Pages from the Philips Seeking God's leading in medical missions

Loneliness

The emergency room is a very lonely place to be.  It’s an even lonelier place to die.  It has been an interesting and sometimes sad look at people and what happens to them when they come to the ER.  It is often times even more noticeable regarding who is not with them.  I cannot begin to count the number of of people that come to the emergency department alone.  They come to the ER because of a work accident, a gunshot wound, a car wreck, altered mental status or seizure and often come alone.  What to me is even more depressing is how many come to the ER and die alone.  To die in a place that is cold, sterile, with no one who knows you – it’s a lonely place even for me.

The disparities between people and their circumstances are perhaps most noticeable in the ER when it comes to who comes along with the sick patient.  At the county ER that I work at primarily having someone else along tends to be more of a rarity.  I get many patients from nursing homes, from apartments, from the street who come to the ER by themselves.  I especially find it sad when the demented, trached, artificially fed nursing home or long term care patient comes in completely unable to communicate with no one there to advocate for them.  These patients are someone’s father or mother, brother or sister but yet they come to the ER with a cryptic note tagged to them from the nursing home like “altered” or “throwing up” or “fever” or “g-tube out.”  I’ll usually try to call their emergency contact but more often than not those numbers (almost universally) seem to be disconnected.  However, this lack of family with patients seems to be much less of a problem in some of the more affluent ERs that we also rotate in.  Again, almost universally there seems to be at least one friend or a family member with them in the ER which I can imagine would be much more comforting for the patient.

There was a man I met earlier this year that I think brought this issue of being alone very clearly to my mind.  His chief complaint was “got the shakes.”  I went into the room to examine this man, a large man who must have been around 300 lbs and at least 6′ 5″.  He looked to be in his middle thirties.  He was unshaven with a t-shirt and sweat pants on.  After I introduced myself he explained how he ended up in the emergency room.  He had struggled with alcoholism for many years.  He would have periods of remission when he would try to clean up his act but a few months into it he would relapse right back into drinking.  He wanted to stop drinking again and so he had stopped cold turkey the day before.  The morning that I saw him he was starting to have trouble with shaking which because of his repeated experiences with alcohol alerted him to the fact that he was starting to go into alcohol withdrawal.  I examined him and he clearly had the signs of early withdrawal with some tremors in his hands, a slightly elevated pulse and some mild agitation.  I told him that I would get him some librium and if he was feeling better I could let him go back to the Salvation Army.  About an hour later I went into the room to discharge him and asked him how he felt after the alcohol withdrawal medications and he said “oh Doc, I feel a little better” but the look on his face told me something else was wrong.  I hesitated about whether I should ask anymore questions because my section of the ER was starting to fill up and I had already picked up two charts of an elderly man with chest pain and a young girl with a toothache.

Every so often you can feel the Holy Spirit tugging on your heart and this was definitely one of those moments.  I asked him how he ended up at the Salvation Army and his full story came out.  He explained how he felt so guilty because he had hurt everyone that cared about him and his drinking kept putting up a wall between him the world around him.  He used to be a professional football player that played linebacker for an NFL team (I looked up his name at the end of the shift and sure enough his name was on an old roster with the number of tackles he had).  However with the money the NFL brought him and his love for alcohol he wound up doing alcohol full time and his football career soon ended as he drank his life away.  He would periodically be able to stop and get a decent job but alcohol would come calling.  By the time he ended up at the Salvation Army he had been living his life in an inebriated state for almost 10 years.  At this point he was in tears.  He had burned all his bridges which is why he had no one left to turn to and how he ended up alone in a shelter.  We talked quite a bit about seeking forgiveness and being able to forgive himself.  I shared with him about how God’s love is unconditional – He does not ask us to be perfect before we come to him.  Jesus is willing to meet us just where we are – broken and alone and even in that state He extends the riches of His grace to us.  How does one fall from such a great height to become so broken and alone?  But praise be to God that often times we can hear His voice much more clearly when we have nothing left to bring to the table.  After he saw me in the ER he saw the psychiatrist because of his struggle with depression and then I’m not sure what happened to him.  I hope that day he was able to see that that there is a God who cares about him deeply and that He offers forgiveness.

I wanted to share two more stories with very different endings that I think illustrate this theme of loneliness well.  The first was a 90 y/o lady that I took care of a couple weeks ago.  She was a frail lady who was in a nursing home for many years suffering from dementia but otherwise had few other medical problems.  Her chief complaint was “fall from standing.”  As I walked into the room I saw an elderly woman sitting up on the bed but with a glaze over her eyes.  She was breathing fine but didn’t seem all there.  The paramedics reported that she had fallen an hour earlier at the nursing home when she was getting out of the chair.  Initially she was talking to the nursing home staff but then she started becoming more somnolent.  The nursing home called 911 and by the time they arrived she had this same glazed over look that I was seeing.  I rubbed on her sternum to see if I could get any sort of response from her but she barely moved in response to my sharp kneading of her chest.  I intubated her quickly and she was in the CT scanner about 10 minutes later.  It showed what I had feared.  She had an extremely large epidural hematoma (a large collection of blood in the space between the brain and the inside of the skull) that had gotten so large that the middle of her brain was pushed over several centimeter.  We called the trauma team quickly and they called the neurosurgeon to come in to see if this could be decompressed.  The trauma team called the family members to ask them to come to the hospital.  The family said they would be there later but to go ahead and extubate the patient because her chances of survival were next to none.  The trauma team asked again if they would like to be there when she was extubated since she would likely die soon after extubation.  The family was clear – they had busy lives and would come later to see her if she was still alive but otherwise to just extubate her without them being there.  She was extubated and because her brain continued to herniate she died a few minutes later with the beeps of the monitor and two physicians and a nurse around her.  She died with no one in her family there to comfort her – she died alone.

Many of my patients die in the cold sterilized walls of the hospital with no one beside them in their last moments except the nurses and doctors caring for them.  However every once in a while we go to extraordinary lengths to have family around when a patient passes away.  Such is the story of a elderly man with dementia who I cared for when I was at Mayo.  It was about 8 o’clock at night when we heard over the dispatch radio, “80 y/o male, hypoxic, respiratory distress, lights and sirens, be there in 10.”  I was a 4th year medical student and just learning about the unique practice of emergency medicine.  I had a great attending that night who wanted me to direct the resuscitation of this patient with him so I met him in the critical care room and we started working together as soon as the patient came in.  The frail elderly man looked blue when he arrived in the resuscitation bay.  The nurses quickly had two IVs in under 2 minutes, we had in on the monitor and the respiratory therapist was at bedside.  The paramedics gave the story quickly.  ”80 y/o man with Alzheimer’s dementia from a nursing home.  He was doing fine until the staff noticed that he was not breathing well and that he was not responding and so they called 911.  Also by the way he has a DNR (do not resuscitate) order with him which is why we did not intubate him on the way here.”  Being a 4th year student yearning for life saving procedures I felt quickly deflated that I would not get to do an intubation.  I started thinking “What exactly are we doing for this man then if we can’t intubate him and he can’t breathe?”  Once his pulse oximetry started to pick up it read 52% (normal is greater than 92%).  We put an oxygen mask on his face to see if that would help but it only brought the pulse oximeter up to 65% – clearly no where close to where he needed to be.  He would moan every once in a while but that was the extent of his communication with us.  The attending asked me to call the family to confirm his wishes with regard to DNR status and when I finally got a hold of his wife she said that he had made it clear that he did not want to be intubated but that the whole family was coming to the hospital so that they could say goodbye to him before he died.  I asked them to come quickly since I wasn’t sure how long he would last on his own.

We tried 100% oxygen on a face mask but he soon started to lose his ability to oxygenate and was starting to take stuttering agonal breaths.  His pulse oximeter was in the high 40s.  His family was still 45 minutes away.  Wanting to respect the patients wishes but also wanting to allow his family to be there when he died so that he would not be alone we decided to bag mask ventilate him.  What that meant is that we put a big mask over the patient’s face and then have a second person pull up on the jaw to clear the airway and we push on the Ambu bag about 10 times a minute to breathe for the patient without actually putting a tube in his trachea.  The attending asked me to stay with this patient until the family arrived.  Every five minutes the respiratory therapist and I would switch places as we rhythmically bagged this patient to keep him alive until his family arrived.  I was soon starting to tire  out and did not know how much longer I could keep pulling up on his jaw and keeping the mask held tight to his face while I waited for the family.  45 minutes later his wife arrived and within a few more minutes two of his children and several grandkids were are bedside.  His wife told me they had been married for 62 years but that the last few years were so hard on her because he no longer recognized her.  However she still wanted to be with him so that he would not die alone.  Once they were all there they were able to kiss and hug this elderly man and then we stopped bagging him.  He passed away peacefully about three minutes later.  I had the chaplain come and we formed a circle around him and prayed.  It was a extremely moving event in my young medical career.  I didn’t save anyone that night.  Initially I felt that what I was doing by bagging this man for 45 minutes was pointless, I kept thinking “just let this poor man die.”  But that attending taught me a great lesson about trying to prevent loneliness – it is a sad day when you have to die alone.  I was glad that even though this man died yet his family go to be there with him so that he would not be alone.

Finally a few thoughts about loneliness in my own practice of medicine.  I think the ER is a difficult place to work because few people understand the heartache and sadness we see each day.  I have to watch people die and suffer day in and day out.  Yet I have to move on to the next patient who comes in seeking help – needing something to alleviate their physical or emotional pain.  I’m so glad that I have my wife to be able to talk with because there are many days that I go home with tears in my eyes and my heart cries out because of what I witnessed that day – an untimely death, injustice, abuse, heartbreak, and depression.   Melissa has been a steady source of support for me – a person who I talk with about my patients, their stories and how emotionally alone I sometimes feel.  I’m even more thankful that God understands my deepest thoughts.  I’m thankful that the Holy Spirit can move in my heart when I feel empty and alone – that He can show me that there is a purpose even in suffering.   It reminds me that this world is not my own and that we long for a day when there will be no more tears and no more heartache when Christ returns and redeems this fallen world.  That is probably what I am most thankful for this year – a family that loves me and let me know that I am not alone and my God who is always with me even in my deepest suffering and greatest joy.  As it says in Romans 8:35-39:

“Who shall separate us from the love of Christ? Shall trouble or hardship or persecution or famine or nakedness or danger or sword? As it is written, ‘For your sake we face death all day long; we are considered as sheep to be slaughtered.’  No, in all these things we are more than conquerors through him who loved us. For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord.”

Have a wonderful Thanksgiving.  I have also posted our final pictures from the Northwest road trip with pictures from Yellowstone below.  Stay tuned soon for a post on perseverance.

• Yellowstone National Park Slideshow