The White Coat Turns Black

Updated: Nov 5, 2020

If you think about it there is a high probability that you will someday die in the ICU. Unfortunately my month, notably my last two weeks became well known for the record setting 14 patients we celestially discharged. For the majority of these people death was inevitable, their last few breaths before a massive heart attack just happened to be on the ramp of the hospital after leaving some clinic appointment resulting in them being intubated just in time to buy a few more hours on the unit. But even in the face of futility there is still a feeling of guilt and sometimes overwhelming hurt when this news must be broken to a family sitting calmly in the waiting room.

Throughout the month I had the displeasure of telling family members such news more than once. I’m pretty sure that my prior experience as an oncology nursing assistant helped me in shooting them a straight assessment of things.

One case the other day was that of a middle aged Hispanic woman who was found down in a parking lot one sunny afternoon and brought in by EMS. She was initially resuscitated in the ER and brought to the ICU. Once she arrived she quickly crashed again. After 45 minutes of brutal CPR and multiple rounds of epinephrine someone asks if the family had been notified about her current status. My resident turns to me in the midst of chest compressions with sweat dripping down his face and says “do you mind? There in the waiting room.”

In the long hallway between her room and the waiting room I was rehearsing in my head what to say. This mainly consisted of your typical sediments such as “we’ve done all we can, and she isn’t doing very well”, etc. As I stepped into the waiting room expecting to see maybe 2 or 3 three people, I was taken back by a room full of people. Given the instant concerned looks I received by about a dozen of them I already knew the pickle I was about to be in. Calling out her last name about 20 people stood up as I expected. I asked if they would like to step out into the hallway with me. In the hallway about a dozen more came around the corner. In the hallway a Hispanic family 40 deep stood in front of me.

There was initially silence as they surrounded me waiting for my words.  For a moment I felt like I was on a podium about to give the grimiest sermon these people would ever hear. The only word that came out was “sooo”, at that point one of the nurses came around the corner to check up on the situation. She thankfully pulled me aside and suggested that in these situations perhaps it is best to take a couple of them back individually, like the decision makers. So I walked back to the room with the husband, sister and son at my side preparing them for what they were about to see.

The tears were at full stream before they even got to the room, the screams would soon follow when they saw their wife/sister/mother naked covered in cords with traces of blood and bile. They quickly withdrew care.  As I stood at the nursing station letting them grieve the entire family slowly trickled in. The hysteria was strong, long, and of course expected.

A different night introduce me to Ms. E who was a 52 year old African American that came in one day with some increased confusion and a headache. In the ED she quickly deteriorated. A head CT revealed that she had suffered a massive hemorrhagic stroke meaning she was quickly bleeding into her brain. The brain doesn’t tolerate bleeds too well. Normally in the body other structures can easily be pushed aside if there is an expanding mass of blood or fluid. In your head however the margin of error is limited by the skull and the only place for the brain has to go when a mass of blood is accumulating is down through the same hole where the brain stem likes to hang out. Naturally the brain stem isn’t a big fan of the brain invading its space and when it gets squished it stops working, we call this process herniation and it quickly leads to brain death. To combat this process the surgeons will cut a hole out of the skull allowing the expanding brain a place to go other than the brain stem.

All of these happened to Ms. E fairly quickly and by the time I saw her the next morning she laid in bed with a large piece of her skull missing. It was however too late and despite multiple trips to the OR she had herniated and lay in bed completely brain dead sustained only on the ventilator and artificial blood pressure medicines.

Normally this would be a pretty clear cut case, and the plug would be pulled once brain death is established. However the great state of Texas says that if there is some kind of lab abnormality than brain death could not be declared, the family could of course override this at any given time. The problem with Ms. E was that some of her electrolytes were way out of wack and the family was not about to give up although they knew very well that there was no chance of long term survival.

For a matter of days we worked to correct acid base levels, and sodium problems so that we could legally reach brain death. One morning the nurse mentions to me as I’m rounding that there is stuff coming out of the staples where they closed her head up. Underneath the bandages it becomes disturbingly obvious that this new cottage cheese like material was likely necrotic brain leaking through the staples. Just to be sure I called the lab and asked if there was a cheap test we could use to know if was really brain, it wasn’t going to change our management one way or the other. The pathologist asked me to describe it, I tried to be professional and use medical words, but couldn’t really come up with the right terms and resorted to saying things like custard and jello. I apologized for this, but the pathologist laughed at me and said they use food words all the time to describe tissue. It reminded me of how in anatomy lab we used to think the muscles looked like roast beef and would get hungry. Bottom line is that we wound up having a very odd discussion about if we were going to bring the family up to speed about this little detail. We decided it was best not to cause any more emotional trauma and let it go unsaid. They eventually withdrew care, but the whole experience was a bit bizarre and resulted in me throwing out a perfectly good tub of cottage cheese from my fridge.

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