Monday, September 28, 2009

The Heart of the Matter

Suddenly I was in the back of that rocking ambulance again. This time with Howard Thorpe. His pallor revealed what his silent lips did not. The wail of the siren bounced around us and the lights of the city streaked past.

He knew what was happening behind the layers of tissue, cartilage and bone. He knew what had occurred deep within his very core. The aorta is the body's largest vessel. A firefighter’s hose of blood which runs the length of the spine where it bifurcates into smaller but also high-pressured arteries at the neck and thighs. A tear in the aorta can cause a man to bleed to death in minutes.

Howard had come in with mild chest pain and leg pain while he was skiing. A neurosurgeon from Montana, he knew that chest pain wasn't to be trifled with, figuring it was nothing but wanting to be sure he came into the clinic to get checked out.

At that time the pain was in the middle of his chest, maybe a 5 or 6 out of 10. His initial exam rang no great alarms. The electrocardiogram was overtly normal, his blood pressure not too low or too high, heart rate was skipping along maybe a bit quickly, but nothing worrisome.

Howard was very personable, kind, unassuming. The clinic was busy that day but he was my primary concern. The broken wrists and dislocated shoulders could wait with ice packs and slings in various positions.

Howard’s family was still skiing on the mountain, unaware of his mid-morning check-in. I administered nitro spray under his tongue, feeling somewhat sheepish as I warned him about the possibility of a headache… like he didn't know! But then, one can’t be sure what medical people forget or fixate on when they are the patient. When suddenly they are on the them side of the ledger. Anonymous in their underwear and open backed gowns status…shuffling with their IV poles to the “patient" washrooms.

Howard said his pain had gone from a 4 to about a 1. I told Bob, the physician, and he advised me to keep his pain down with nitro and continue to monitor him. We nodded knowingly, the new onset of angina now under control. A cardiac foreshadowing. It was minor in the grand scheme of things. Thorpe was in good shape. He'd go home, and with his connections in Montana he would have the best cardiologist who would fast track him in to the cath lab where they would isolate those pesky narrowing arteries and do the things they do to them.

Howard would probably never even have to be an inpatient. He'd be tickety-boo and back operating himself in no time. All of this Bob and I were comfortable with. A nice guy with a not-too-bad diagnosis.

I went to get bed 3 ready for the next fractured wrist reduction. I heard my name from bed 1. "Erin? I just can't seem to get comfortable. Could you give me a hand?"

I walked quickly to his bedside. The head of the bed was raised and he was fidgeting in a strange way, fussing with the pillows. "I just can't seem to get comfortable. Can you lower the bed please?"

There was something about his movements that struck me as odd. Even bordering on alarming. "Where is the pain, Dr. Thorpe?"
"Right here, between my shoulder blades". He reached awkwardly around and pointed to that area on the back that immediately caused the hairs on my neck to stand. A classic sign of an aortic dissection. The tearing-of-the-lumen, pain referred to that area.

Trying to mask my reaction in my face or demeanor I helped him settle and quickly found Bob.
"His pain is mid-scapular,'ve got to get in there now".

Bob and I exchanged looks which confirmed that we shared the same thought. Our initial apple-pie assessment of his prognosis had just soured. This was not good.

We moved Howard to the trauma room. Bilateral blood pressures on his arms and legs showed a marked discrepancy in pressure. On top of that, the pulse in his left foot had disappeared. His major blood supply was compromised somehow… his circulation wasn't going where it was supposed to. Now the leg pain made sense. Clinically it was clear that he was dissecting. If he was lucky it would be contained, with the more delicate vessel tearing inside while the thick outer lumen remained intact.

We were arranging the med-evac to the tertiary center which housed the vascular surgeon. At this point it looked like ground transport would be faster than landing the chopper. Someone had to go with him, and that someone was going to be me. Bob explained to Howard what was happening. Strange… or was it… that Howard hadn't come up with that differential on his own. Emergency staff are so versed in the tell-tale red flags of triage that Howards’s textbook discomfort immediately drew the two of us to the same conclusion. Maybe it was Howards denial and his own rosy hope that it was angina that blocked out his objective analysis of the situation. Can a man indeed be objective when he’s subjected to such an experience. …

We loaded up in the ambulance. His son-in-law had arrived but was unable to locate Howard’s wife and daughter on the hill. They had planned to meet in about an hour. His son-in-law was planning to bring them to the hospital as soon as he could but now Howard would have to go without seeing his family.

