A death in the office

Physicians are trained from the very outset of medical training to deal with death. Its a huge part of the medical world, obviously. The natural cycle of life moving on to death. It is rarely a welcome, if not grudgingly accepted, part of a physicians life.
Especially in the hospital. From severe injuries and overdoses and heart attacks in the emergency room to the more expected loss of seriously ill patients in the intensive care units and hospital wards, death is not an uncommon occurrence in a hospital, varying of course on size, location of the hospital. Its expected that one will encounter death in a hospital setting.
I did a trauma medicine rotation at Ben Taub hospital in inner city Houston , Texas where we had at least one gunshot or other violent death per shift. Of course at a smaller hospital you might have one death a week.
However, when you have an office based practice you just don't expect to see much of death in your workplace, however it can happen.
I was the county coroner in my rural county of 15,000 folks for 7 years, so I was no stranger to deaths elsewhere in the county. Motor vehicle accidents, farm accidents deaths at home all happened at least several times a month. So even after training I was no stranger to death. But I only had one death in my office. It was my first year in practice here ,about 1o years ago.
Mr. James (not his real name of course) was a police officer in our small town. A real salt of the earth, rural raised kind of fellow, he was the type of man who never went to a doctor. I had never seen him as a patient but knew his extended family, including his children well.
It was during a very busy cold and flu over run kind of day that his wife called and spoke to our nurse and explained that he was having chest pains.
I did not take the call as I was seeing patients but it was relayed to my senior partner and the patient was told in no uncertain terms that he should seek immediate care at the ER of his choice.
A less desirable option was given when his wife explained " Oh he will never go to the hospital", was to be seen at our office immediately, as in right now, get in the car come here kind of right now. His wife said she would talk to him and try to get him to come.
Very frustrating to me in retrospect as I lost my own Father the SAME WAY, as he was having chest pains for 3 days and for reasons known only to him, be it denial, fear or some other hope that it was just indigestion, simply refused to go to the hospital.
So before we left the office late that night we tried to call his home, got no answer and hoped that he had decided to go to the ER.
All these interactions were dutifully recorded in his chart.
Of course the daily grind of a busy little rural office went on with or without this patient as it tends to do. A call the next day by my nurses revealed that he had gotten better and decided not to do anything at all. An option for which they were admonished.
Now two things locked in my meeting with fate.
One was the fact that the senior partner was now taking Thursdays off, more to allow me a chance to fully integrate into the medical practice by being the only man around for a day than to give him a well deserved step back from his 30 year medical endeavors.
The other circumstance was that I had INSISTED upon a cardiac monitor with built in defibrillator when I came to the practice. I just felt it was tempting fate not to have such a tool in this rural isolated setting. And the entire staff had dutifully trained on the use of this awesome little intensive care unit in one little portable package.
Early that afternoon we got the call that Officer James chest pain had not only returned but had worsened and that he was on his way to the office. So we set up our little trauma room with our monitor and ACLS drugs (those are all the meds used to try and treat a heart in distress like you see being used during a code in all the movies) and I told the nurses to hook him up to a monitor and get a 12 lead immediately on his arrival.
This was done efficiently and quickly and within minutes after his arrival i was handed an EKG with his name on it.
One quick glance at it revealed that he was in the throes of a full blown heart attack with "tomb stone" T waves in the inferior leads.
"Youch!" I said not even realizing or caring that I said that out loud. "he's having a full blown MI right here in front of us." Call the E squad start an IV line, put him on 4 liters of oxygen by mask!" We had a pathetic little bottle of oxygen that held probably 30 minutes of oxygen.
I strode into the room to see a man looking older than his years, he was pale, sweaty and he looked scared. The kind of fear a man gets when he knows that something very bad is happening.
I told him that his heart was not getting enough oxygen and that he needed to get to the emergency room, well like 2 days ago.
I asked him about where, when, how bad...he answered my questions briefly and in measured short breaths.
Our eyes met, and he said simply " do what you need to do doc.." he said in a grimace as he dealt with what was obviously classic crushing chest pain.
Those were his last words.
I turned to tell the nurse to give him 2 mgs of morphine. On paper we did not have any controlled substances in the office, but we actually always had on vial of morphine on hand. My ever resourceful senior partner had literally years ago found himself "one vial ahead" as he explained it, so when we used this one we wrote a script for whomever we used it for and replaced the always present single vial of morphine. A little trick that would never work in any other medical facility except our little backwater clinic.
I had no sooner said those words when out of the corner of my eyes I saw the patient go limp, I glanced at the monitor and instantly recognized classic V-fib. Not a good rhythm. Not compatible with cardiac blood flow or well ... life.
One of the RN's in my office looked at me with fear and pain in her eyes and said (literally, I am not making this up.) "He's my uncle , Doctor, don't let him die!"
I didn't find out until later, but this intelligent, beautiful ,and talented young lady had a cross of her own that she had born, rightfully or not, for years.
She had been driving her cousin to the mall years before, not long after she had gotten her driver's license and a tragic accident had occurred in which the cousin had lost her life. A cousin who was the daughter of the man now before us. Only in a small town, I remember thinking later.
I can only imagine how his heart must have broken when he heard that news, but right now this man's heart had had enough of this low oxygen game, and was in the middle of giving up.
We all launched into our positions, observed collapse so one precordial thump, Shock, check rhythm, shock, check rhythm, shock, epinephrine, shock, lidocaine ...monitor?? asystole... well this went on it seemed for hours but it was only 22 minutes. Check monitor between compressions and med administrations nothing..nothing...nothing. Time to call this code....Time? That's the time of death.
The nearest hospital is 22 miles away, and I supposed that even if the E-squad had gotten a crew together his chances were better with me than with an untrained ambulance crew. Which is all our county had. It had been probably 45 minutes since we had put out the tones but in this small town daytime crews were hard to come by. People had to work.
I told the family that had assembled in my waiting room that he was gone. Yes a heart attack. Yes, he should have gone to the hospital days ago. I know, I know he just wouldn't go. What could you do? Put a gun to his head? Yes we tried everything this little clinic had to offer. He needed clot busting drugs 2 days ago.
The overwhelming stress of the situation hung heavily on my office staff. They had performed well , especially given the circumstances, and I told them so and gave them hugs all around.
I never told anyone, but I cried that night. For my lost patient yes, but also for myself, as I had lost my dad the same way nearly 15 years before. The irony and similarities were just too much to bear. I had always sworn that I would never lose one that way...