
40 minutes with lights 'n siren. The Cad's made for this trip. Cuts
through the air like a fish through water."
"Doc,
talk to my wife first," Barry interjected, overhearing the exchange.
He motioned Stewart over. "Sara should be here. She followed the
ambulance in." He paused to take a breath. "I'm not going
anywhere 'til you talk to her. She'll tell you what we decided. Hurry
doc. This pain is killin' me!"
"His
pressure's up," Carla said, "now that we've got some fluid
in ... 98 over 70."
"Give
him the ten of morphine then. Add five if you need to."
Stewart
spun around, and took three steps into the hall where he stood along
a wall of soft cream tiles across from a tall, slight, 80 year-old woman
wearing a long, coat-like, gray woolen sweater. Her reddened eyes emitted
tears on a face long in grief, like a window dripping after the rain.
A quality of calm accompanied her sadness. "Hello, Mrs Colton,
I'm Dr Eddie Stewart." The tone of his voice seeked resonance with
her feelings. "I'm sorry about your husband. He said you knew what
to do." Like the wisp of a wing in flight his fingers touched her
forearm.
"Dr
Stewart ... it's his aneurysm?" She clutched her small black embroidered
purse. She knew but didn't want to.
"Yes,
Mrs Colton."
"Oh
dear ... we knew it would happen." She blinked, blinked again,
then looked down and away, as if searching through the fog for ground.
"We
have a plan though, Mrs Colton," Stewart said, eyelid twitching.
Sara
looked around Stewart into the trauma room and saw the people fussing
around Barry. She saw Tony. "Is he going somewhere?"
"To
Houston. It'll take a team of vascular surgeons to operate on his aneurysm.
As a back up, Dr Sovitch is on his way in. Honestly, even a great general
surgeon couldn't save him in Tyler. It's a very complicated operation."
"It's
leaking then?"
"I
think so, yes, Mrs Colton."
"Dr
Stewart, he'll never make it through surgery. He's 84, and he's got
a bad heart."
"The
best thing for his heart could be to fix his aneurysm."
"Dr
Gibon, his family doctor ... do you know him?"
"Yes,
I met him last month."
"He's
Barry's family doctor ... always has been. Dr Gibon told us it was coming;
we just didn't know when or where. He said we could either wait and
panic or we could prepare and flow with it. After many talks we agreed
to no heroics ... no tubes." Sara searched for Stewart's reaction.
"We're
definitely not there yet, Mrs Colton, though I'm an emergency doctor."
"Dr
Stewart, I don't want you to be that kind of doctor," said Sara,
"I want you to be Barry's doctor." She cupped his elbow in
her hand and turned him toward the trauma room, "Let's go in by
my husband."
"Hi
Barry honey, how are you?" she said, as she grasped his hand in
both of hers.
"I'm
hurting real bad, Sara. Dr Gibon didn't talk about this part."
Barry looked at Stewart in a plea and said, "Doctor, I gotta get
some relief. This is no way to go. Have some compassion for an old man."
Barry's face and forehead glistened with beads of sweat. Sara looked
at Stewart, then back to Barry.
Carla
pressed up against the other rail of the gurney and blotted the sweat
over Barry's eyes, then pushed in the last three milligrams of morphine.
"That's
15, doctor. I gave it all." She took down the empty bag of saline,
replacing it with the unit of blood Jimmy had handed her.
Tony
stood by holding the top rail of his shiny tubular aluminum lift with
a clean, pressed, white sheet drawn taut and neat around the mattress
ready for the transfer. He shifted his weight from one foot to the other.
Stewart knew Tony wanted to be rocketing down the road. It's what he
got up for in the morning.
Mrs Colton
turned to Stewart, "Dr Stewart, Dr Gibon said straight to Barry's
face many times in his office, 'You'll never get off the table, Barry,
you're too old, and your heart's too sick. If you did survive, you'd
suffer a stroke.' Barry wished for the old man's friend--pneumonia--but
he's got good lungs. Never smoked."
"I'll
never get off this table if I don't get some relief! Give me somethin'
more for this pain, please. It's all that matters now."
"Carla,
give him another 15 of morphine, please. Carefully. His pressure."
"Hurry,
doc! This dyin's hell!"
