It was near the end of a busy shift that I first met Mr. K.

As I get closer to leaving the ER for the day, I find it increasingly difficult to fight off mental fatigue.  I get tired of listening to problems, sorting through complex medical histories, and answering the never-ending stream of rapid fire questions from the nursing staff.  The last 2 hours or so of my shift I, more than ever, hope that the problem is straight-forward, the workup quick, the disposition clear.

Mr. K was not that type of patient.  89 years old, he was nonetheless in good health, living independently with his wife.  He was the kind of guy that avoided doctors and hospitals at all costs, and found his way to me only at the insistence of his wife and daughter.

They had returned home to find him balled up on the couch in pain.  He described it as sharp and severe, waving a hand over his upper abdomen/lower chest area.  He wife also mentioned that he had fallen a few days ago, scraping the last 3 fingers of his right hand.

I looked again at his chart.  He had a fever of 103.  He was breathing a little too fast, and his heart was beating a little too rapidly, although his blood pressure was holding steady.  Although he was trying to be stoic, it was clear that he was enduring a debilitating amount of pain.  Despite all that, not a lot showed up on his exam.  His belly was slightly distended and only slightly tender at the epigastrum.  I removed a dirty band-aid covering his pinky finger and found a scooped out area of missing skin with some greenish gunk at the edges.

When I begin a work up of a patient, I always hope to make a diagnosis.  More importantly, though, I’ve been trained to think of all the really bad things that might be causing a patient’s symptoms, and be sure to rule them in or out. 

His list was particularly long.  Heart attack, pulmonary embolism, thoracic aortic dissection, perforated peptic ulcer, mesenteric ischemia, intraabdominal hemorrhage, bowel obstruction, intraabdominal abscess, cholecystitis, ascending cholangitis, leaking abdominal aortic aneurysm, sigmoid volvulus, pneumonia, urosepsis, wound sepsis, and osteomyelitis all came to mind.  I looked at my watch: 45 minutes until shift change.  I massaged my forehead for a few seconds, trying to work out some of the tension, and got to work.

Fortunately, the answer was revealed in his blood work.  His lipase was over 7,000, clinching a diagnosis of pancreatitis.  The two most common causes are alcohol use and gallstones, but he denied any drinking, and an ultrasound of his gallbladder showed no direct or indirect evidence of stones.  I had also ordered a non-contrasted CAT scan of his belly when he first arrived, mainly looking for indirect evidence of a perforated abdominal organ.  From this, the radiologist was able to see the pancreas and saw that all in all it was pretty normal looking.

I ordered fluids, antibiotics, pain medicines, and made it illegal for him to eat anything, not that he was arguing about it.  He was still in the ER by the time I had finished with the rest of my patients.  Just before going home, I went back into his room to check on him one last time.  The tension on his face had eased, and he had fallen asleep.  I sat down next to his wife and daughter to make sure they didn’t have any lingering questions.  We chatted for the next several minutes and then parted ways, as Mr. K was taken upstairs to his room while I made the drive back home.

I went back to work the next day, and the day after that, as the memories of various patient encounters slowly began to melt together.  It remained busier than usual, spurred on by flu and rotavirus season, and despite working as efficiently as possible I routinely found myself struggling to keep up with the seemingly never-ending stream of fever, malaise, and diarrhea.

And then finally one night a reprieve, as I started my shift with a half full department and only a couple of patients waiting to be seen.  Even as I enjoyed the more leisurely pace, I remained somewhat apprehensive.  Even, or maybe especially, during the less busy times I am acutely aware that the relative peace can be disrupted at any second by the arrival of an expectant mother, a drooping face, a gun shot wound, a blue baby.  I swear that sometimes I have a sixth sense about these things, feeling their presence in the air moments before they arrive.  

And then pow, just like that, it happened.  Not through the doors of the ER, but from above.  “Code blue, 4th floor; code blue, 4th floor,” came the clear but impassive voice of the hospital operator.

“I knew it,” I said, and took off for the room, arriving about a minute later.

