“Hi, my name is Paul.”
“Hey Paul, I’m Bernard.”
“I’ve never seen you here before Bernard, are you new?”
“This is my first time. I came in through Emergency. They did some tests and found my kidneys had shut down so they sent me here to dialysis.”
“Well welcome. I’ve been a patient here for 8 years now. You’re safe here. They are excellent.”
I was lying in the dialysis unit in bed #17. Bernard had just arrived by stretcher and was in bed #18 – at the end of the bay of 6 and the closest position to the nursing station – a statement of their concern.
This large room with smaller open ended rooms called bays attached was not originally designed for dialysis. As a result the positions – each one with a machine hooked into the water supply, the data lines, generator protected electrical supply – were jammed close together, the patients about 36 inches apart. In the center of the large room sat the nursing station – actually 5 computers for nurses, the Lead Nurse position, and two administrative positions with the attending electronics and supplies.
Bernard had just come from Interventional Radiology (IR) where they had spent ½ hour installing a plastic catheter high on his chest that accessed his jugular. This gave them the ability to remove, clean and return large quantities of blood as it had a high flow returning to the heart from the cranium. That access to the circulatory system is one of the key aspects of dialysis.
The nurses flocked around him as they hooked him up to the machine and gave him the short explanation of what they were doing. Typically patient training was a year long process involving modules of learning that were covered by different specialists. But when a patient came in through Emerg it was just a talk as you go process – if the patient was aware and alert, and Bernard was. He seemed to be an otherwise healthy 40 year old. A new patient got a lot of attention.
The dialysis machines are designed to be ultra sensitive to any changes in pressure or conditions of any sort and they alarm with each issue. Typically I get about 10-15 alarms through a regular treatment. Doing a treatment without an alarm was a rare occurrence. The first time his machine began to beep, I explained this to Bernard – trying to alleviate his concerns.
After about 15 minutes, Bernard’s family arrived – his father, his younger brother, and his wife with their two children, a girl about 13 and a boy about 11. They surrounded his bed and it was evident that they had arrived from a rural Quebec community, speaking in French about the long trip to the hospital. After some discussion, the family announced that they would go down to the cafeteria to get some supper and would come back when they were done – the treatment being 4 hours of normally boring duration.
With the position lights out so we could sleep, we settled in. Bernard’s machine alarmed a few times when he rolled over or coughed but the nurses were watching closely and dealt with it immediately.
About 30 minutes later I was watching TV and Bernard was lying unmoving with his eyes closed when his machine alarmed. A nurse was there quickly and she felt his neck for his pulse. The machines would sometimes give incorrect readings and I couldn’t see his control screen from my station – I assume it indicated a low heart rate. After a few seconds of immobility the nurse bellowed:
“Help! Help! I need help over here!”
About six nurses came running as the original nurse explained:
“He has no pulse. I’m starting CPR!” and she jumped on the bed and straddled Bernard, starting chest compressions. Another nurse arrived with a ventilator bag and placing it over his face began to simulate breathing.
In a few seconds, with some trigger I didn’t catch, the original nurse yelled:
“Call a Code!”
A few seconds later the hospital PA system echoed with
“CODE BLUE DIALYSIS! CODE BLUE DIALYSIS!”
Then in French:
“CODE BLUE DIALYSE ! CODE BLUE DIALYSE!”
And then repeated :
“CODE BLUE DIALYSIS! CODE BLUE DIALYSIS!”
“CODE BLUE DIALYSE ! CODE BLUE DIALYSE !”
At this point, one nurse pulled the privacy drapes around the bed and I heard the Lead Nurse, who had arrived after the CPR had started, say,”Bruno. You’re the timekeeper –get the book.”
Bruno ran to the nursing station and returned with a ledger and a pen. He started and through-out the process, he could be heard announcing each entry accompanied by a time, documenting every step they took, who took it, and what happened.
Portable equipment, including the defibrillator, was rolled to the bedside and within a few minutes, the Code Team ran into the Unit. There were six team members – all doctors and residents of different specialties.
