Friday, December 3, 2010


It's been a month and a half and I still can't shake the guilt and sadness of a patient dying under my care. Surprisingly, the process of dying is not something we see very often in the ER. We see lots of CPRs in progress, but to put it quite frankly, these people are already dead. They don't talk to us. They don't move or blink their eyes. We never saw them smile or interact with their families or heard them say thank you. They lie there while we try to revive them, and it almost never works.
When we do see death like this, it's not in people who are ready for it. This man was no different. He had not been given a terminal diagnosis or an amount of time he was supposed to live. He was older but healthy- he looked much younger than his 70 years. He came to the ER because he was feeling weak. He walked up to the desk and checked in without a fuss. When the triage nurse took his blood pressure, it was 68/40.
I could tell immediately by looking at him that he was very sick. We were able to establish a couple of IVs on him and we gave him some fluids. He said he felt better, but he was very tired. His blood pressure was rising, but not a lot. He really seemed to be doing better. His sweet wife gave him a kiss and ran down the street to get him some clothing and his meds from home when we told her we would be admitting him. When she left, I stayed with him, and something frightening started to happen. He would fall asleep, but his breathing would slow and his oxygen saturation would start to drop. I stayed with him for about a half hour straight. He would fall asleep and I would call his name and shake him awake. "Mister, mister", I said to him, "Are you okay? Are you still with me? Please stay with me." He would open his eyes and say, "I'm with you. I'm feeling better." I was so frightened for him. At this point I just had to step out of the room for 5 minutes to go to the bathroom- I grabbed one of our nurses who was floating to stay with him. I just told her to watch him very close, that I was very worried about him. When I came back a few minutes later, he was breathing with snoring respirations, and his wife had showed up at the same time as me to see the other staff panicking and pushing his bed into a trauma room.
She burst into tears and I got her a chair to sit in and gave her a hug. I told her very hastily that we were going to help the doctor with a sterile procedure and that afterwards she could come in a be with him. It all happened so fast after that. We put in a central line and an arterial line, I learned how to use the arterial line, we started more fluids and vasopressors. We get his blood pressure half way decent, but he's becoming less responsive so we have to intubate him. We get his tests results back and his troponin is through the roof- chances are, he's had or having a massive heart attack and is going into cardiogenic shock. He's not stable enough for any type of intervention, but I start a heparin drip in addition to the blood pressure meds to try and bust up any kind of blockage that may be happening in the heart. I get a second and I'm able to talk to his wife and niece and her husband. They never had children, but they are very close with their niece. They all filter in and out, trying to be there for him but give us space to work.
Despite everything, his blood pressure starts to drop again. I start two more vasopressors and quickly bump them all to their maximum dose. We get the doctor in and she talks to the wife about the fact that not many options are left. She agrees to stick to the vasopressors but decides she doesn't want us to do CPR when the time comes. It comes slowly. The blood pressure stops reading. The heart rate drops. I go to get his wife but she can't bear to watch. She came in a little while after his heart finally stopped. She took his hand and wept and whispered his name. "What am I going to do without you?", she asked him. I wondered, too.

My grandfather died a few months before this happened. He suffered from Alzheimer's for years. We got a chance to say goodbye, but it doesn't make it much easier. Suddenly I'll be surprised by something that makes me think of him and I'm reminded of just how much I miss him.
When I think of him, I often think of this family, too. How much his wife must have hurt on her first Thanksgiving without her husband. About how the reminders must sneak up and hurt her, too.
After she left his room and I was running amok trying get things in order, I walked by her crying outside his room. I walked up and hugged her, unsuccessfully fighting tears. "I'm so sorry," I told her, " If only I could have done something more." I will always remember what she said to me. Even in her moment of grief, she hugged me and said, "No baby. You did a great job. It was just his time. God was ready, but we weren't."
I can't completely explain why, but this particular thing has just shaken me to my core. I don't know whether it's own experiences at the time or just how unfair the whole thing felt. I always look up the other ER visits when I go to call the medical examiner, and it was obvious just by looking at his visits that this man took care of himself. He went to the doctor and did what he was supposed to do. It was clear from the short time that I had to interact with the patient and his wife that they were very sweet- the kind of people you feel blessed to take care of. The kind that remind you why you do what you do. And I guess even with the outcome, I do feel blessed to have taken care of them. I just wish they could have gotten something different.


  1. I'm so sorry. It's very difficult to process these things sometimes. Do you have a in-hospital counseling service you can use? Or a debriefing team?

  2. Oh my, this story is so well written. I could relate to losing a loved one and knowing the grief and loneliness you feel during special times when they aren't there. You did a great thing by comforting the wife and she is right, you did a great job, but it just must have been this man's time to die. Thank you for sharing.

  3. Thank you for caring. It does mean a lot to all of us.

  4. Great read. Response post forthcoming.

  5. (HUGZ)
    Nothing more.
    Don't ever stop being the nurse you are.

  6. There is nothing more heartbreaking than seeing someone lose a spouse that they have been with for ages. The depths of despair they feel almost radiate off of them.

    Kudos to you for not fighting that despair. It show's your true character and how much you actually care.

  7. There are always some patients who stick with more more than others. You really seem to have connected with this family in some way. I guess this patient's situation isn't something that happens often in the ER. This is a situation that you would more often see up in the ICU. And even though I have experienced it several times, it doesn't always make it any easer.
    Please don't feel guilty that this patient died. It was his time. It sounds like he knew it, as did his wife. That doesn't make it any easier. But please be happy that his family could be with him and he passed peacefully.
    I have a belief in the ICU. Sometimes, you have to know when to stop fighting and let the angels do their job.
    I agree with AtYourCervix, if this continues to bother you so then it might be good to talk to someone about it--to help sort through it all. (Although I hope that sharing it here helps a bit!)

  8. Thank you for sharing your feelings. I worked as a nurse for 10 years and left the field officially three years ago. I still carry a few special patients around with me. You are a kind person with a big heart. You will connect with certain people at certain times in a way that will make them impossible to forget. You will learn with experience how to deal with your feelings. You just need time, and possibly to talk to someone who can help you sort things out.
    You did a great job with your patient. Don't forget that. Sometimes it is not your job to save someone, but instead to usher them to the other side as painlessly and with as much dignity as possible. This case was a hard one, but look at how much you grew through it. You are an even better nurse today than you were the day before because of it, and every patient after him will make you even better and better.

  9. My mother had similar symptoms. She was finally diagnosed with Addison's disease after they perfed her bowels and she went into cardiac arrest! Yeah they said her stomach pain was caused by constipation. I was like okay, then explain why her bp is dropping. She kept going in and out of conscience too. No explanation. Thank God my doctor worked at this hospital and diagnosed her or she'd be dead! All the ER doc seemed interested in doing was flirting with one of the nurses on duty. When my mother started vomiting blood he finally got off his butt!