"Dr
Stewart," said Ginny, one of the OR nurses who'd popped into view
in the hall doorway, "we've got the OR ready. All the trauma trays
are open, blood's in the OR fridge, and Dr Sovitch is getting out of
his car."
"Thanks,"
Stewart said, turning back to Sara. "Could I please talk to you
for a minute?"
"Yes."
She looked to Barry. "We're going to stay together, Barry."
Stewart
took her arm and guided her into the hall. "Mrs Colton, this is
very serious. This is life or death."
"Yes,
we're ready. Only surprise has been the pain."
"What
do you think we should do?" Stewart looked to her imploring for
resolution.
"As
long as he's comfortable when he goes. That's all that matters."
"Yes,
we're doing that. But usually we make every effort. Surgery could save
him. We can do that here. Everyone's ready."
"Doctor,
he'll never get off the table." She looked annoyed.
"That's
easier to say than do," Stewart said.
"Once
you took him into the OR I'd never see him again. We planned to be together
at the end." She reached for his hand. "Your work now is to
relieve his suffering."
"I'll
call off surgery then. Tell Dr Sovitch and the crew. I'll call Dr Gibon.
He'll be awake. We can take good care of Barry right here."
"Thank
you." Her face lightened with a faint smile. "Barry said when
he passed he'd wait for me. He always does." Looking
down and away, like a heron tucking its head in its wing, she stood
motionless.
Dad
thought of mom the same way ... when she wanted to give him a pill ...
he accepted ... it was the end.
Stewart's
mother was poised at his dad's bedside at home to place a pain pill
on his dry tongue, water in hand, saying, "Conrad, here ...."
"Margaret,"
he responded, "I don't have pain anymore, but I'll do it for you."
He swallowed it, and stopped breathing. His eyes widened as if he was
seeing beyond, as if he saw friends waiting in the light, drawn to it.
He died in that instant. It was a joyous moment, until the reality of
death struck her heart.
"His
pressure's down to 70 over 40. That's the second unit of blood hanging
there, almost in." Carla reached up and squeezed the bag. "We've
finished our third liter of saline. And he's got PVCs now. Is it the
table ... or the Cad, Dr Stewart? Table ... or Tony?" Impatient,
she wanted action.
Tony
caught Stewart's eye and started wheeling over his lift.
Stewart
stood silent, arms hung at his sides. His eyelid was still. The green
EKG tracing blipped rapidly across the blue screen. Oxygen hissed through
the nasal tube. Mr Colton's eyelids hung heavy leaving only a slit of
white. His bulging belly had smoothed out the waves in his gown patterned
with turquoise diamonds.
Duty
... science or heart? Barry wanted it ... Sara did, and Gibon agreed.
Never get off ... the table ... or the bed. The table or the bed. Go
... no, not you, it's about Barry ... at peace with death ... but with
pain? ... hope now. Dad said, "This is no way to live," before
I knew he'd decided ... slipped off ... I was already gone ... planning
on Christmas together. Sara's here, Barry's here. Their town hospital
... and Gibon ... their friend too ... right here. I'm in the way. Losing
him. Not sure ... morphine could knock out breathing. Advanced age ...
pouring in fluid ... heart failure. Hope he doesn't arrest in the ER.
Reflex reaction to V Fib near impossible to suppress ... a circus.
Jump on him, thump his chest, press his sternum, slap on a mask and
pump the bag. A wild primitive dance to restore life. What it would
take now. Easy to say, "Do nothing" .... Not sure we relieved
pain, or oversedated. Either way, it's good. Sometimes best we can do
... technical training, how's it help? Breathing's slowing. Don't stop
breathing here, Barry.
Stewart
suddenly saw Tony across from him. Tony held his lift's side rail behind
him with his left hand; his right hand floated above Barry's rail. Stewart
called Tony off with a slight wave of his hand and shook his head back
and forth several times messaging a no go.
"Let's
get him down to his room," Stewart said to Tony, Carla, and Jimmy,
all still anticipating action. "Come on, let's go. We're admitting
him to treat his pain."
"Doctor,"
Carla said, while snapping the wheel lock with her foot, "I haven't
notified the floor yet."
"Call
ahead and find an empty room," said Stewart. "I'll take him
and Mrs Colton."
Finally
got him in bed ... only a slight grimace.
They
were in a single room at the end of the wing that looks out over the
hillside through the oaks to the pines up on the ridge. Private. Peaceful.
