When We Keep Going.

Abstract

What does it feel like to have acidic blood? In medical school we learned that a pH below 6.8 is generally thought to be incompatible with life. But is it painful? Nauseating? Before my fellowship in palliative care, I completed my residency in emergency medicine. In the ED, diabetic patients presenting with vomiting from ketoacidosis could clock in a pH below 7 and recover quickly. But that was before the hospital ran out of residents to staff the COVID ICU and drafted many of us as fellows to fill in. It was my second to last day covering in the ICU when I saw Mr. L’s pH dip below seven. I wondered again what it felt like to have acidic blood. Mr. L had presented to the hospital about a month before. He was in his late sixties and had spent the last year in a nursing home. Now, COVID-19 was ravaging his body. After spending weeks on a ventilator, he developed septic shock related to multiple pneumonias. Eventually, when he started to decompensate, a lab tech called every six hours to inform me that his pH was “7.03,” then “7.02,” and then “6.96.” By policy he was not allowed visitors. During daily calls with his family, his wife was clear that she didn’t want her husband to suffer, but deferred to her son to make decisions. His son said his dad was a fighter. Mr. L loved the Chicago Bulls and had been married to his wife for thirty years. The son was sure his dad wouldn’t “give up.” It was Saturday evening when I was paged. His pH was 6.8. “Unfortunately, I have bad news,” I said. “Your father’s blood pressure is low. I’m worried he’s dying.” “We can shorten his suffering if we pause some of his infusions and let him die naturally.” His son wouldn’t have it. “No,” he said. “Keep going.” “He’s a fighter,” his son declared. Sensing his resolve, I thought to myself, “fighting for what?” Maybe he was a fighter. Maybe Mr. L wanted to spend his last days “fighting,” raging, burning for every minute on this green earth. But his son was home with his family. And I was with Mr. L watching him die. His son ended the call quickly. I could hear laughter before the phone clicked silent. While I held the phone to my ear, I felt myself sink away from their peculiar joy into a swamp of melancholy. I finally put the phone down and looked at the telemetry monitor. Mr. L’s heart continued to beat, beat, beat. “Hello, I am so sorry to bring you this news but your father died this morning.” His son replied stoically, “I need to be with my family now. You did everything you could for him.” I don’t feel like I did everything I could for him. Maybe I could have been more clear on the phone with his family. Should I have spent more time speaking with his wife, describing how sick he was? From where I stood, with only a pane of glass between us, his last moments were grueling and lonely. His family will remember something far more dignified: a fantasy I peddled over and over again during our daily phone calls, eager to deliver when they ached for good news. The way I see it, I was his only visitor and I had trained to alleviate suffering. But I failed Mr. L. That’s what I’ll remember.