Bellyache

In the morning before he went to work, she reported that her belly hurt.

When he got home that afternoon, she was on the floor, unresponsive.

At the hospital, they rushed her into the OR for an exploratory laparotomy, where they didn't find anything of note. There was a lot of swelling, though, so they left her abdomen open and just closed the skin on top. 5 big black X shapes made of thick suture held her together.

When we arrived the next morning, she was getting worse. Her lactate level was high, a sign that cells are trying to make do without oxygen. We picked up where the night crew left off. While I started the vasopressin drip, my newly graduated RN orientee manned the double spike tubing, hanging bag after bag of fluid to squeeze in with a pressure bag.

Her belly was looking bigger and bigger, her blood pressure not coming up. We implored the surgical team to return to the bedside once again. As the chief resident arrived she began to drop her heart rate.

He grabbed a pair of scissors and cut the big black Xs. The contents of her abdomen erupted, welling up as liquid poured down her sides and soaked the bed. The smell was warm and not quite right. With his sterile gloves he poked around a bit. We all watched the monitor for signs that perhaps she liked this relief of pressure.

There was no improvement.

While her loved ones waited outside the curtain, we placed the sterile plastic wrap over her open belly and covered her with blankets.

Serial blood gases indicated she was increasingly acidotic and her lactate level now into the teens. We kept pouring in the fluids, blood products, and powerful medications. Boxes from amps of sodium bicarbonate were littered all over. The fluids were leaking rapidly out of her vessels, and she began to puff up dramatically now, like some strange alien creature distantly related to the Michelin Man.

The family was large and loud. Her husband developed chest pain and shortness of breath, and was wheeled off to the ED for evaluation. One daughter became terribly angry upon realizing that her mother was lying on a wet bed. I explained over and over that we couldn't move her mother right now because she would likely die immediately as a result. It was painfully clear that everyone wasn't prepared for that yet.

She was far too sick for transport to the OR. Lactate now >15, the highest value our equipment accurately measures. Her belly was welling up higher and higher, like a great mountain in the center of the room. A niece developed an asthma (panic?) attack, and was next to leave for the ER. About this time a grandchild returned wheeling Grandpa, who had left against medical advice when they tried to admit him for the chest pain.

Things were getting worse by the minute. The room was packed, the wailing nearly continuous. One daughter, who had been designated medical power of attorney by the patient, agreed to refrain from shocks and chest compressions (CPR). She was nearly beside herself, declaring that her siblings were second guessing every choice she made. She felt she had to leave it up to her father whether to continue aggressive support. There was yelling back and forth across the bed between various members of the family.

"Dad, you've got to let her go! You're just prolonging things now."

"Shut up and leave Dad alone. It's his decision!"

"I need to get out of here, I can't take this," he said.

"Dad, you can't! You have to stay here with her. You cannot leave her."

About this time, a very pregnant granddaughter turned to me and asked, "Is there somewhere I can throw up?"

I ushered her into the tiny bathroom where she sank down beside the toilet. "We need more nurses for this family!" I exclaimed as I scrambled to care for my patient. The pregnant one was escorted out, not a moment too soon.

"How will I ever live without her?" her husband cried in anguish, the chaplain by his side.

"Daddy, we'll take care of you," the angry one said.

He started to leave. "I need to get out of here, take a smoke," he said.

I was watching the monitor closely as he said this. I knew it was time to get my amps of epinephrine and atropine in my hand and ready to go. I stopped him with a hand on the shoulder. "It looks like she might go at any minute now. We have tried everything we know to stop this process, but we are out of options. Do you want to stay? It is okay either way."

He shuffled back to her side. I called the ICU resident to come, and when her heart rate suddenly plummeted, I pushed the atropine. She didn't respond to that, but some epinephrine gave her a heart rate and pressure for about 4 minutes. Then she went nearly asystolic-- flat line. I pushed another amp of epi and got the same result. All their eyes were fixed on the monitor.

"She may keep responding temporarily like this for a while, but we can't fix the underlying problem," explained my colleague who had joined us at the bedside. As I prepared to push the 3rd epi, her husband said, "Stop. No more."

It was hard to zip the body bag closed, her belly was so big.



When those patients finally “die,” it becomes apparent just how fuzzy the line between alive and dead is. If a patient has a heart rate on the monitor of 30 with a pressure of about 21/18, are they still alive? You won’t be able to feel pulses with that, though there is technically a pulse pressure. Do you wait for the last physical beat of the heart? That comes before the last electrical activity of the heart. If you see 25 complexes a minute but the blood pressure is 4, when shall we stop calling it pulseless electrical activity and start calling it dead? How about 12 and a BP of zero, or shall we say less than six per minute? We must pick a time. If we didn’t have a monitor, we’d call them dead when we couldn’t feel a pulse. But since we do, families, nurses, physicians all stare up at it and keep pushing drugs, waiting for it to show us what we already know.