The Last Moment (2014)

It is a dark, wintry, Saturday morning as I drive to my 7 a.m. shift in the ED. Approaching the university, I pull behind a slow-moving ambulance, meandering, with no urgency, toward the hospital. Ten minutes later as I enter the ED ready to take check out from the nighttime attending, I pass by Room 9 and stop. A patient is being placed on the monitor. He is awake and groaning as his automatic implantable cardioverter defibrillator (AICD) fires. The bedside cardiac monitor shows a wide complex tachycardia. I piece together that the squad I had followed in had been called by a local nursing home after the patient's AICD fired. EMS had noted stable vital signs and a complaint of pain caused by the AICD firing. Now on the monitor, the AICD sequentially fires multiple times. The resident assures the patient's wife that the ACID is performing properly. Very soon, however, the patient is no longer responsive. The patient is now pulseless despite the paced cardiac rhythm visible on the monitor. Suddenly, chest compressions begin, bagging is instituted, medications are given, and the external defibrillator pads are placed. At this moment the patient's wife, who is here by herself, is outside of the room trying to call family members. The resident steps out to talk with the wife and quickly returns to say the patient has a DNR-CC order (paper work not received). Meanwhile CPR is ongoing. Initially the AICD fires again, but then stops despite the obvious tachycardia and the patient is successfully externally cardioverted. As I step outside the room to talk with the wife, she is on her cell phone, trying to reach other family members to seek their advice, but to no avail. She is unsure as to what to do with the DNR order since resuscitation attempts are under way. During this brief conversation, the patient loses his pulses and CPR is restarted. Immediately, another dose of epinephrine is given. With anticipation that this resuscitation will soon be over, I bring the wife back into the room to be with her husband. I pull a chair to the bedside so she can sit next to her husband and hold his hand. At that very moment the patient begins breathing spontaneously, regains pulses, CPR is stopped, and a blood pressure is registered. A resuscitation success? No—it is what happens next that constitutes the miracle that the patient's wife will always remember. The patient, who has been unresponsive for the past 25 minutes with CPR and bag-valve-mask ventilation ongoing, unbelievably regains pulses, opens his eyes, looks directly at his wife and says a few words. She in turn responds with a few words and then he is gone. In checking, he is again pulseless—all of this in the space of about 60 seconds. I tell the wife that if we are to continue we need to restart CPR. She asks us not to do so. The resuscitation attempts end. She remains at the bedside holding her husband's hand, crying softly, and then pulls out her cell phone and calls her brother. Everyone in the room tries to comfort her. I tell her that I am so glad that she was able to come back into the room at the exact moment that he awoke. She says she is very grateful for that final moment. Two hours later, as I see her leaving with her brother at her side and other family members in support, she again tells me, “thank you, thank you for allowing me to be with him in the last moment.”