More than a little out of breath, I took in the scene.  A grey, lifeless appearing body lay on a bed.  The respiratory therapist was bagging the patient, and a nurse was performing compressions.

I confirmed the lack of a pulse, and quickly intubated him as he was being placed on a monitor.  An initial rhythm of asystole returned, further decreasing any chance of survival.  I moved on to the next phase of the resuscitation, ordering the appropriate medicines and looking for reversible causes, although I already knew that any sort of meaningful recovery was very very unlikely.

A nurse began to give me some of the patient’s recent history.  “He’s 89, and was admitted several days ago with pancreatitis,” she said.

“Pancreatitis?”  I took another look at the patient, this time focusing not on his skin, his lungs, his pupils but instead directly at his face.

“Mr. K!  Crap!  No, no, no…” as he instantly transformed from a corpse into fellow human being.

I had been following his progress since admission through the hospital’s computerized medical charting system.  His blood pressure had become progressively lower on the floor, and he was again transferred, this time to the intensive care unit.  Bacteria grew out of his blood, and he required increasing amounts of oxygen.  At his age, his prognosis was tenuous at best, but he managed to beat the odds, staving off intubation as his body began to respond to the antibiotics.  Slowly but surely he improved, requiring less and less oxygen.  His lab values normalized.  He escaped the ICU, and was working his way back to a normal diet on the general medical floor.  

I wanted to redouble my efforts, to try harder, to make something happen, but there was nothing to do.  No reversible causes found.  No response to the medicines.  Each minute that passed was another nail in his coffin.  The ten, twenty, and then thirty minute marks passed without any change in his condition.

I was told that his family had just arrived.  I went out in the hallway to meet them.

Once again, it was his wife and daughter, as well as some others I had not yet met.  As I began to talk my eyes met Mrs. K’s.  They showed that god awful combination of terror and dread, of knowing that something is horribly wrong.  I felt her searching my face, sensing its grimness, looking again for something, anything to pin her hopes to.

I told her that his heart stopped working tonight, and that despite our best efforts, we were unable to restart it.  I told her that he had died.

“We just saw him an hour ago,” she said, her eyes now expressing sorrow and fatigue, as they began filling with tears.

I felt my own tears forming as well.  I told them how sorry I was, even though I thought it sounded hollow.  My pain was so trivial compared to theirs.  I answered their questions as best as I could over the next several minutes.  The head nurse emerged from Mr. K’s room, and once again we parted ways, this time much more somber, as they went to say goodbye and I returned to the ER.

During my absence, the department had predictably exploded.  I was greeted with a full waiting room and seven patients waiting to be seen.  Feeling emotionally spent, I picked the first chart off the rack and went back to work.  It remained chaotic all night, and I ultimately saw 25 patients in a little over 7 hours.  This was probably for the best, forcing me to concentrate on the tasks at hand, leaving little time to dwell.

I realize now that I don’t feel much grief or sadness at the death of my patients.  Rarely do they die in front of my eyes.  Rather, they are brought to me dead, delivered from a nursing home, a street, a bedroom; a sweaty paramedic pounding on their chest.  I continue the near-futile process a little while longer, to see if the air in the ER holds any magic, and then move on, recognizing that I cannot bring the dead back to life.

Or, they come to me dying, but not yet dead, and I freeze time for them, staving off their inevitable death for hours, maybe days, so that when it belatedly arrives, it occurs somewhere else, away from me.

Rarest of all is the seemingly well patient who goes on to die.  While this may bring on some sadness, more conspicuous is the sense of dread that something may have been missed, and guilt and fear of retribution if in fact it was.

Death is simply part of life, and the groundwork for its arrival has almost always been laid far far in advance of their encounter with me.

Breaking the news of a death to family, however, remains the most gut-wrenching and least favorite part of my job.  It’s the ultimate reminder of a patient’s humanity, that they were someone’s dad and someone else’s best friend.   

Mr. K, I hope you’re in a better place, and peace be with your family.