August 2007 | Back to Table of Contents

Perspective

First Code

By Meghan Lelonek with Therese Zink, M.D., M.P.H.

Death brings to life the intangibles of professionalism.

The 86-year-old, retired farmer slouched in the plastic chair in the exam room next to his plump wife. “Something’s not right,” he mumbled. Grumpy because he could not solve the problem himself, he was not thrilled to see us. “She insisted I come,” he said, pointing to his wife with his gnarled thumb. The result of cumulative years in the sun, his wrinkled face was dotted with pea-sized, flat crusty spots—actinic keratoses.

As a third-year medical student spending nine months in this small town with my preceptor, Dr. Smith, I often went into the room first to find out about the problem. This time, it was hard to figure out what was going on. The patient, I’ll call him Mr. Larson, had a list of medical problems: renal failure, coronary artery disease, high cholesterol. Today, he complained about feeling unsteady. “I’m better off if I stay in my chair,” he said as I supported him when he climbed onto the exam table.

We admitted him to the hospital for dizziness.

After we’d seen all the clinic patients for the day, Dr. Smith and I walked over to the hospital to check on Mr. Larson. He shared a room with another elderly gentleman. The wives knew each other and had pulled back the cloth curtain that separated the two beds so they could chat. They were reminiscing about their summer of golf, now weeks past. Mr. Larson’s monitor showed a steady heart beat—beep, beep, beep … like a metronome. He slept, exhaling muffled snores, so Dr. Smith and I went out to the nurses’ station to write orders.

Suddenly, Mrs. Larson appeared at my elbow. “Come quick. Something’s wrong.”

We bolted into the room and gawked at the monitor—beep, buzz, beep, buzz, and then a steady buzz. The line was flat. Dr. Smith palpated the side of Mr. Larson’s neck. “No pulse. He’s coding,” Dr. Smith yelled back toward the nurses’ station as he began CPR.

One of the nurses dragged the crash cart into the room. “Put the Ambu bag together,” he directed me. I struggled with the bag, mask, and tubing. After what felt like forever, I got it connected to the oxygen spout in the wall. I handed it to Dr. Smith. He guided me to position the mask over Mr. Larson’s nose and mouth. I squeezed the bag, pushing oxygen into his lungs. The nurse unsnapped his hospital gown, baring his chest for an electric shock. Dr. Smith placed the paddles and called, “All clear.” Mr. Larson’s body jumped an inch off the bed. Mrs. Larson stood near the opening in the curtain and the other patient’s wife quietly led her into the hallway.

The anesthetist arrived and took over for me. She skillfully slipped an oropharyngeal airway, shaped like a comma, into his mouth and reapplied the Ambu bag over his face and mouth, tilting his chin toward the ceiling. I was an observer, unsure how to join in. Dr. Smith must have sensed my discomfort and asked me to take over the CPR. I located Mr. Larson’s zyphoid bone, which protruded through the wizened skin of his bony chest, and placed the palm of my hand just above it. With my other hand on top of the one against his chest, I thrust downward with my palms. I counted in my head: one and two and three and four …

After several minutes, Dr. Smith instructed me to pause so we could check for a pulse and assess the heart rhythm. We stared at the monitor; it showed an occasional fluorescent blip in the otherwise flat line. The nurse checked to make sure that the electrodes were attached; they were. Mr. Larson had no pulse. His eyelids fluttered and his eyes rolled up as if he was looking at the anesthetist who stood at the head of the bed.

“As I remember, the Larsons and I talked about what they wanted,” Dr. Smith said. “He wasn’t interested in resuscitation.” He directed us to continue CPR while he checked with Mrs. Larson.

One and two and three and … It felt strange to do this on a person, his skin papery and warm, rather than on the cold, plastic manikin we practiced on during our resuscitation course. I was afraid that I might break Mr. Larson’s ribs. I marveled that this frail man had once thrown hay bales, wrestled cows, pounded fence posts, and stretched barbed-wire. The nurse anesthetist complimented me on my technique, but we didn’t talk much; somehow, it seemed irreverent.

Dr. Smith returned and told us that it was time to quit. “Mrs. Larson said that we should not prolong things.”

The nurse noted the time of death. I removed the electrode pads, and the anesthetist pulled out the airway. Mr. Larson exhaled a large breath, then jerked and grunted.

“What’s happening?” I asked.

“Sometimes that happens with death,” Dr. Smith explained. “The air caught in his lungs and stomach is being released.”

The nurse reassembled his gown, pulled the sheet up to his shoulders, and closed his eyes. He laid still on the bed, no more air escaping, his body hardly a sack of corn and two corn stalks under the crisp white sheet. This was death, I thought. Earlier today, he had talked with us. I’d steadied him as he stepped up on the exam table. Now silence. I was not really religious, but I silently whispered a prayer.

“We’ll bring Mrs. Larson in now,” Dr. Smith said. I trailed behind him into the hallway. He touched Mrs. Larson on her arm and told her it was over; she could come in.

Moisture filled Mrs. Larson’s eyes. She reached into her pocket, took out a tissue, and dabbed them with it. “We would be married 66 years next spring,” she said. “Lots of living.”

“Lots and lots of living,” Dr. Smith repeated. He seemed to be in no hurry and allowed Mrs. Larson to reminisce about her husband.

She leaned against the wall in the hallway, reluctant to move, and told us that her husband was raised in an orphanage; they’d met through a church youth group. “He was sweet on me the moment we met,” she said. “It took me a while to decide he was the one.”

Dr. Smith had been their doctor for more than 20 years and talked about Mr. Larson’s independence. “He usually tried to doctor himself, like he ministered to his cows, before coming to see me. When you brought him, and it was usually you who insisted, he was pretty sick.” They chuckled, Mrs. Larson laughing through her tears.

I could feel the sadness mounting in my throat like a cough or sneeze, it was impossible to suppress. Was it OK to cry with a patient? I didn’t have a choice. Mrs. Larson handed me one of her clean tissues. I blew my nose and mopped up my tears, gaining my composure as I listened to Mrs. Larson talk. Clearly, she needed to talk, and Dr. Smith ignored his rumbling stomach and his dinner waiting at home to give her the time to do so.

Mrs. Larson wanted to wait for her daughter to see her husband. The daughter must have lived nearby because she arrived within 10 minutes. The image of her mother, she was accompanied by her 9-year-old daughter, who had long yellow braids and as many freckles as a strawberry has seeds. The youngest of their seven children, the daughter had always been close to her father, and this granddaughter was the “apple of his eye.” She played cribbage with him whenever she visited.

Dr. Smith and I followed them into the room. Mrs. Larson knelt down at the bedside and clutched her husband’s hand, her head against his thigh. The daughter and granddaughter did the same. Dr. Smith bowed down next to them, his hand on the shoulder of Mrs. Larson. Tears and more reminiscing.

As I plodded home to my rented house, only a few blocks from the hospital, the adrenaline seemed to drain with every step. The air was crisp, only a cuticle of a moon in the inky star-studded sky. Quite a day: That morning, before the clinic day started, we had delivered an infant boy, now this evening—death. I needed to share the drama with someone. I fumbled to poke the key into the lock, pulled off my coat, grabbed the phone, and called my Mom, a nurse.

I shared the saga with her. She understood. In fact, it brought back memories from her days as a student nurse.

“You fumble at first,” she said. “Don’t be too hard on yourself. It will feel less awkward after awhile, almost second nature. But don’t ever lose your awe of birth and death.” MM

Meghan Lelonek is a fourth-year medical student, and Therese Zink is an assistant professor in the department of family medicine and community health at the University of Minnesota.