Daybreak. No nursing station calls. "Mrs Colton, here, let's pull
this chair up for you alongside his bed. He looks comfortable now. Resting."
She sat on the edge of the chair leaning toward Barry as if looking
for signs of distress to relieve, and cupped his hand with her hands.
God,
he's snoring! Sounds awful. Could lead to an obstructed airway ... struggling
breaths ... long, drawing ... pulling for air ... could just stop breathing
trying ... then a guttural release of air. Such noises. Quietly ...
has to go quietly ... best for her.
"Hand
me an oral airway please," Stewart requested Betty, the floor nurse
now at bedside.
"Number
four alright?" she asked.
"Yes,
thanks."
"Betty,
I'm so glad you're here," said Sara. "We've known you since
you were seven. Knew your mom."
Betty
smiled. Offered her presence.
It
worked ... tongue up ... obstruction's gone. Breathing quietly. So undignified,
that square plastic protrusion from his dry lips. Could gag him. If
terminal gasps, even more pleasant. Guess this airway's better.
"I'm
sorry, Mrs Colton. I wish we could do more."
"It's
all right, doctor." She turned to Stewart long enough for a meaningful
connection. "You did the right thing." Sara slid a hand out
from Barry's to touch Stewart's.
Warm,
firm grasp. She is thankful. Knows now she'll go home alone. Doesn't
want to let go. Touching the dying ... touching the living ... the dying's
fading.
Stewart
turned away, hearing someone.
"Doctor,
there's a sick baby in ER," Carla said, reappearing in the hospital
room. "Can you come now?"
"Yes,
soon as Dr Gibon arrives." Stewart turned back to Sara, now stroking
her husband's forehead.
She's
with him. I wasn't with dad. "He'll be fine, Mrs Colton."
Squeeze her hand ... hate to pull away.
Stewart
hesitated. Sara said, "I'd rather be alone with him."
Barry's
breathing quietly now. Hardly breathing ... seems so much better somehow.
Slip his lids shut. Rest his eyes. No chance to shave. Looks unkempt
... whiskers, clammy pale skin exuding sour scent, matted hair, mucous
visible in his nose, drool sliding off the corner of his mouth. Wipe
it ... find something ... the sheet. How can it matter to a dying man?
Mrs Colton doesn't mind. Dying at the end of summer's better than the
middle of winter. Was for my dad. Winter's a cold death. This was really
a warm death. Though he probably felt colder the more his pressure dropped.
Maybe he didn't notice with the morphine.
Sara
seemed to breathe with Barry. She turned half her face to Stewart looking
out the window, and said, "I called our children, but they live
too far away to come this quick."
Took
us so long to relieve his suffering. Dad suffered too. My plea to his
doctor for more morphine ... sounded like asking a doctor's favor. Dad
said it was fine ... didn't want to bother anyone. Heroic--this saving
life at any cost. Training ... the right thing ... no liability ...
no family emotions. Too busy to sit with them. Barry didn't suffer too
long. Would've going to Houston. OR ... the table ... ICU ... a bed
like the table ... the vent. Die alone ... strange place ... the last
hour.
Still
staring out the window, Sara started when the oak leaves moved in the
wind, and said to Stewart, "I wish we were home ... but ... we're
here."
"Dr
Gibon. Thanks for coming." Stewart shook out the reverie then took
the hand of the doctor who had guided them. He had a full head of gray
hair, and was dressed in a white shirt, blue and burgundy striped tie,
and charcoal sport coat. At 5:00 in the morning! He had posed the inevitable
dilemma for the Coltons. How to act when the quality of your life hangs
in balance with the quantity of your life. "In the crisis, Dr Gibon,
I tried to understand and follow your plan."
"Yes,
Dr Stewart," said Dr Gibon, "We talked about it, but you carried
it out."
"Sara,
how are you?" said Dr Gibon, bending down close to her face, hand
on her shoulder. "I'm so sorry. Barry looks peaceful."
"Oh
yes," said Sara. "Thank you for coming out in the middle of
the night."
"Dr
Stewart, the baby," said Carla, reappearing. "It's crying."
"Yes.
Right away." Stewart backed away from the bed, turning toward the
door. While his eyes lingered on Sara and Dr Gibon, left to complete
their relationship with Barry, his heart felt the presence of his dad.
