Wednesday, January 14, 2009


It is my first rotation in my third year.  I am completely clueless about everything on the ward.  A sorority-girl beautiful, peppy, petite pulmonologist (lung specialist) acts as my liaison.  She is our attending for the week, the head of our motley crew.

"C'mon team!  Next patient is Mr. V!  Gather around.  Oh!  Notice his breathing, a Cheyne-Stokes pattern.  And he is also a DNR (Do Not Resuscitate)!  He is probably about to die."

The Cheyne-Stokes pattern of breathing is the medical term named after the people that described what is otherwise known as the death rattle.  Basically, your respiratory center slowly shuts down, and doesn't respond well to oxygen and carbon dioxide in your body.  Mixed signals get sent.  You spend periods of time not breathing, also called apnea, and then when you hit a dangerously low level of oxygen, you breathe really fast (tachypnea) to catch up.  The slow/apnea/fast pattern is periodic and regular, but the intervals lengthen, until it stops altogether.  As the heart shuts down, blood stops circulating, which is why dying people will become cool and have blue lips and mottled extremities.

So we all gathered around his bed; residents, nurses, medical students, and respiratory therapists.  It was very cramped in the small, curtained-off makeshift room in the ICU.  The patient was probably in his late 60's, but he looked much older.  He was lying in bed, propped up on pillows; cachectic, jaundiced, and laboring for every breath.  

The peppy pulmonologist whispered conspiratorially.

"Do you see his breathing pattern?  Memorize it!  It is end-of-life."

Throughout my third year, I saw many patients near the end of life.  This was my first.  In the hospital, a lot of dying patients garner the complete attention of the medical team; crash carts, chaos, drugs in syringes trying to reset the heart back to normal rhythm.  This man was different; he would die with no interruptions.

So I watched, and I didn't.  I wondered where his family and friends were.  I looked at his clubbed fingers, and tried to guess at his cause of death.  I looked around at everyone else in the room, trying to find physical evidence indicating whether or not they were as uncomfortable as I was.  Finally, I looked at him, and studied his breathing pattern.  I waited for some sort of metaphysical sign to appear when he left this world for whatever came next.

Death happened.  While we were all standing there, watching.  One minute he was struggling for breath, and the next he was not.  

"Okay!  Nurse, will you call the morgue?  C'mon team, let's go see Mr. W!"

We shuffled out slowly, bumping into each other, and finished rounding.


Anonymous said...

DNR, DRE, DNC- hope you guys don't ever get confused

Gizabeth Shyder said...

That reminds me of a hilarious story about a woman coming in for a D&C. I will save for future blog.

I promise if you ever come in for a D&C I won't perform a DRE and then declare you DNR:)

Chris Panza said...


Hopefully this guy was not awake at the time and watching as the staff used his case as on-hands experience of what happens when someone is about to die.

Gizabeth Shyder said...

Guess that depends on your definition of "awake." This guy was not on the vent, and propped up on pillows. Recent studies show that even patients who are ventilated and sedated in the ICU are benefitting greatly from getting up and moving around daily; getting more interaction and stimulus from the environment. Even though we think patients are out of it, long periods of stay in the ICU are severely detrimental patient's physical and mental well-being, even young patients. So I'll leave the guessing up to you, Mr. Philosopher. I was obviously uncomfortable. And although I remember looking into his eyes, memory can play tricks.

Chris Panza said...

Oh, I just meant awake in the "aware that he was playing this role for the seemingly callous sorority girl doctor" sense.

Hopefully not. That would be a real crappy way to go out.

Hopefully when her turn comes, she goes out in a similarly ignoble fashion!

Nice blog, by the way. Interesting theme!

Gizabeth Shyder said...

I have found that it is generally best to always assume awareness, no matter how sedated your patients are.

I have, since I started this blog, began to infuse fiction to exaggerate a point or feeling. Trying my hand at creativity. The sorority-girl doctor is an example. But I think her callousness represents what we are all in danger of becoming, and what some health care workers DO become. Her personality is a nice contrast to the situation. And there is truth in every fiction.