I haven’t run a code this long in years. In fact, not since residency. I’m shocked at how smoothly it’s gone. Of course, the outcome is the same as most codes. I’ve known it was futile, barring a miracle, since the outset. But I’ve run the code now for an hour, entirely for the benefit of the care providers. And for myself. With all my heart I want to believe that there’s some small chance this will work. I’m now an Emergency Physician. This is something I’ve done dozens of times and can do flawlessly in my sleep. This is a code.
It’s 12:43AM. I tell Janna to give one last milligram of epinephrine IV push and I tell Bronwyn to continue chest compressions for two more minutes, then we’ll stop. I spend the two minutes wondering what else I can do for the care providers surrounding the bed, admiring the chest compressions done out of a heartfelt mixture of desperation and love, and running through the events of the last hour in my head...
I got the call at 11:45PM. ‘Come now, desatting,’ was all Janna had to tell me. I already knew the outcome, but I also knew we had to try everything. ER doc mode kicked in. ‘Stop whatever you’re giving her and run D50 in one IV and mannitol in the other.’ I hung up. Mannitol was my when-all-else-fails treatment. I suppose we’re now there. Janna is the best nurse I’ve ever worked with, and I apologize to no one for saying that. I trusted her to watch my son’s IV quinine drip while I slept and I’d do it again. I knew she would do exactly what I asked. There was no need for further conversation. Besides, I was already grabbing shorts and shirt to run in. And I ran.
During the run to the hospital, I recapped the case. 43yoF PMH mitral valve prolapse seen for... You know what, I know the history as well as I know any history. A malaria test result of 0.75%. Henri, the chief of my lab, told me, ‘I can count the stars in the sky, but I can’t count all the malaria under this microscope.’ He had never seen blood so full of malaria. That was Thursday. We hospitalized her on IV quinine, but she still fell unconscious the next afternoon. We gave her an IM shot of Fansidar. We gave her dexamethasone (which has not been proven to help, but doesn’t hurt). We gave 1:1 nursing care. We gave her a nasogastric tube. We gave her a urinary catheter. We have her IV fluids. We gave her the best care humanly possible in this part of the world. The D50 is because both quinine and malaria make you hypoglycemic and the mannitol is to take the pressure off the brain. Mannitol has not been proven to work, but doesn’t hurt.
And yet, there I was at 11:48PM, walking into a room and being greeted by the sight of CPR already underway. The patient’s on the floor, as that’s the only way to get something solid behind her back for good CPR. Bronwyn is doing an impressive job, even though she’s not a nurse. Janna, the only nurse in the hospital who knows CPR, is also the only one who can draw up meds.
11:49PM. I want chest compression continuous, but I also want respirations. Janna starts attempting to bag the patient, but runs into some difficulty. The bag won’t seal, even after we take out the nasogastric tube. I take the bag from Janna and start bagging the patient. We have good respirations. Bronwyn is doing good chest compressions. I ask Janna for one milligram of atropine IV push, which she gives.
I have a chance to regroup. I’m at the patient’s head controlling her breathing. I can see all of the patient and what medications she’s getting and what everybody’s doing. Typically, I run these from the feet of the patient, but I guess this will work just fine.
11:51PM. I ask Janna to give one milligram of IV push epinephrine, which she does.
11:53PM. The patient has a pulse. I ask Bronwyn to continue two more minutes of chest compressions. While I breathe for the patient, I ask Julie to call Danae to the OR and set up suction. I can already feel the liquid building up and can see her stomach bulging. She’s been putting out amazing amounts of bile from her nasogastric tube and I’m sure she’s a set up to aspirate. Unfortunately, I can’t intubate her here. I give Janna my keys and ask her to bring me a stretcher from the OR.
11:55PM. I do my best to bag her up and we hoist her up into the stretcher. I breathe for her for a while there too. Then we sprint the thirty yards to the OR. Once inside, I resume breathing again. We get her over to the OR table and I suction out her mouth. She’s now vomited and aspirated huge amounts. She can’t even protect her own airway. She’s lost an IV so Janna starts a second one within seconds. By now Jamie and Tammy have arrived. And a hoard of curious Tchadians are standing outside, with nothing better to do at midnight.
A chance to relax and see what our options are. She has a pulse. She’s not breathing, I’m doing that for her. Her sat is in the toilet, hovering in the 30s-40s, I’ve sucked out as much as I can, but she’s already aspirated a ton. She’s received enough D50 that she’s definitely not hypoglycemic and she’s receiving a second bottle of mannitol. There’s no point in giving any more of that. So we’re at a relatively stable point. I could intubate her, but I have no device to suction out her endotracheal tube. And Marci has also joined us in the room. We get the patient hooked up to a blood pressure cuff and she’s 80s/40s. Not ideal. Her atropine and epinephrine are wearing off. I put in a nasopharyngeal airway to make her breathing a little easier. I start an epi drip.
12:09AM. She loses her pulse again. We give atropine. We give epinephrine. The pulse comes back. She loses her pulse again. We give a third dose of atropine, a third dose of epinephrine, a fourth dose of epinephrine, a fifth, sixth, seventh, eight, ninth...
