This is a reflection from some time ago but I believe it still has something to say and share.
Julia
We're bringing in a 25 year old woman complaining of difficulty breathing, pulse is 180. We can't get a BP.
Are there any palpable pulses?
No radial pulse. The patient feels dizzy. Lung sounds are clear. Can we give Adenocard 6 mg?
Can you palpate femoral pulses?
Yes, and the radial pulse is faintly palpable now.
Hold Adenocard, run fluids wide open and come in as soon as possible.
Lord, she's got a PE doesn't she? Please help me to help her. I don't have a good feeling about this though. Lord, she's only 25!
The squad arrived a little while later. It didn't take medical training to know she was in trouble. She was in severe respiratory distress, cyanotic, mottled, awake and in a panic. Vital signs? Pulse 180. BP 80 palp. Pulses barely palpable. Respiratory rate well over 40. She was cool to touch.
Call respiratory therapy. We need stat ABG's then 100% O2 via nonrebreather. Open the saline wide and start a second line if possible. Monitor shows SVT(supraventricular tachycardia) 160-180.
Lord she's going to die and there isn't anything I can do that will help. I know this the minute she arrives. I know it with the part of my heart that is closest to You, and so founded on You, is true. Still I hope to be wrong and I have to try to "save" her. So I embark on a fruitless endeavor because I have no choice. People (doctors among them) actually believe that doctors can save them. I know better, still I must play the game. Lord make me an instrument. Healing comes from You and You alone.
OK, let's start with denial. Maybe I'm wrong, maybe it's cardiac.
Give Verapamil 5 mg IV.
No change.
OK. Give Cardizem 25 mg IV followed by a drip of 125 mg in 100 cc of saline at 10 cc/hr.
No change with the Cardizem bolus.
Julia sat up with the last bit of strength she had and grabbed the lapels of my white coat as she looked desperately into my eyes and screamed: HELP ME!!!!!!
Time to stop denying and to offer her what comfort I can. Her words and her gaze pierced me to the heart.
Are those ABG's back yet?
Here they are. pH 7.34 /pCO2 33/pO2 54/sat 87%/HCO3 19 on room air.
Even the nonrebreather mask hasn't increased her much, her sat's hovered around 90 to 91. Yes, Lord she has a PE and it is massive. She is going to die here in front of me like water passing through my fingers. Still I will do what I can to try to stabilize her if it is only to make her passage gentler under the guise of trying to "save" her.
Oh put me to sleep or something. I can't stand it, Julia moaned.
Forget the Cardizem drip. She's got a bit PE, and this is sinus tach. I need to tube her.
Give her Valium 10 mg IV. Get a number 7.5 ET tube ready and bag her.
We're all ready doctor.
Okay give her another 10 mg of Valium and 75 mg of Succhys. IV.
At least the intubation was easy. Please Lord, let me be wrong. Use me as your instrument of healing.
If it is your will that she come home now let me ease her pain in her birth to new life.
We'll need an NG tube and a foley whenever. How much fluid is in?
She is finishing her third liter now.
What's her pressure? I can barely palpate it and even femoral pulses are thready.
Start Dopamine and titer to a BP of 90 or greater.
Call pharmacy and ask what amount of strepto is recommended for critical PE.
Put her on the vent at 700 TV-100% O2-AC12 for now.
Lord, I'm not wrong, am I? Oh Jesus, why is death always so hard for us to understand? I know going Home is the most wonderful thing possible; it is the whole point of our journey to complete our mission and return Home to You and the unlimited joy of heaven's celebration of Your unveiled love. Still Jesus, moments like this are so hard for those of us on this side of the veil. Heal us too. What are the words of that song: night is our diocese, silence our ministry, poverty our love, and helplessness our cry. How true those words, except Beloved, I have yet to love the poverty of these moments.
The pharmacist says 250,000 units over 30 minutes of the strepto followed by a drip of 100,000 units per hour.
