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“We need to stop the CT and get him out of there right now—his O₂ sats are dropping too low!”  We entered the room, pulled him out, and tried to prop him up higher.  The nurse had warned that he couldn’t be laid flat.  I did not notice what his O₂ sats were at that time, because I was preoccupied with looking for the oxygen tank that we had brought with the patient’s bed.  There was only one oxygen supply tubing in CT, so the patient was on high-flow O₂ via non-rebreather mask, but in ICU he had also had a nasal cannula.  Not finding the oxygen tank, I returned to the patient.  The nurse was obviously very concerned. “He’s going to code on us—call the crash team.”

The nurse had been trying to schedule a CT scan for her patient all morning, and finally a spot opened up.  The patient, an elderly man, was almost completely unresponsive, only responding to painful stimuli, such as when an NG tube was being inserted through his nose.  I had steadied his head and tried to explain what we were doing, but I don’t think he had any idea what was going on except that it hurt when the tube was being shoved down one nostril and then the other after it didn’t go all the way in. During this procedure, his vagus nerve was stimulated, causing his heart rate to drop to 35, and his oxygen saturation to drop to 87 percent.  The other nurses noticed this drop in heart rate, which set off an alarm on the computers.  They suddenly appeared with the crash cart and some atropine, but his heart rate started to rise again so it was not needed.  After a DuoNeb bronchodilator treatment and the addition of a nonrebreather oxygen mask on top of his nasal cannula, his O₂ sats eventually returned to the upper 90s.  He needed a CT scan to get a better view of his lungs, because an X-ray had shown some problems.

While the nurse called for a code, and requested several other people be paged immediately, her voice was raised, and she spoke with a strong sense of urgency, but she remained calm.  “He’s DNR and DNI” she stated.  I understood that DNR meant that there were written orders in which he had agreed beforehand that if he ever went into cardiac or respiratory arrest, he did not want resuscitation efforts done.  I guessed that DNI meant he would not be intubated.  I found the oxygen tank I was looking for, and connected a nasal cannula to it, and brought it to the patient to provide as much oxygen as possible.  Many people started showing up in CT in a short amount of time, and one of the other nurses from ICU arrived.  “Oh, look at him—he’s agonal breathing.”

There were several of us crowded around, but I was pretty oblivious to what the others were doing.  I was intent on monitoring the patient, who was going for longer and longer periods of time between labored gasps for air.  “I don’t think he’s—” I started to say anxiously after a very long pause, but I was interrupted by another gasp.  I tried to palpate a radial pulse, but was not feeling anything.  I felt around, thinking I must be missing it.  I heard a sigh, and I sensed that the people around me had stopped what they were doing.  It hit me then that this man was going to die right there in CT.  I stopped feeling for a pulse, and held his hand instead.  The oxygen mask was taken off of his face, and I was confused momentarily, because he was still gasping occasionally after very long pauses.  The vitals monitor was facing away from me, but I assume his heart had already stopped.  Agonal breathing can continue even after the heart has stopped, but I did not remember this.  Finally, he breathed no more.  Between five and ten minutes total had passed since we had first put him in to get scanned.

After a brief silence, the various medical workers looked at each other, and some laughed softly.  “I’ve been working here over seven years and I’ve never had someone die in CT.”  “Let’s prop up his head more so his eyes will close.”  “Do we need to cover him?”  His monitor was covered with a towel, but his face wasn’t.  “I’m sorry George,*” his nurse said, touching him.  An entourage of us pushed him quickly back through the halls to the ICU.  We got a few looks, and someone whispered “Shhhh…”  It was an odd procession—sad, and yet slightly comical in a way because of the strangeness of the situation.

“That just shows how sick he was,” the nurse told me, commenting on how quickly he died.  “I hope I die like that,” another nurse said.  “At least it was quick and didn’t seem painful,” I agreed.  I was still a little bit stunned, trying to register what had just happened.  “You’re not allowed to help transport patients anymore,” the unit clerk joked.  I laughed.  I felt more sadness when I heard the nurses say they weren’t able to contact his wife, and they were going to request a police officer go to her home to tell her.  I was relieved to hear that at least his wife had come in to see him that day, and had been told that he was not doing well.  Having a patient suddenly die in front of me made me realize that even though I knew better, I was still taking it for granted that patients shouldn’t die while good care is being given to them.

*Name changed

This entry was posted on Wednesday, June 24th, 2009 at 11:13 pm and is filed under medical. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.