During my penurious years of service as a junior medical officer in Her Majesties Armed Forces, I moonlighted in the Emergency Room of a local community hospital. It was a small hospital and the ER doctor on the night shift also covered the ICU. Since the worst disasters went directly to the larger General Hospital most of our ER work was routine. Occasionally, however, a serious emergency would arrive and require ICU admission. When that happened on my shift I would generally try to cope with both the ER and ICU until morning. That was the case the night Mr. Antonio was admitted.
Mr. Antonio was rushed to the ER, crumpled in the back seat of the family sedan, after collapsing at home. His was a classical history. A robust working man of about 50 years, in good health except for hypertension, he suddenly cried out that his head was splitting and fell to the floor. Although he had been mumbling incoherently when they carried him to the car, he was comatose on arrival in hospital. This was long before CT and MRI scans. Probably it was completely unnecessary, but I did a quick Lumber Puncture to confirm that there was fresh blood in his CSF. I’m not sure now whether the LP was done to allay my anxiety or strengthen my case when talking with his family. In either case, I wanted to be certain of my diagnosis that he had had a massive intracranial haemorrhage and the prognosis was hopeless.
He was quickly shifted to the ICU for observation. Meanwhile, the number of anxious relatives now overflowing our tiny waiting room was rapidly increasing. As delicately as was possible I prepared them for the worst, his teen-age daughter acting as my interpreter. There was little hope to offer them. It was my considered opinion that he would not live through the night. The message perhaps came through more bluntly in the interpretation than was intended and it triggered a chorus of wails and tears that continued unabated for the remainder of this episode. As the number in attendance increased so did the volume. They must have derived some comfort from each other’s company because they left my patient entirely to the care of the ICU nurses. Perhaps they realised that the sheer weight and volume of their support was the best they could do.
There was little more I could do so I returned to the ER where there was now a substantial backlog. Even there we could still hear the weeping of the grieving family.
The ICU nurses knew their job well and kept me posted with updates on his condition. When he became totally unresponsive to painful stimulation I was sure the end must be near. By now the disruptions of his noisy and restless retinue were beginning to grate on our nerves. When he developed Cheyne-Stokes breathing I briefly considered the life-support options, but immediately dismissed the notion. There was no need to write ‘Do Not Resuscitate’ or ‘comfort measures only’ orders. The nurses knew what to do and were not about to initiate futile attempts at CPR. That was just as well because the ER had become even busier and I had little time to devote to a hopeless case. Their family priest had arrived and he was quietly advised to administer the Last Rites. When they finally called to inform me that Mr. Antonio had stopped breathing I was relieved, hoping that would bring denouement to the tragic drama that was disrupting the routine of our small hospital.
A quick examination indicated absence of both respiration and radial pulse. I wanted to get the most unpleasant duty over first, to inform the family of his demise. Locating the immediate family members was less difficult than extracting them from their clinging support group but eventually we got them into a small private room where we could be heard. As expected they were devastated and their crescendo of grief was sufficient to transmit the message to the others. For several minutes anguish prevailed. Now they wanted to see him. Perhaps it was a premonition that held me back, the hot breath of my omnipresent evil genie on the back of my neck. I hesitated, “Just give the nurses a few minutes to make him look better”.
While I was sitting at the nursing desk completing his death certificate my genie struck. The practical nurse who was tidying the body for family viewing darted out of the room with a look and manner that I had come to recognize always presaged trouble. “You’d better come back quickly,” she said, “he’s still breathing.” Only after my re-examination confirmed her report did the full impact of my situation hit me. The nurse was mostly right; he wasn’t exactly breathing but he was gasping at a rate of 3 to 4 per minute, agonal breathing. And they weren’t gasps that could be ignored, they reverberated in that small room, accompanied by a heaving chest and flaring nostrils. Moreover he had a clearly palpable femoral pulse and a visible apex beat under his left nipple. It should be obvious to any fool that he was not dead; no lay person stepping into that room would have a moment’s doubt. Within moments his grieving family would expose me as just that fool.
I have since seen many patients undergo neurological death and have come to understand that the exact timing is uncertain and the physical signs deceptive. The medullary brain-stem centres that control breathing do not shut off like an electrical switch; they wind down like a potter’s wheel. Agonal gasping can continue for minutes, sometimes hours. If the heart is basically healthy it requires only a little oxygen to keep beating, and I have seen strong hearts continue to contract for 30 minutes after breathing has ceased entirely. Blood pressure, pulse rate and force of cardiac contraction vary unpredictably. Electrical activity of the heart, the ECG, may continue long after pulse and heart sounds have ceased.
At that moment the reasons for my misjudgement were unimportant; I feared that I was on the verge of more than just embarrassment. The noisy throng milling in the corridor were a sturdy lot of bricklayers and plasterers. They were of an ethnic origin noted for volatility and mistrust of official institutions. When they discovered that their dear relative, who I had just declared dead, was perceptibly alive I wanted to be somewhere else. It would be uncomfortable enough to be identified as the perpetrator of a morbid hoax, but, more seriously, they might immediately conclude that his treatment had been careless.
I needed time and the first necessity was to divert the approaching wife and children. Nurses were dispatched to delay them by any means, using any excuses necessary. With the door firmly closed and locked I had time to consider my plight. What were my options? One: I could slip out the back door and leave town. Two: I could admit my error and face the consequences, but I knew that he was bound to die soon and my humiliation might be averted. Three: I could hold a pillow over his face till he stopped breathing, but my good intentions might be misinterpreted. Four: I could sweat it out.
The next thirty minutes were among the longest of my life. I counted each gasp, I anguished, and I waited. When there had been no gasps and no pulse for a full 15 minutes I came out. His family was restive and didn’t understand my strange ritual. Thankfully they were respectful enough not to enquire. It was the nursing staff that saved my reputation. I never learned what they told the wife and children that kept them pacified for a half-hour, or how they explained my need to be alone with the patient for so long. But they made it appear as if it were part of the routine and hospital routine is inviolate.
Now, when I am called to pronounce a patient dead, I get very busy. For at least a half-hour I am engrossed in another task, cannot be located, or am otherwise urgently engaged. After all, on a scale that stretches to eternity it makes little difference if the patient’s official departure time is delayed for a half-hour. For me that experience was a half-hour that seemed like eternity.