Bleed

There are good deaths and bad deaths, easy deaths and terrible deaths. In the ER, we see so many kinds of death we get used to it. We understand we can't always win. We become good at knowing, quickly, instinctively, if we have a chance at winning this time, the way a champion poker player knows whether his cards have a chance of netting him the prize.

But sometimes, against your best instincts, you still find a way to hope. You find a way to hope that perhaps your gut is wrong. Even though you know it's irrational. Even if you know it's futile. Sometimes you meet a patient and something about him or her makes you want to fight, makes you want to rage against the dying of the light.

She came in early this morning during my overnight shift, a frail and thin elderly woman gagging on the blood pouring from her mouth. She had been brought by ambulance alone - her family was on their way - and she looked so fragile lying on her stretcher. No, she didn't have pain, she said, it was the vomiting that was the worst. That was all she really managed to say in between gagging and coughing and vomiting up blood.

Her blood pressure was dangerously low; her heart rate was clipping along quickly. She was obviously in hemorrhagic shock. We put two IVs in her, poured fluids in, called urgently for blood. But I knew - and we all knew - that we wouldn't win this battle. There was too much blood - she was too old to withstand that sort of bleeding - she was bleeding from a place we couldn't get to. Still we tried.

At one point her eyes rolled up in the back of her head and she slumped over and we thought we had lost her. CPR and intubation would have been futile - we got ready anyway while my boss went to speak to her family who had arrived by then. I had my laryngoscope out, endotracheal tube ready - just in case. But I knew as well that intubating this poor lady would be awful. Running a code on her would be awful. We'd break her ribs, shove tubes down her - and for what? My boss returned - the family had decided to make her a DNR - Do Not Resuscitate.

So we kept pouring fluids into her. We poured in litres of saline, bags of blood. We poured it into her veins - she poured it back out onto her stretcher, our floor - blood everywhere. We called in the gastroenterologist - that was the last hope she had, that somehow he would be able to put a scope down her, find the source of the bleeding and stem the red tide. If you have a bucket with a hole, you can never fill it up enough. Maybe he would be able to plug the hole. If he could, she would have a chance. A slim chance, but still a chance.

As soon as he stuck the scope down, she spewed out a massive amount of blood all over the floor and his shoes. We threw hospital sheets on the floor to soak it up. He got in, and looked around - nothing in the stomach but blood. Where was it coming from? He retracted the scope, advanced it again. Flushed the mucosa with water, suctioned blood out, looking for the source of the blood.

And then we saw it and we knew.

At some point, she must have had a gastric ulcer. Left untreated, it had slowly - little by little - been eating its way into the lining of her stomach, the way most ulcers do. Except most ulcers cause patients enough pain that it sends them to the doctor and they get discovered and treated. She had not been so lucky.

Her ulcer had eaten its way into her stomach lining - the way ulcers do.

And then it had eaten its way through that lining.

And then it had reached its final destination. It had eaten its way into her aorta.

She had an aorto-enteric fistula.

"She's done," I said. It wasn't a question.

The gastroenterologist shook his head, withdrew the scope.

"She's done," he said.

There was nothing more to be said. Nothing left to do. There was no way we could plug that hole. Not a hole that size. Not a hole that led directly from her aorta to her stomach. We could keep pouring blood into her - she would keep pouring it back out. There was nothing left to try. Now she would die. Not a slow death - thankfully - but death by exsanguination. Death gagging and coughing on her own blood.

"Give her morphine," he said. "Keep her comfortable."

We put in a request for her admission to a private room in the hospital. The gastroenterologist went out to speak to her family. The nurses cleaned her up - changed the bloody sheets, wiped it off her face. Changed the diaper which had leaked because of the massive amounts of blood she had swallowed, which had sped through her intestinal tract. The nurses are good at trying to give the dying their dignity.

I left the room, stood outside. And I felt something I haven't felt in a long time, in the ER. I felt profoundly sad. I always feel a little sad when patients die. But little by little I've become hardened such that it no longer deeply affects me. I do what I can for them - and then I move on. When I know that the cards I've been dealt are a losing hand, I distance myself emotionally. It helps. It helps me to do my job, to keep fighting the war even when we've lost a battle.

But sometimes, I can't help myself. She was so fragile, and yet she had fought to live - we hadn't thought she would even survive to have that scope put down her. And yet she had - only to have a death sentence pronounced on her. Yes, she was old - she'd lived a good life - it was likely her time to die. But to die by exsanguination - to die choking on her own blood - and for all our skills and knowledge, to not be able to do anything about it... I didn't want her to die like that and there was nothing I could do about it.

So I feel sad. I feel deeply sad this morning, at the end of my shift. I'm tired but I'm sad. I'm sad not that I lost the battle, not that this woman is going to die. I'm sad that I can't change how she's going to die. And I'm sad because when she came in, I wanted her to live. I wanted her to fight, and I wanted to fight for her. Against my instincts and my best judgement, I'd hoped that we had a chance.

But we never did have a chance, I don't think. All the odds were against us from the start. And we knew it. Still, it didn't stop me from hoping. Perhaps I'm naive. Perhaps I'm still young and early in my career and idealistic. But I still hope, sometimes, even when I know the cold hard truth offers none.

I always said that when the day comes that I no longer feel sad at all in the course of my work, that's the day I know it's time to call it quits. Sometimes I fear that I might unknowingly lose my sense of compassion and kindness - because it's so easy to do in the midst of the chaos and everyday suffering of patients in the ER. Today I'm reminded that underneath my doctor persona, behind that professional smile, my heart is alive and well. And I suppose this is a good thing. Even though it makes me sad, even though it hurts.

This patient of mine, she will die. She will exsanguinate and there is nothing I can do to stop it. But we tried. And it is the nurses, in the end, who will do the most important thing for her. They'll keep her clean. They'll wipe the blood from her face. They'll change her sheets. They'll administer her morphine. In the end, they will give her as much dignity as can be afforded her. And when she dies, they will clean her up one last time, tuck her sheets around her, and draw the curtains. And as I write this from the comfort of my home, it is likely that this has already occurred.

Today I watched a woman bleeding to death. And it makes me feel sad. But it also reminds me that I am more than just my title. I am more than just my degree. It reminds me that I became a doctor because I care. I care even when caring hurts and is frustrating and even when it makes me want to curse and swear at my patients. I care about them. And maybe that - more than my smarts, more than my studying, more than all my knowledge - maybe that is what is at the core of being a physician.