My Afternoon in the ER: A DNR gets R’d April 21, 2007
Posted by jaotte in Ethics, Medical School, Medicine.1 comment so far
I spent Wednesday afternoon in the ER for the second week; I was observing, taking histories, performing physical exams, establishing differentials, recommending lab workup and possible treatments, learning about medical politics, and saying “I don’t know” a lot. It felt good to be in the hospital for once. Starting in September, that’s what it’ll be all about for me. For now, it was just an afternoon.
I’m probably breaching confidentiality somewhere, but I’ve removed/changed as much identifying information as possible; I think it’s an important illustration of how theory and practice don’t always look the same in Ethics. Here, the DNR is the case in point.
It’s the end of my shift. My supervising doctor says “Jessica wants to stay around and see this.” I do? The more experienced doctor taking over the shift was happy to have me. He began, in a painfully slow voice, to impart his wisdom upon me. Something about enjoying your job, not being bored, and then I lost track of his point.
I didn’t know what ‘this’ was. I was just following the sheet of paper that said to report to the ER on a Wednesday afternoon. People were scurrying around, moving equipment, repositioning beds, and clearing the path. For what? I heard something about ‘resuscitation’.’ Meekly, I asked the wise old man what was going on. “There’s a DNR resuscitation coming in.”
I couldn’t figure out all the fuss. Why would an ambulance hurry a dead person to the hospital if there was no intention of reviving them. So, I waited. I tried not to get in the way, which was hard to do when there were about 15 quick-moving bodies including RNs, RPNs, clerks, and orderlies doing there jobs. The grey-haired man just stood with me outside his office and continued to share his ideas, none of which had anything to do with the present situation. Well, I wasn’t listening anyway. I still didn’t understand what all the fuss was about.
Oh. We glove up. The paramedics roll in and we get the quick story; the woman fell, the neighbours called the ambulance, she was resuscitated for 20 minutes at which point the grandson remembered she was DNR. There were some language issues as the Asian grandfather was also present and had his own DNR. The son found the papers, but the family wanted to rescind the order since their grandmother’s quality of life was good. The original DNR didn’t expect her to collapse for another few years, when her dementia would be progressively worse.
I am hearing this as I watch them suction her, put a backboard under her, climb on the table, and attack her sternum with the heels of their fists. The paramedic squeezed the manual ventilation bag every once and a while. There is no pattern like I learned in my CPR course. They’ve pushed adrenaline, they’ve defib’d her. This has been going on for an hour. Even though she had a DNR? Even though she had a DNR.
There really wasn’t much going on. The resuscitation would stop as we lined-up to take an ultrasound of her heart. The valves were still.
I was waited in the sea of calm for the moment I might be useful. Someone asked if I wanted to ‘get in’ on the CPR. I was partly too startled and thinking exactly what I said: “well, he’s gonna call it in a minute anyway.” Was that cruel? A woman who had been asystolic for an hour? The family, from their wait-room imprisonment agreed to cease and desist. The wise man told us their decision.
The time is read out. The little curtained room clears, save for a few lingering bodies. The tiny woman lays on the table, still intubated, lifeless, 82. Not two hours earlier, the coroner was in here looking at a man who hung himself in the same way I am looking at her.
This was unusually glamorous medicine. And yet, so crude.
Journal 8 – Eight: Pangong Tse April 2, 2007
Posted by jaotte in Culture, Healthcare, Himalayas, Humour, India, Medicine, Travel.2 comments
(just a reminder: these posts are copies of entries from my paper journal, written Summer 2006)
Wake up early to do some Yoga breathing exercises, while we pirch on large rocks in the field around our teacher. Breakfast at to 7 and we pile into the jeeps, ready for a short trip to Pangong Lake – the closest I’ll get to Tibet on this journey. Tonnes of animals in the valleys as we pass. A himalayan marmot, many donkies, horses, goats, and one hare (brown with white ears) look a bit insignificant against the tall mountain backdrop.
I understand why SUVs were invented, and thank their makers as we crawl over rocks and plow through streams that have washed the roads away. It’s not smooth, but the fact that we even get through is pleasing enough for me.
At the lake, as beautiful as the photos I’ve seen. Breathtaking to know I could just dip my toe in, and I’ll have touched Tibet. So many of our patients, with their warm smiles and hearty laughs, have come from that land at some point. Their presence shapes the Ladakhi culture and makes the province a whole different experience than the rest of India; it’s horrible to think that they aren’t in India by choice.
We walk closer to the lake and there is talk of going into the water. I’m shivering with many fleecy layers, mittens, and my trusty toque, but a few brave souls put caution to the roaring wind and hop in. Other, slower participants take their time changing their clothing to swimsuits behind the shelter of a 3-foot metal shield. This is much to the amusement of nearby soldiers who recognize the metal barrier as their urinal.
Epic feelings were crushed by all the “Restricted Area” signs and razor-wire coils forming a disincentive to walking around the lake to Tibet. I took childish joy in photographing the “Restricted Area: No Photography” sign as well as the soldier’s socks, hanging outside the bunker to dry.
We re0fuelled the cards and headed out. Got to chat with a colleague I didn’t know well yet, and rode in the comfiest jeep but discovered its shocks weren’t so great when we returned over the spilled boulders.
We had lunch at home base and did an afternoon clinic at the same location as the previous day. I was meant to do general med but felt sorry for the student distributing eye glasses, so I went and helped hi,. That was a difficult job. Lots of patients just needing sunglasses or a weak prescription which we had run out of.
One girl really liked a fashionalbe pair of +1.25s. We thought it was just because they were nice, so we had her try on the same prescription but in a pair of ugly-framed glasses. She said the latter ones made her dizzy (“zim zim”).
We accused her of just wanting the nice frames but then we then realized the ugly ones were in fact a stronger prescription (the handwriting made +1.75 look like +1.25) and would indeed make her dizzy.
I felt horrible. I just didn’t want to give her a pair of glasses that would make her dizzy or not correct her vision adequately, but we had been rude. I asked the translator to apologize and explain that we didn’t want to give her the wrong glasses because they might make her dizzy and nauseous. I apologized, and my partner said in his loudest, “I am speaking to an ESL student” accent said: “Me soooo sorry!” I nearly burst out laughing at the patronizing tone. Saying it louder, slower, and annunciating more clearly will not make her understand English. Nice try, though! Hahahaha!
We shut down the station early which was a relief, because I had developed a headache from the kerosene burner the dentists were using to sterilize their equipment.
I thoroughly enjoyed the idea of the toilet shack up on a nearby hill. No fourth wall/door but instead a view of the dunes above. Upon exiting, a nice view of he valley and gompa below.
Tonight was cricket in the most competitive way. Balls being lost in the stream, people tripping over stones in the fields, jumping into the water to retrieve the ball, etc.
Our Indian Pharmacist/trip organizer does a victory/”you’re a cheater” dance by swivelling his hips and shaking his hands above his head. I tried to take a video but was laughing too hard so I missed most of it! Alternate this with his rival since boyhood (currently on the other Cricket team) coughing his lungs out like the smoker he is. Lots of fun into the sunset.
An American dinner: Indian versions of pizza, spaghetti, fries, and an apple pie that was not quite as good as it looked. A short talk on Rheumatic Heard Disease. We disperse. Earlier, we’d played a little group game called Assassin/Mafia but in the darkness, there is only fire and song.
My tent-mate and friend is ill, so I head to bed early after the usual hold-flashlight-and-hold-breath trip to the toilets (outhouse-style). Vengaboys and wind, along with two male voices carry as we drift off. My nose is plugged. I bet we all snore like chain-saws at this altitude.
