Stop Smoking

We looked all over the department when we found the room empty. With a history of throat cancer, and a complaint of coughing up blood, we decided she needed to be seen sooner rather than later. We checked with a nurse who said she went into the fast track portion of the ER. This is were simple complaints like sore throats and coughs went– a basic “urgent care center” area of our department. Another nurse said she had been moved to a different room. We found nobody. After a few moments, we found her in her assigned room. It had taken triage half a life time to bring her back.

She looked every bit of sixty five plus twenty additional years. She was frail and held a wad of paper towels up to her mouth. The toweling had flowers imprinted on them mixed with spots and blotches of bright red blood. Her son, a strange looking long haired fellow, accompanied her. He wore a look of concern mixed with an expression of experience. He had been caring for his mother and had watched her deteriorate in front of his eyes for the last year. He had taken her to all of her doctor’s appointments. He was there when the surgeon told them how uncertain he was regarding the removal of her extensive throat cancer. He was there before then when she was diagnosed with breast cancer, colon cancer, lung cancer, and when she was diagnosed with this new aggressive beast consuming the anatomy of her throat.

It had devoured her larynx, leaving in ruins the voice which had scolded him, praised him or advised him as he grew from infant to man. She communicated through a whisper which was easily overwhelmed by the sound of a gurney wheeling by, a page overhead, a door being closed, the air conditioning kicking on and off. The tumor added girth to what should have been a slender neck. She had the neck of a woman three times her 88 lbs.

She coughed to clear her airway, holding the tissue to her mouth, as she sat on the side of the bed. “I’ve talked to Dr. B about the surgery and…” She was cut off as her body’s instinct to protect its airway took over.
“She decided against the surgery,” the son, who leaned casually against the wall next to the otoscope, said for her.
In a whisper, she said, “I’m not sure if I want to try the surgery or if I just want to go gracefully. This certainly wasn’t worth the cigarettes,” she chuckled weakly. Between she and her son, it was explained that the bleeding had started in the morning and hadn’t stopped. Her color was good, for a patient dieing of cancer. She was in good spirits despite blood running down her throat.
“I don’t see any active bleeding,” Dr. M said after examining her. “I want to order a blood test and speak with Dr. B before we let you go.” She nodded, her son nodded, and as the doctor and I left, he said to me, “Get an H & H on her and have Dr. B paged” after dictating the rest of the exam out of earshot of the patient.

We spoke with her doctor who said this was the natural progression of the tumor. He stated no major vessels were involved, so she could go home. We talked him into seeing the patient in the department, which he did. Fifteen minutes after he left, a nurse got us. “Her bleeding is worse. She’s just spitting blood.” It wasn’t an exaggeration. We found her over the sink with her son holding her up. We hoped she was vomiting blood she may have swallowed, but something wasn’t quite right.
“Lets suction her,” the doctor ordered and we began clearing her airway. We laid her down in bed, continuing to suction as needed between talking to her and her son. It happened so quick, it’s a blur. She stiffened, lost all color, and became unresponsive. A quick assessment showed us she wasn’t breathing. “We’ve got a code,” the doctor announced and we bagged her quickly. She still had a pulse which was good.

We quickly moved her to a trauma room. A team had assembled, meeting us as we rushed her down the hall with her son jogging behind us. A paramedic walking his stretcher to the ambulance stopped to give us the right of way.
“Shit,” the doctor muttered twice as we pushed her into the big room. We quickly accessed her veins to pump fluids into her while her son stood outside the door. The doctor had his tools in hand to intubate her, to provide life supporting oxygen.
“Suction her and bag’er,” he said. Respiratory had just arrived and took over bagging after the doctor suctioned copious amounts of blood from her airway. The doctor placed the tube, taking a moment longer than it usually took him. “Have we got a pulse,” he asked as he listened to her chest. He quickly shook his head, “We’re in her stomach. Lets try again.” Because of the tumor, her airway was obstructed. Blood was pouring everywhere which further complicated the doctor’s ability to visualize her vocal chords.
A nurse shouted, “She’s brady down in the 30′s!”
“Start CPR,” the doctor ordered and searched through some tools. “Lets give her one of Epi and one of Atropine!” He selected another tube and attempted again.
Again, air was being pumped into her stomach instead of her lungs. “Lets check a pulse,” the doctor asked. “Is she on the monitor? We need her on the monitor!” He glanced over at a tech and barked, “We need pads on her! Get the pads on her now!” To another nurse, he said, “Lets release that feeding tube to keep her from puking.” Air whooshed from the tube as the nurse did so, and her stomach noticeably came down.
With a new long flexible hose, the doctor again attempted to intubate her, halting CPR to do so. Again, the hose snaked around because of the mass and distorted anatomy from that ugly beast, the tube was in her esophagus. “Goddamnit,” he growled and continued to attempt to get her some air.
“I have asystole on the monitor,” a nurse announced. Asystole is flat line.
“Continue CPR,” the doctor said, ripping off his gloves. “Let’s give her another epi.” He left the room to get permission from the son to cut open her neck and intubate her that way. Or, to discuss what the son’s wishes were.

The son stood with disbelief shining through wide eyes. His hands were in his pockets and a social worker had already come to his side. He looked up as the doctor greeted him under such grim conditions. “I can’t intubate her because of her mass. What I can do, what I would need your permission for, is to go through her neck. I know you mentioned she had expressed her wishes should something like this come up. How far do you want to go?”
I could tell the son had his hands in his pockets to hide their trembling. Even so, I could see the tremble in his hands and in his shoulders. “She didn’t want to be on life support,” he said, his voice shaking. “She didn’t want to have the neck thing done.”
The doctor nodded. “Okay. I’ll see what I can do,” he said to him. “I may not be able to save her if I can’t intubate her, you know.”
The son nodded with understanding, “It’s what she wanted. She didn’t want a big effort.”
The doctor nodded and gave two more tries of intubating without luck. Defeated by a clump of tissue, he looked at everyone, “Any suggestions that anyone would like to make?” Nobody spoke. He waved his hands to the silence. “Lets call it. Clean her up.”

The son didn’t break down or fall apart once given the official news. He stood trembling with wide eyes. He didn’t realize these were his last few moments with his mother. I think later he’ll realize it was a good thing he was there with her, that she didn’t die alone, and that he was selfless enough to respect her wishes. It was a somewhat ugly way to go, but it could have been worse. Much worse.
I saw him walking down the hall, probably leaving to make funeral arrangements. It would be his first steps out into the world without his mother in his life. It must be odd to walk in with someone, and leave without them. I watched him as he rounded a corner, disappearing from my sight. I silently wished him the best. I wondered if he was now free to live his life without having to care so much for his mother. Was he devastated by her death? Would he be relieved? How harsh would the sun be as he went outside, or would it be soothing to him? And I wonder how different things might have been for him had she never had a single puff off of a cigarette.