Dusk and damp misty rain greeted us when we rolled Howard out of the clinic. The fresh evening air did nothing to untie the knot in my stomach as I carried the bulky cardiac monitor behind the stretcher, a cell phone and Doppler to amplify pulse sounds. Two large-bore IVs were running into his arms and I had a pocketful of morphine and Gravol to keep him comfortable during the ride. I had no other drugs or equipment to rely on.

Shaun pulled the ambulance out of the bay… the sirens came then. It’s an altogether different matter when you are riding inside their wail.
As we accelerated down the dewy road toward the highway Howard was asking me questions… almost talkative.
"What are my blood pressures?"
"They are dropping, Dr. Thorpe. The left side is only 70 now."
"Why are you using the Doppler?"
"I can't feel your femoral pulse on the left side. It’s gone." A place where normally the bounding heart rate kicks at your fingertips now gave me only a swoosh-swoosh-swoosh when I pressed the Doppler to his groin.
"These things are so sinister in my mind,” he said. “The only time I see them is when I am trying to repair spinal damage from them".
"I suppose it must be worse to have the medical knowledge, to know all the worst case scenarios. Worse than being blissfully unaware."
He nodded.

I have a strict pact with myself to never reassure patients when I don't know what an outcome might be. "It'll be okay" or "You'll be fine" are phrases that never escape my lips unless I am putting a bandage on a skinned knee.

Thorpe arched his back grimacing with pain, said, “It feels like it’s more in my throat now.”

I thought that he was going to bleed out right in front of me. Unsure as to the best thing to do as I watched his pressure plummet, I grabbed the EHS cell phone and called the clinic to update Bob and figure out what the hell I could do in the back of this ambulance if this man suddenly blew on me.

As Bob answered the ambulance lurched to the side, passing an unaccommodating commuter. The phone slipped from my hands and fell into several pieces on the metal floor.

I flipped open my own cell, so thankful that I had thought to bring it. Bob came on the phone again.

"His pressure is dropping. I've lost his femoral and he's getting pain higher up the sternum".
"Nothing you can do, Erin. Keep him comfortable, pain meds, fluids, that is all you can do in the back of an ambulance. It is out of your hands."

What I already knew but couldn't swallow.

Howard refused any morphine. Looking back I think he wanted to be as clear as possible for what could be his last moments. He knew he was a time bomb ticking.

He was silent and I forced myself to respect the desire he had to be alone in his thoughts.

Was he happy with the way his life had turned out? Satisfied? What haunting thoughts came to the surface now? Was it fear… resolve… peace?

His face revealed nothing.

He turned to me.

"Erin. My wife's name is Pauline. My daughter is Isabella. This is my wife's cell phone number. If I don't make it please call them for me. Promise me you'll call them and tell them I loved them." With a shaky hand he scrawled a number on a scrap of paper from his wallet.

I took the number and folded it into my scrubs.

"I promise". Was all I could say. My own heart was thumping in my throat.

He nodded, closed his eyes and seemed to go deep within himself. I bit hard at the inside of my cheeks. I felt myself go cold. I was going to watch this man die. The tinny interior of the ambulance his last vessel, a stranger at his side. My eyes remained locked on the cardiac monitor with its reassuring blips every second.

We arrived at the hospital in record time despite the rush hour traffic and the bridge. Shaun smoothly rounding corners, passing lanes and lanes of hassled motorists.

Howard is whisked into the ER, a trauma bay and team waiting for him. I pass on my report to a disinterested male nurse who is only half listening until I get to the part about the vanished femoral pulse. He glances up at Howard, several feet away being hooked up to monitors, oxygen, new IV bags.

I squeeze Howard’s hand as I leave.
"My name, Howard. Please remember my name, so you’ll know who to leave the message for at the clinic when you call to let us know how you are doing after surgery."

He repeated my name.

“I won't forget. You all did an amazing job. It may be a small clinic, but you all know what you are doing. Had me on my way as soon as possible. Other places might have missed the diagnosis. Shaun's driving was superb. I know how bad that bridge can be. Thank you for everything."