I could hear the lead doctor take charge as he spat orders, injecting stimulant into Bernard’s heart, continuing CPR, debating an open heart massage. An abdominal probe discerned that it was distended and hard.
The doctor had CPR stopped when he detected a heart beat and for a few seconds Bernard’s heart was on its own, beating once more – then it faded to silence and CPR was restarted. This happened three times and each time everyone held their breath waiting to see what his heart would do –and each time his heart faded again. Then it no longer started any more. After about 15 minutes the Lead Doctor said loudly:
« Stop ! »
And all activity ceased. He continued, “We are going to stop all treatment for two minutes. Does anyone have any ideas or suggestions ? I have run out of options to try.”
There was silence except for Bruno, the scribe. “Treatment stopped by Dr. Goshen. Suggestions requested Time : 20 :34.”
Then total silence for another minute and a half.
Once again the lead Doctor spoke, “I’m calling it. Time of death 20 :36. Everyone please stand back from the body. Leave everything exactly as it is, even the garbage on the floor. Just pickup any unused medication for removal. The Medical Examiner will want to see everything along with the record.”
And Bruno’s last entry : “Time of death 20 :36. All materials except unused medication left in place for the Medical Examiner. Code Team exits.Time : 20 :37.”
With the privacy drapes pulled a nurse was put on guard to prevent anyone entering until the Medical Examiner arrived.
Bernard was gone – just his body left surrounded by idle equipment , discarded packaging and the evidence of an heroic attempt to save his life.
I could hear the Code Lead Doctor talking to the Lead Nurse and replying to her question as to what had happened. He thought that the distended abdomen indicated internal bleeding – likely an anurysm that ruptured with the dialysis pressure. The autopsy would tell the story.
He could not have gotten treatment any better, faster or more efficiently – the cause of death was one that could not be stopped once started.
No one was to blame.
At that point I heard the guard nurse speaking, “I’m sorry, you can’t go in there.”
“My husband is in there I demand to know what is happening !”
Oh My God, the family. They had returned from supper and in all the urgency, no one had gone to tell them in the cafeteria.
The Lead Nurse hurried over. “Can we talk over here please.”
“No, I want to know what is happening to my husband, I’m going in there.”
“I’m sorry you can’t.”
“Get out of her way,” I heard the father say.
They pushed through the curtains followed by the Lead Nurse.
“Please, let me explain…”
Then the screams « BERNARD ! BERNARD ! OH GOD, BERNARD ! »
With everyone’s confusion, the children were forgotten and they followed the adults through the curtain to where their dead father lay.
Now the father and brother’s voices could be heard.
“He was alive when he came in here.”
“He was fine until you started treating him.”
“He’d still be alive if we hadn’t come here.”
“We’re suing you and the hospital for killing him.”
And then, with a sob, “We only went for supper and now he’s dead.” More sobbing in multiple voices…
And then the children’s voices – not accepting it :
“Dad ? Dad ? Say something please Dad . You’re scaring us. Please say something Dad.” Now begging.
I felt the tears start to roll down my cheeks at the sound of their small pleading voices. Jesus, the kids shouldn’t have to find out this way.
A grief counselor appeared and between her and the nurses, they convinced the family to go to the board room to talk. They disappeared and all was quiet – just the occasional beeping of the dialysis machines and the silent presence of the Bernard’s body just 36 inches away – a man who I had chatted with just a short time ago ; a man who came for treatment and now was leaving in a body bag ; a man who I had told he was safe ; a man with a young family ; a man who had left this world 40 years sooner than most, in the prime of his life.
The thing about this experience that struck me was that the patient got immediate attention, perfect treatment, the full resources of a huge acute care hospital with bedside x-rays, ultrasound, ECG, etc. , and a list of specialists that can only be had at a large hospital. Absolutely no stone was left unturned and all delivered within minutes – treatment started in seconds. The system worked absolutely perfectly – the result of centuries of medical experience and training and betterment. And yet he died. There was no one to blame, no what ifs, no maybe’s, no hindsight – it was all done perfect the first time and in record time.