Extubation

I've been really lucky over the past few months in that at the end of the workday, I go home and have dinner and go to sleep and don't have to return to the hospital: my sleep is not interrupted by the pager going off. And I am being paid for all of these hours, half what I get per hour during the day. So when I got a page 15 minutes before quitting time requiring my presence at another campus, I couldn't be too unhappy about it, though I had gotten a crappy night's sleep the night before and I was hungry and looking forward to going home and eating and going to sleep.

I waited half an hour for a shuttle and went to the other campus, where I spent 90 minutes with an older woman who has dementia, unbeknownst to herself. According to herself, she was minding her own business at home and then was forced into an ambulance and conveyed to the hospital, where she said she had no intention of staying. But reading her chart note made it clear she is unlikely to go home ever again. When I left, she said she felt better. She said, "I felt low when you arrived." She cried at times during the visit. So did I.

While I was charting that visit, I got a page requesting Sacrament of the Sick for another patient at that same campus. The name rang a bell and I was able to confirm in his chart that he had received the sacrament a couple of days prior. Meanwhile, the P.A. system announced a Code Blue, and a short while later another. During CPE, we had to report to every Code Blue, but at my new job we don't do that, so there was nothing I needed to do—until I got a page saying that both codes had been for the same patient, and that a very distraught family member was present—could I come?

I said I was on my way, and then got another page for the same patient who had wanted the Sacrament of the Sick; now they just wanted the chaplain to come. I couldn't believe it: four emergency pages in a row after hours, though at least they were all at the same campus.

I went to see the distraught family member, who was in tears, begging her relative not to die. In between moments of weeping, she told me about the other terrible losses her family has sustained recently, including of quite a young person. At that point, the patient had been receiving chest compressions for 30 minutes, meaning that, one way or the other, she was not coming back.

In CPR, they do chest compressions for a while and then assess. I kept hearing a doctor say, "Stop compressions. No pulse. Resume compressions," and my heart sank. CPR is violent and horrible; it can break ribs, and your brain is missing out on a lot of oxygen. As I have mentioned before here, many doctors specify that if they ever need CPR, they would prefer not to receive it—just to die.

Finally the relative said, "Stop. Just stop." And the patient was gone. It was terrible. Other immediate family members had arrived, and the partner of one of the family members was also there. When I left, the family members were bent over the patient's bed sobbing, and the partner was outside the room. He quietly pulled me aside and asked, "All that emotion—is it normal?"

"Yes," I said firmly, fearing that he was going to go in and exhort his partner to get past it and move on with life.

Then he said, "When my mother died, I didn't cry like that." Pause. "But I guess everyone is different?" It was very moving. I looked him in the eye and said, "Everyone grieves in a different way." After a moment I added, "You didn't do it wrong."

During the 90 minutes I was with this family, I went to call a priest for emergency last rites. While I was doing that, another care team member sidled up to me and quietly reminded me about the other patient waiting for me to come. It turned out that they were planning to extubate this patient—for him to go on comfort care—but they were waiting for my presence until doing this!

Finally I was on my way to that last patient, who had three family members at his bedside. His nurse pulled me aside and said she expected the patient to die right after extubation, and that she didn't think the family members realized that was going to happen. I sat down in the patient's room and after a while, the respiratory therapist came in and removed the tube. I don't think I've ever seen this done. Normally, everyone is asked to leave the room, and all the family members did leave the room beforehand, two in a decisive rush, and the other after thinking about it for a moment.

I decided to stay to see just how terrible this is, but it's not that awful. The tube is longer than you'd expect, and there's a bit of slime or gunk on it, but that's the whole thing. The family members returned and now the patient wasn't getting oxygen or pressors—medicine that keeps the blood pressure up. However, he did not die immediately at all. Two hours and 20 minutes after I'd arrived, he was "chugging away," as the nurse said. Other family members had arrived. When one of them pointed out that "it might be hours," I said, "I confess I was starting to think about that," and all agreed that it would be fine for me to depart. When I finished my quick chart notes—I don't use the formal template in this kind of case, but just write freehand, per my own preference—it was 11:45 p.m.