The pulse

When I arrived at the hospital, it was already dark. October has a way of somehow creeping up on me every year and the end of dark purple twilight filled my rear view mirror as I pulled in for a shift. That was 8:30. In truth, I never know what I'll be walking in to. There are nights as calm as a pond without wind- and I treasure the ability to actually sleep for an hour or two. But then there are nights like the one I was about to have. Regardless, I paused that night as I locked the car and threw on my white coat- there was a waning moon rising from the east. There was something different in the air and I felt it and I knew it would be one of those crazier nights.

A college professor of mine, a famous one at Cornell, once gave a lecture on ESP. In the beginning of the class, he called a young woman up and asked if they had ever met or spoken and she swore no. He then proceeded to tell the 2100 of us in the class all about her. Every detail of her life was revealed to the astonishment of the class. At that moment I began to believe in the supernatural.

As I picked up the pager from the Saturday day float, he smiled and said, "It's been quiet, have a good one." I made my way to the hospitalist room and checked my email. I made a phone call to home to check on the kids. And then the overhead pager stated simply: "Rapid response to CCU." Since 2001, many hospitals have adopted some sort of systematic method for dealing with urgent medical issues. Whether it's a Code Blue (cardiac arrest) or other urgent issue, most hospitals have gotten better at dealing with such issues. In my residency, our hospital adopted such a system early on. Soon after a patient was in trouble, a "trigger" was called. Several parameters dictated whether a patient was sick enough to merit the attention of a trigger, but if all else failed, "nursing concern" was enough to send interns running, get a call placed to the resident and attending and have several people in a room within minutes. At my current hospital, a team of skilled nurses assemble to help facilitate next steps in such a situation. And most importantly, given that at night I am the only doctor in a 150 bed hospital besides a sleeping anesthesiologist and the ER doctors, the overhead page is really for me.

I entered the room to find, to my surprise, only one nurse taking a blood pressure on a man who was mumbling incoherently. He had been admitted to the ICU with a gastrointestinal bleed and several studies had failed to localize the source. He had been very stable, per the nurse, until about 20 minutes prior when his blood pressure dropped precipitously. Luckily, I know as a GI fellow by day, that a drop in blood pressure in a patient like this almost always represents a big bleed. "But I haven't seen any blood" she told me. I didn't care. Within a few minutes I had 4 more nurses in the room frantically working. His blood pressure was 50/30. His one IV became 4 IVs for access for blood, saline, and medications to raise his blood pressure. The medications weren't working.

Then came the blood. Out his bottom it poured like molasses. And now he wasn't talking at all. His breathing became labored. At my request, soon after I arrived, his family had been called and arrived in time for me to confirm that they wished, for this 79 year old, for all possible measures. The timing was important, as he then went into a code and lost his pulse. I woke the anesthesiologist from his usual slumber to help me intubate him as we compressed his chest and administered medications- a hail Mary pass in a game long over. By 10pm he was dead.

I looked around the room. In about an hour a calm night in the ICU had led to 11 staff members, 5 covered in blood, in one room. A dead man lay before us with cracked ribs from 20 minutes of CPR, his arms were cluttered with IVs and medications and blood hung on a pole still dripping. A family of eight were crying in the waiting room expecting his death based on my candid discussion with them about his condition. 3 of the 4 consultants I had been in contact with throughout this ordeal were about to show up- and all would agree that he was too violently ill to move to an operating room or an angiography suite: in short, there was nothing we could do.

At the end of the psychology lecture on ESP, the professor called the girl back on stage. He confirmed again that they had never met or spoken. But then he revealed that his secretary had called her the night prior to obtain all of her information in preparation for the lecture. The secretary had then prepared a detailed document which the professor had memorized prior to the lecture. In summary, he concluded, ESP was a hoax. It was showmanship. There was no supernatural. What is, frankly, is.

But as I held my dead patient's wife of 41 years and she sobbed and repeated "He was fine today. He was completely fine," I wondered. Why did this all go down on my shift? Why was I chosen to shepherd him into death? Why was I the one to hold this woman? Why didn't he die days ago? Why did he wait for me? All doctors ask these questions. And perhaps the answer is what the majority think- that when your card is pulled, time's up. But perhaps the feeling I had as I looked up at the moon and watched a flock of late geese head southwest towards something warmer was one of connection. Perhaps in all of this science there lie things completely unaccountable and new.

What I can account for is how I felt, at 10pm that night. I felt a hollowness in my heart. I felt humbled by a wife beside her dead husband. I felt that I had failed him. I felt that I could have done more. I felt heavy. I felt alone. She must have seen it in my face because she gave me a gift so rarely given in those moments. "You did the best you could, doctor." At the end of the day, at least I knew that to be true.