Doesn't seem like much to fight the size of the problem that she has, but I order it anyway. Lord, what else can I do? Why must helplessness always be our cry? So you will always remember I alone am your help. Ouch. OK. Duly corrected. It just hurts, Jesus, to watch her die and know nothing I can offer will help much. I know the pain and I bear it with you. If you did not hurt this way you wouldn't be so close to my heart. The only way to distance yourself from the pain is to walk away from my heart which you are free to do, but I wouldn't recommend it. You always corner me this way. I think you even enjoy it. But thank you for being our help and our strength for moments like this. I do enjoy loving you always. Now be at peace and stop fighting, doctor, help her make the passage gently. Be not afraid, I am with you and with her.
Run the strepto bolus wide open. Do we have central pulses yet? No, I don't feel any.
OK open the dopamine wide for 2 minutes and start compressions. Take her off the vent and bag her. She's gone brady. Atropine 0.5 mg IV. Her rate is back up to 120. Any pulses with that? No.
Keep running the fluid wide open. Continue CPR. Is the strepto bolus in? Yes, run the 100,000 units wide as well. It's in doctor. She's brady again. Atropine 1 mg. No response. Epi 1 mg. Rate is up to 80. Any pulses? No. She's dropped her rate again. Epi 2 mg IV.
Well my sister the game is up. I knew when we began the code you weren't really here anymore. You haven't gone completely but you will all too soon. Part of me wants to grab you and find some light in your lifeless eyes and scream back at you: HELP ME!!!!! just because I don't want to give you up. I don't even know you, haven't even talked to you to have a real conversation. Still you are 25 and you have a husband who loves you and two babies who need you. And in a real way I need you to live. More I have learned enough of life to know we are all part of each other. Part of me lies on this birthing bed, this bed on which your spirit will leave the womb of this life to be born into the fullness of Life in God unencumbered. All veils and clouds will be removed. Part of me envies you the privilege of the passage. If it were possible I would give my life for yours. I do not leave a husband or children and I have lived 18 years more than you will ever know. Still it is not possible; for God is God and has made His incomprehensible choice. Intellect and reason won't answer this one. No reason ever be given for this death that will ever make sense. So what are we left with? Faith and love born of faith.
Any response to the last dose of Epi? No response. No palpable pulses. Monitor shows an agonal rhythm. How long have we been running the code? Twenty minutes, doctor. OK. I'm going to call it. Stop CPR.
She continues to have a few agonal breaths as well as a few agonal beats on the monitor; so I make my way close to her head, stroke her hair gently and say: It's time to decide Julia. It's OK. You either have to give me some major sign that you are going to stay with use so I know to continue to fight for you, or you need to move on into the Light. I know maybe you don't really have a choice anymore but don't be afraid. Just move in whatever direction you are lead. It's OK. We're here with you. Come toward my voice or head for the Light now. Just as I finished talking to her, she stopped her breathing and a few seconds later was asystolic (flat line).
Time of death? Too soon, or was it? Seven-fifty.
How do you tell a young husband that his 25 year old wife that he left just a few hours ago is dead of a blood clot to the lung? Why her, why now, why, why? We wish we had reasons; we look for a meaning in the incomprehensible, but we do not find one that is credible. Even the knowledge that she is "with God" does not bring immediate comfort or solace in this empty moment of grief. Faith does not make us impervious to pain. No, we believers bleed just as much as everyone else does maybe more because to believe we have to open our hearts to God. The open heart is a vulnerable heart. We cannot choose to be open to God and be closed to anything else. God is a part of all life. Even in the midst of truly evil events, God is there as healing presence offering mercy and as Light combating darkness. So truly as psalm 139 says: there is nowhere we can go to escape the presence of God. So open and bleeding, what do we do with the pain?
Pain is another strange thing. Pain is the most common reason people seek me out as a physician. We don't like to hurt. As a physician I have come to understand a little of the gift mysteriously wrapped up in pain. Pain is one of the dark angels. He is not an instrument of evil but rather an instrument of healing and so very close to the heart of the Father. Pain tells us that something is wrong, something is out of balance,something is missing. Pain is necessary that life be preserved. Pain disturbs us enough so that we will not ignore needed messages. Pain needs to be distressing, or simply put pain needs to be painful to get our attention and to move us to attend to and seek healing. Still we often ignore what we can because pain inconveniences us. We frequently ignore pain until it is disabling. Strangely though disabling pain enables us to be healed. We seek help when we are in pain. