Sometimes death is not the worst option.
On Sunday morning, I went into work a little early so that I could spend time feeding the abused twins that we’re taking care of on my service. It?s a rare weekend day that I go into the hospital for call early; as it is, I can expect to be on the wards — and actively running around — from 8 AM until at least 10 AM the next day, so even spending an extra 15 or 20 minutes there is a pretty big stretch. But at 7:30 AM on Sunday, I planted myself firmly in the chair between the twins, grabbed one of them, and settled in with a bottle of formula.
It was around 7:45 that I thought that I heard one of the nurses say the word “arrest” in the hallway outside. My ears perked up a little bit, and about 10 seconds later, the same nurse called out over the intercom, “All doctors to room 1032.” I stood up quickly, tossed the twin to the police officer guarding the room, and raced around the corner to see what was going on.
Now, a little background on childhood oncology might be in order here. Most people are familiar with what would be considered standard treatment for cancers — chemotherapy is the mainstay, and for the most part, a typical oncology ward at a children’s hospital is populated with kids who are undergoing chemo. There are, however, children who have forms of cancer which don’t respond to this, and for many of them, the only available option is bone marrow transplantation. BMT is a completely different beast — we use even more toxic medicines to completely remove a child’s native immune system, and then install a new one in the hopes of eradicating the cancerous cells. The children undergoing bone marrow transplantation can get very sick, and any little insult — a viral illness, an ulcer, a urinary tract infection — can overwhelm what little reserve they have left. Most of the time, taking care of children around the time of their transplants involves fighting off every little threat in the hope that their new bone marrow will take hold (“engraft”) and ramp up to normal function. At the time, we had six children on the ward in various stages of transplantation, and three of them were within the couple-month window where anything could happen.
When I heard the room called out over the intercom, I knew the patient immediately. Nancy (not her real name, of course) had had a bone marrow transplant around six weeks prior, and her course had been a particularly hard one. She had experienced the typical set of complications that plague these children — fevers, mucositis, anorexia — but had also developed a few more serious problems, including the one most feared in transplantation, graft-versus-host disease. GVHD occurs when some of the immune cells from the donor’s bone marrow realize that, now transplanted, they are in foreign territory and attack the recipient. Everything possible is done prior to transplant to try to prevent GVHD — certain markers on a patient’s blood type are matched to the donor to make sure that there aren’t incompatibilities, and recipients of bone marrow transplant are maintained on high-dose immunosuppressants during the time when they are most susceptible to GVHD — but nonetheless, there are times when the feared occurs. Nancy had developed the worst grade of GVHD, in which the immune cells were attacking her skin, her liver, and her gut, and we had been spending a significant amount of time fine tuning her therapy to attempt to ameliorate the problem. Despite this, she had been deteriorating, and towards the end of the week, she had developed relatively severe inflammation throughout her GI tract.
I was the third person to arrive in Nancy’s room. Already there was my senior resident, as well as the intern who I was to be relieving that morning; they quickly called out that the nurse had found Nancy unresponsive. We put a monitor onto her and saw that her heart rate was around 30, and she did not appear to have any respiratory effort to speak of; my senior resident began chest compressions, and I grabbed the bag-valve mask to start breathing for Nancy. By that time, the arrest cart had arrived outside the room, and one of the senior residents had arrived from the pediatric ICU; he took control, and started calling for arrest medications. I pushed epinephrine once, then a second time; at that point, her heart rate came up to the 50-60 range, but she still had no palpable pulses. I then pushed atropine and sodium bicarbonate, we hung an epinephrine drip, and (having arrived a few moments prior) the ICU fellow intubated Nancy. We started running fluids into Nancy wide open — first, using just saline, but quickly moving to albumin, a thick protein-filled liquid which helps a patient maintain volume in their arteries and veins. Somewhere in the fray, Nancy was moved onto an arrest board (since doing chest compressions on a soft, cushy bed is next to impossible); it was handed into the room by one of the dozens of people (residents, fellows, students) who had collected outside the doorway to the room.
While one of the residents was placing an arterial line, we quickly reevaluated the situation, and realized that things had gotten better. Nancy had a blood pressure and pulses in her arms and legs; she was also moving a bit and responding appropriately to questions. I placed my hand in hers and asked her to squeeze, and was rewarded with a gentle pressure around my fingers. I asked her if she wanted to see her mom, and she nodded yes, so her mom quickly wiped the tears from her own face and was shepherded through the mass of people to the bedside. Next, though, the ICU nurse who had taken over the ventilation job reassured Nancy that she was going to be OK… and she began nodding her head back and forth. She was clearly miserable — lying naked, a tube down her windpipe, another tube down her throat, terrified about everything that had just happened. Tears were pouring out of her eyes. People were flurrying around her, getting everything ready to move her as fast as possible to the ICU.
After Nancy was moved, my senior resident grabbed the other intern and I, and we decompressed for a little bit. We then started rounds so that they could sign the team over to me, but we all found it very hard to keep from returning to what had gone on for the previous half hour. It was, to say the least, surreal — we had gone from relaxed to 100% adrenaline, and we were all still shaking from the arrest.
About ten minutes into signout rounds, there was a knock on the door to the conference room, and one of the ward nurses came in to tell us that Nancy had just succumbed. She didn’t have any details, though, so we quickly finished up and went down to the ICU. Apparently, within 10 minutes of arriving, Nancy arrested again, and the ICU team began another entire round of resuscitation. A few minutes into the code, however, Nancy had a massive pulmonary bleed, and at that point, it became impossible for her to get enough oxygen to live; within sixty seconds, she died. By the time we got there, the parents had already been brought into the grieving room and told what happened, and the bone marrow transplant team was outside the room, beginning all of the paperwork. I walked into the room, and Nancy was lying in the middle of the bed, as peaceful as I’d ever seen her. The nurses were gently cleaning her up, removing all the catheters and bandaging up her wounds, and for the first time that I had known her, there were no noises of pumps running, no beeps from monitors, no whispers from oxygen masks. There was nothing except the quiet acknowledgement of a life ended by tragedy, but also of pain replaced by peace.
Later in the day, when someone asked me how I was doing, it hit me that it was that last moment that I saw her when I realized that I had been coming into work every day for the past month expecting exactly what had happened. Nancy had been sick — far sicker than any of our other patients, and constantly teetering on the brink between able to fight and willing to give up. She had also been miserable, nearly inconsolable, and over the course of taking care of her, I began to realize that there are times when it is appropriate to acknowledge a basic fact of life: death is not always the worst option. Nancy had endured tortures far worse than anything I can imagine, and Sunday morning, she was at the point where the pain and misery had stopped taking breaks. Finally, she banished them forever.