We continue ACLS. Everybody performs their part perfectly. Untrained people are giving great chest compressions. Gary shows up right as we’re dusting off the abandoned defibrillator, which show an unsurprising asystole. We don’t shock.
So here we are, back at 12:44AM. Fifty-nine minutes of coding. I look around the room and see so many faces. I see all my friends. There are nine expatriates doing a code in the middle of the night. I never witnessed this before. And then I look down once more at the patient. Minnie Amor Pardillo. My expatriate volunteer who has been here with me now over a year. My volunteer who started our public health project. We’ve buried children of volunteer missionaries, but never a volunteer him/herself.
And this is the great secret of Emergency Medicine. There is no rule saying that you should run a code for x number of minutes. You run the code until the physician deems it futile. While, that’s not always the reality. Often, codes are run in the first place or are run long for the sake of the family watching, just so they have the peace of mind and comfort that everything humanly possible was done. Often it’s for the staff, who might need that time. And when your staff and the family are one in the same, you run it even a bit longer still. And the staff has to know that we’d try just as hard for any one of them.
I run my H’s and T’s one more time in my head.
I watch the seconds tick to 12:45AM. I put my hand on Bronwyn’s hands and she stops her chest compressions. I stop breathing for her. There is still no pulse.
‘We’ve now been going for an hour. She was in asystole when we checked, she has received three doses of atropine...’ I summarize for all in the room what exactly has happened in the last hour in the space of ten seconds. ‘Unless anybody has any other ideas or any objections, we’re stopping.’ Somebody had to say it and it was my responsibility as the Emergency Physician. It would be cruel and unfair to expect anybody else to do it...
‘It’s now 12:45AM. Time of death.’
We clean her up, take out all the tubes. We place an open Bible on her chest.
I walk outside in the dark. Never alone, I have Africans all around me, but they won’t understand the following conversation. It will be in English.
‘Mr Pardillo, I’m so sorry to tell you that your sister Minnie has just died.’
We’re taught in medical school to use the word ‘died’. It leaves no room for interpretation, as opposed to ‘moved on’, ‘passed away’, or you could list any number of other euphemisms.
We're also taught in medical school to never be more sad than the family of the deceased is, otherwise the family will feel the burden to cheer us up. It's an undue, unnecessary and unfair burden to place on the family of the deceased.
This family is sad, it’s clear. But during the following hours, they showed more grace and faith than I have ever seen. More than I could ever conjure up in myself. I’m utterly humbled. And ashamed.
All prior deaths here have been buried here. But the family expresses that their first choice would be repatriation. Trying to honor her family’s wishes as best we can do is the least we could do to honor Minnie’s memory.
We are in a very warm place and it is rainy season here. These are not ideal factors for preservation. Minnie stayed in our OR and we turned on the generator and the AC. The girls went to Minnie’s hut and packed up her things. Gary and I set to getting everything lined up with the insurance company and preparing to fly Minnie to N’Djamena as soon as it was light out enough to take off. She would also need me to sign a death certificate. Not many people slept at all and those that did slept very little. At 4:45AM we were loading Minnie’s body into the LandCruiser and trying to explain to the Tchadians why we couldn’t spend the three day funeral typical here.
At the airport and ready to go, we realized that we had just spent the last five hours so busy that we hadn’t had time to digest and say goodbye. So we took the time to sing songs, read the Bible, pray and share thoughts about Minnie. Many local Tchadians came as well. There were many people missing Minnie dearly and many tears shed, both by the expatriate community and by the locals.
Minnie was one who worked quietly behind the scenes, and you never really knew what she was up to, but she made people like her. And because they liked her, they like us and our hospital. She worked to soothe many wounds that were opened between the hospital and the community villages. Wounds that existed long before she ever arrived. Wounds that nobody else had been able to salve. She spent so much time one-on-one with people, whether it was a Bible study, building relationships with village chiefs, talking to abused women, talking to suicidal patients, I've seen Minnie do it all. Even in the rush of our weekly dental clinic, she would ensure one-on-one time.
When you were in discussion with Minnie, you knew that you had her undivided attention, and that's a rare thing.
She will also be sorely missed by any volunteers who fall ill. When a volunteer got ill, Minnie saw it as part of her ministry to nurture them. (She would stay with them all night fanning them, encouraging them to eat and drink, holding their hair out of their face while they vomit, etc.) But she didn't stop there. She saw an opportunity to nurture even those not suffering physically.
When I think of Minnie, I will always think of her walking along to talk somebody, with a never-ending smile that still held sincerity, with a cheerful wave and a heartfelt 'GOD Bless' and of course, the ever-present backpack. I'm not sure I ever saw her without it. We used to joke with her as to what was in her mysterious backpack. Such a large backpack for such a tiny woman. That's a memory that can bring a smile to my face even in this difficult and grieving time.
When we were talking about Minnie just before loading her into the plane, Janna said, 'If I ever met a child of God, it was Minnie.'
A better eulogy was never written.
Until the trumpet sounds, Minnie, sleep well.
