Mr. Smith wanted to die. He decided to kill himself, so he wrote a note, placed a small caliber handgun against the side of his head, and pulled the trigger. For most purposes, that is the moment he died. Certainly, he no longer existed as a person, as a consciousness.
My first look at Mr. Smith was in Bed 3 of my unit. He was "very sick." The reason he was there was that he was potentially going to be an organ donor. The representatives from the donor service were on hand, the family had been contacted and consented to donation, the wheels were in motion. The fight was already underway.
I often say it is much harder to keep a dead person alive than it is to keep a live person alive. What I mean, is that when someone is "dead" but their body is being kept in a stable state in order to harvest organs, it body fights to die, sometimes quite hard. The blood pressure, body temperature, heart rate, electrolyte levels, respiratory functions; so many of the body's normal functions - when alive - are left for the medical team to regulate when the brain gives over control. And so, we fought.
The Plan was to find recipients for the organs while getting his "numbers" all corrected, then pronounce him dead (by withdrawing the medical care and waiting for cardiac death, or by doing tests that demonstrate that the brain is dead) and take him to the O.R. to begin removal of the organs. Brain death was the original plan. Mr. Smith wasn't in on the plan, however. His oxygenation began to decline because he had received so much IV fluid to help keep his blood pressure up, that his abdomen and chest were tight. When that happens, the lungs cannot expand inside this tightness (imagine how you feel almost short of breath when you overeat, for example) and the oxygen level goes down in the tissues.
It was decided to use ECMO, or Extracorporeal Membrane Oxygenation. Think of it kind of like a heart bypass machine for the lungs. It removes blood from the body, oxygenates it, then returns it to the body. It is used infrequently as a last ditch effort to save a very sick person, and used with some success. So, it was decided that they would cannulate the body (put the large IV tubes in), allow for cardiac arrest to occur, then change Mr. Smith's name to "Organ, Donor" and move him to the O.R. Meanwhile, his dopamine was at max dosage, his Neo-Synephrine was, too. We started Vasopressin at max dose as well. These were all to support blood pressure and heart rate, and they were all failing. We had already abandoned the brain death plan because we couldn't get him stable enough.
Because his vital signs were failing so fast, we had to initiate yet another plan. His abdomen was cut open. Usually patients undergo this procedure in the O.R., but when they are this unstable, the doctors are forced to perform surgery right in the ICU. I've seen this done numerous times. Once the abdomen is open, the liver, stomach and intestines are able to protrude somewhat outside of the body, thus relieving the intra-abdominal and intrathoracic pressure, allowing the lungs to be more "compliant" and improve oxygenation. The organs are sealed under an adhesive plastic sheet that has suction tubes passed through it. These tubes are hooked to a vacuum and fluid/blood drains into collection cannisters, thus keep the abdomen relatively empty of this pressure creating fluid, which is a result of fluid shifting from the blood vessels to the tissues and spaces of the body. This is a normal reaction to severe trauma (just like swelling around a bug bite).
Once he stabilized slightly from this procedure, it was decided to opt out of the ECMO, transport him immediately to the O.R. and allow cardiac death to occur there. After "death" his kidneys could still be harvested quickly enough to use them in transplants. He was whisked out of our unit by 12:45am, about 6 hours after our shift began, and I transferred him in the computer to the O.R. Nearly everyone in the unit was drained from our efforts.
It isn't for me to understand this situation, I don't think. It is frustrating to work so hard on someone who had full intentions of dying anyway. It is hard to be emotionally upset about the death and to not feel cynical about the method. I almost feel angry that he put us through so much, yet I know he was in no emotional state in his last minutes to consider the consequences. I am happy that others who want to live so bad and are suffering as they wait will get organs from him that will improve their lives. I am mentally and emotionally confused, and I'm left unable to completely process the events and "move on."
This is the hard part of my job. I don't perform strenuous physical labor, but there is a toll on my mind, body, and spirit, nonetheless. I see the same feelings in the fatigued eyes of my co-workers. We enjoy the numbness, knowing that soon we will have time for questions without answers, and personal feelings we can't hope to explain to anyone else. I actually find that I deal with the situation fairly well. The snag is that it doesn't stop. It never will end. There is always someone out there waiting to kill themselves. People drink and drive every day, everywhere. People buy, sell, and consume drugs, carrying guns and living the thug life portrayed in popular rap tunes. People cheat on their spouses and shoot at cops, climb trees and buildings without safety equipment, and ride tractors on steep slopes.
Nearly all of the work I do is to help people who have done truly stupid things heal, often knowing they are likely to do such things again. That's realism, though I realize it may sound like cynicism; or maybe it really is, I don't know. It is a necessary job, I guess. At least that is what I try to convince myself of, repeatedly. But GEEZ! If people would just LEARN. It isn't that hard, is it?
It isn't that hard.