Tuesday, June 1, 2010

Too Busy

I walked through the doors into the ICU and set down my bag.

"You just missed it like five minutes ago," Kate said. "We were coding her for about an hour, and then they called it."

The deceased patient's nurse was standing nearby spewing a steady stream of frustration to the charge nurse.
"When she came in, she was doing fairly well. She was up and talking to her family. Not too long after they left, she started having a really hard time breathing -- at one point she even asked to be intubated. I called Dr. Rubenstein (who admitted her) two hours ago when she was in respiratory distress and told him that he needed to come and see her, that I was really concerned about her," she said, "but he told me that he was too busy, that the intensivist could see her. He never called later to follow up on how she was doing, so now, we need to call him and let him know that his patient is dead."

Dr. Rubenstein arrived a few minutes later.
"When we say we need you to come check on one of your patients, we really mean it," said the charge nurse.
"Okay. That's good to know. I feel badly about this." He replied awkwardly.

They continued to converse as I walked into her room to get her cleaned up for the family. Things are always a mess after a code. The floor and the bed are usually littered with empty medication boxes and wrappers. There are three or sometimes four triple-IV pumps, maybe a ventilator, the crash cart, and an ultrasound or EKG machine to name a few. It is amazing that the people performing the code can even fit in the room among all this equipment and the maze of wires and tubing.

Her eyes were half-open, fixed upon the wall. Her face was obscured by all our equipment: her mouth, lips concaved around her bare gums, hung open to accommodate her recently placed endotracheal (ET) tube, her forehead covered by a large 02 sensor, and her cheeks hidden by the ET tube holder.

I took off the sensor and the tube holder. I disconnected IVs and wheeled the extraneous equipment out of her room. I cleaned the blood off of her skin with a washcloth. It was time to get the family. I am thankful this job didn't fall on me - I knew almost nothing about the patient or the sequence of events that precluded her death. Her nurse went to the waiting room to get the family.

I sat at a the nursing station, printing EKG strips, trying to be busy, trying to avoid interaction. I didn't know what to say. A younger man and woman stood on either side of the woman's husband, physically supporting him, slowly walking him to her room. I have been sitting here trying to find words to describe this man's grief, but I don't think I'll ever accurately describe it: he was visibly broken. An otherwise dignified man, he sat beside her dead body, holding her limp hand, unable to contain his weak, wobbling cries, head in his hands. His wife, who was alive and talking to him a few hours ago, was suddenly gone forever.

I can't help but wonder if things would have been different if Dr. Rubenstein had showed up when he was called. I don't think the patient would have fared differently, though. The intensivist in the unit showed up right away, and so did the cardiologist on call. There were two physicians with her, both of whom were probably better prepared to take care of her than he was. Still, if I were in Dr. Rubenstein's situation, being too busy that afternoon would have weighed heavily on my conscience.


  1. Maybe Dr. R was at *another* code when the nurse called him. I doubt his non-presence changed the outcome though. Intensivists are usually really good in these situations. Still, I do see your point. It's too bad he wasn't there. And it's too bad he couldn't have been more respectful to the nurse.

  2. It's a really small hospital, so I know he wasn't at another code, but that doesn't mean he wasn't up to something similarly urgent and/or valuable. I just think it would suck to be in that situation. I'd feel seriously guilty even though (I agree) the outcome probably wouldn't have changed.