It was weeks before I heard the end of the story. A physician friend of his came to our ER department with gifts, wine, and a letter for the staff.

I still have a photocopy of it in my strong box at home. His handwriting is terrible so there are many words I cannot make out. He had dissected, from iliac crest to aortic arch. 7 hours of surgery and full recovery expected. In the letter he graciously thanked all of the staff. I smiled when I saw my name underlined—I am sure as a reference to my insistence that he remember my name and update me regarding his recovery.

But in it he says, “You all saved my life that day. You saved my life. There is no greater gift we can give each other. So I feel strange presenting you with these small gifts and a card. What can I say to the people who are responsible for me being alive today? Thank you really doesn’t cover it.”

In a strange way I am still haunted by that day. It simply comes at me from nowhere sometimes. As nurses we are placed in situations where a profound intimacy with strangers can be thrust upon us. We bear witness to the most pivotal times in our patients’ lives. In crisis we share moments with patients that is normally reserved for their most treasured loved ones.

“Promise me you’ll call them…”

I can hear his voice. I am in that ambulance. And I am scared. But more than that I am grateful for the precious burden of this work. Work that pains me, pushes me, frustrates me and scares me, but also honors me. Work that takes much from me, but gives moments in return that are profound in a life where superficiality often reigns.

I’m grateful just the same to come back to the present, to be running on the treadmill wondering what I need pick up from the grocery store for dinner.

(This is a re-post so my apologies for those who have already seen this. Working on a few posts right now but they are taking longer than usual as I feel guilty sitting in front of a computer when I should be memorizing the innervation of the pelvis...)


OMDG said...

Great post -- I hadn't read it before. I was on the edge of my seat. It's amazing he survived.

BTW -- minor point -- He had an aortic dissection, which you correctly identify at the end of the piece. But at some point you refer to it as an aneurysm, which is not the same thing (took me a year to learn that, I'm slow.). You probably already know this though.

Albinoblackbear said...

OMDG--Oh thanks! Glad you enjoyed it.

And thanks for the correction! I made the appropriate change. :)

Bostonian in NY said...

this was the post that got me reading your blog!

Albinoblackbear said...

BINY--Yeah, I remember that actually! Yeaoza that was a little while ago now...

Fordo said...

Good post, nonetheless.

WWWebb said...

You took this old ex-EMT back in time a few decades.

That was simply "Dr. Charles" quality writing, m'dear.

It doesn't get any better than that.

Wounded Healer said...

Perhaps the most compelling blog entry I have ever read. This is the kind of stuff they can't teach you in nursing school (at least not in mine). Thanks for sharing.

Albinoblackbear said...

Fordo--Thank you. Much appreciated.

WWW-That is a huge compliment.Thank you.

I read this book last year, "Burning Down the House: Fighting Fires and Losing Myself" by Wagersky which really hit some places in my memory that I had tucked away quite effectively. I came away from that book having a better understanding of the shared experiences of front line workers and the danger of having those experiences destroy you (or parts of you).

It is partly why I force myself to sit down and write out the events that seem to keep resurfacing over and over again. It is an important step for me in processing what I see and do at work.

WH--That is very kind of you, thank you.

I think >90% of my functional working knowledge came after I graduated. Knowing nursing theory and anatomy will only get you so far...they can't teach you what it feels like to watch someone die or take their first breath. Or what helplessness and frustration feels like when there is a life in the balance. It's just not in the curriculum.

Bostonian in NY said...

They don't teach any of that in Med School you're a few steps ahead of the game there!

WWWebb said...

John Stone, M.D. was a physician who wrote a good bit.

I still feel privileged to have known the man.

You might like his work.

Keet said...

I loved it the first time and I love it now. Those moments are so worth remembering again and again, as difficult as they may be. We are truly blessed to have a vocation that leads us to experience such things.

Albinoblackbear said...

BINY--Yeah, you are right.

I did have one lecturer talk about how certain cases will sneak up on you very unexpectedly...and that it wouldn't be things you'd predict would get to you. I thought this was very true in my experience.

WWW-I will try and track down some of his work, I read the bio and he sounds amazing. Thanks for the recommendation.

KK--Thank you. I was thinking about that when you were telling me of the hug you got on 62. It's true--there are those diamond in the rough moments which are unbeatable in our field...