Too Young to Die

Heart failure...one of the most dreaded services in this hospital. It's not so much the patient load (which was usually less than six patients per team) or the numerous medical problems the patients had, but fear of the attendings. The two heart failure attendings expect a great deal from us and we are expected to know every single cardiac detail about them. To make a single mistake on this service is to fear for your license, even for something like giving a heart transplant patient Percocet. Fortunately the two heart failure teams work together as one. My sister resident and I get along great, and the two interns called each other their "work spouses" to provide emotional and friendly support. It wasn't uncommon to see all four of us getting breakfast in the cafeteria or chatting in the lounge. But because heart failure patients are so sick, they often come to the hospital over and over, and inevitably they will die after we've gotten to know them.

A few months ago, a 19-year-old boy named N.L. was playing basketball when he gradually became weaker and suddenly collapsed in the middle of the game. His CPK was through the roof so it was believed he had rhabdo, but a high CPK did not explain his EF of 30%. A heart biopsy revealed that he had a genetic marker for some sort of X-linked muscular dystrophy, which was odd because most patients with muscular dystrophy exhibit symptoms as children, not young adults. And even though it was not the correct diagnosis, the unofficial diagnosis for his condition was called Duchenne's (DMD) by almost everyone. The first time I saw this guy 3 weeks ago, his EF had already plummeted to 15%, but both he and his mother remained hopeful that with medications they could control the progression of his heart disease. He was a college student, and he was anxious to get back to his studies.

This morning my intern called me and asked, "Do you remember N.L.?" Of course; how many 19-year-olds with so-called DMD were there on the heart failure service? I just didn't know he got readmitted last night. Then my intern said, "He just coded upstairs so I'm helping the other team out." WHAT? I quickly ran up to the tele floor and saw that N.L. had been transferred down the hall to the CCU. The CCU team was working on him, giving compressions, trying to put a central line in him. He had been on the other heart failure service the last time he was here, and the intern who had taken care of him looked extremely shook up. To say he was upset was an understatement; the poor boy was crying and wiping his eyes while trying to maintain his composure. He was on call overnight and had admitted N.L. for hypoxia (likely another sign of progression of his DMD), but no one had expected this.

The code (which I did not participate in since the CCU team was running it) lasted almost 90 minutes, but not surprisingly (ABG had pH of 7 and lactate of 10) N.L. didn't make it and died at 8:30 a.m. There was an extremely somber air on the tele floor for the next 3-4 hrs. Everyone kept talking about how young he was, only 19 years old. "At least it was quick," my attending, who was in his 70s, commented; having seen examples of prolonged suffering in the ICU/CCU setting, I had to agree. The CCU resident came by to offer support to the heart failure intern, then pulled his resident aside and asked her to let him go home. Fortunately she did; that poor guy only got 2 hrs of sleep last night and then to lose a well-acquainted patient on the last day of his heart failure month...I can only imagine how bad he needed to get away and get some rest.

Seeing this intern mourn the loss of his patient reminded me just how much the interns still have to learn about dealing with death at the hospital. I can still remember my intern from July expressing shock when I told him we wouldn't be doing anything for a DNR/DNI patient in respiratory distress except putting him on oxygen and a morphine drip. "That's it? We're just going to let him die?" he'd asked at the time. Sadly, no matter how many people we see die in the hospital, dealing with it never gets easier.