Calling Time of Death is Hard
Someone Died on Our Watch Today
It’s a very average morning on a very average ICU in a very average hospital, somewhere in Germany. While the rest of the world might be under the impression, that the infection with the Corona Virus is the only life-threatening disease these days, that’s of course not true.
On our ward, people are suffering from cancer, hepatitis, autoimmune diseases, and more.
While the new virus is overshadowing the year 2020, other sicknesses have not stopped.
I have been doing my internship on this very average ward in this very average hospital for about four weeks now and I am already loving my job. Every disease is exciting to me, I can finally see why I have studied so hard for so many years and every day brings something new.
Fortunately, the atmosphere on my ward is also very positive. There are no strict hierarchies and I was welcomed to the team immediately.
In a quiet minute after rounds, we’re having breakfast together. I brought some of my self baked Christmas cookies, we have freshly cut fruit and some hot coffee mugs in our hands. It’s the only time of the day when we shut the doors of the physician's office to prevent family members from coming in every other minute.
“It’s going to be a tough day”, says one of the physicians and quickly checks our To-Do-List. “We have three new patients coming in, I need to write a couple of emails, we still have to take blood from each patient and then there is the video conference this afternoon.”
Everybody sighs. Another video conference where nobody is able to pay attention to. While we all follow our own thoughts and think about the countless online presentations we had to endure over the last couple of months, we suddenly hear an alarm coming from the hallway.
“Code Red. Code Red”. A nurse is yelling from the outside of our closed door. The physicians jump up from their chairs. A cup is being knocked over and coffee spills all over the desk.
“Shit.” In the blink of an eye, we all run through the corridor. It only takes one look to see which patient is in danger. Mrs. S. in room 4.06. The monitor which can be seen from all places on the ward is blinking. The alarm is still going off.
I grab the ultrasound machine while the physicians get a hold of the defibrillator and the emergency cart and we all run towards the patient.
Mrs. M., a 67-year-old woman who was diagnosed with carcinoma of the endometrium, a very aggressive type of cancer, is laying flat in her bed. I just talked to her about ten minutes ago. She seemed to be fine, but with multimorbid patients on intensive care units, you can never be too sure.
Her eyes are shut and irregularly, she gasps for air.
“I don’t have a pulse. Starting CPR.” The nurses are already in the room and they are starting the cardiac massage.
I quickly put on some gloves and get in line behind the nurse. In an ideal situation, the people performing cardiac massage are supposed to switch every two minutes. Everybody who has been in this situation knows just how exhausting the compressions are. And now, during COVID19-times, we are all wearing our facial masks, making it even harder — I am already sweating after the first round.
After two minutes, the physician standing at the patient’s head has inserted a ventilation tube. Another two minutes and the chief, who has magically appeared in the room, has put in an arterial line. The ECG shows a pulseless electrical activity (PEA) meaning that the heart is still sending electrical signals like it is supposed to, but no volume is pumped out of the heart to supply the organs.
The reasons for a PEA are diverse: It could be due to a pulmonary embolus, an intoxication, or an adverse effect of a medication. In this emergency situation, we do not know, we just follow the protocol.
I keep on pushing. In my head, I try to sing “Staying alive”. Apparently, the rhythm is just right to perform CPR in the right speed — kind of morbid, don’t you think?
While I perform CPR, I try not to look at the patient’s eyes, which are now slightly open and her head is moving due to the pressure I am applying to her body.
Adrenalin is given. Still, there is no pulse. A physician performs an ultrasound of the heart while we stop CPR for about ten seconds to keep the no-flow-time as short as possible. The heart is not moving at all. Only the septum twitches a tiny little bit.
Every five minutes, we take her blood and look at the electrolytes. It’s not looking good. Her pH is too low, her oxygen level is a disaster.
In the third round, I feel a rip break underneath my hands. It teeters against my hands, every time I push.
My own pulse is at about 180 beats per minute. Sweat is running down my spine. It’s been twenty minutes since we found her. Everybody in the room knows, what this means.
After 40 minutes of performing CPR, with repeated adrenalin injections and transfusion of fluids, the resident speaks up.
“Ok, everyone. I think we are losing the battle here. I think she doesn’t have a chance of coming back. We don’t have a rhythm, we don’t have a blood pressure and her heart looks catastrophic.”
He pauses, while we still perform CPR.
“Does anyone have any objections to stopping CPR and calling it?” He waits as we look at each other. Everybody thinks it through.
But we all know: There is no chance of getting her back. “Ok. Stop CPR please. Time of death 13.24” We stop CPR and everybody is catching their breath. We look at the patient who was doing fine an hour ago and who has just left this world.
She is 67 years old, which is not that old, to be honest. But, on the other hand, she just got diagnosed with terminal cancer, leaving her with chemotherapy, radiotherapy, a lot of pain, and a long time in the hospital.
During rounds, she told us that her husband had died last year and that she was all alone. No kids, no relatives, just a couple of friends.
We start to clean up the mess, getting all of the machines out of the patient’s room. The nurses will wash her, dress her and we will call her friends to see if somebody wants to come and say goodbye.
Even in times of Corona, while all other visits for patients are banned, this is possible. It’s important to say goodbye to a loved one.
After having had some sips of water, I feel a little better. Yet, I know that I will be super tired tonight.
It is never easy to have a patient die while you are working. In one year, I will be the responsible physician on the ward. I think this will be even harder.
We talk about her and the medical incident that might have led to this. We won’t ever be sure though.
The human body is a mystery. Some things happen without us knowing why and how. Still, it’s important for all of us to talk it through. To make sure, that everybody is doing well and coping fine.
I think it’s a lie when people say that they don’t take their jobs home with them. You can’t go home after a day like this and not think about the fate that some people are faced with. You just can’t. Anybody who says this is a liar.
For Mrs. M., I think she would be ok the way it went. We did our best to save her. But she was terminally ill and just found out about her cancer. She didn’t suffer. She didn’t have to face any side effects of the chemotherapy. She was fine until she wasn’t. I hope she found her peace. I think she has.
*all names and personal features of all patients are changed due to data protection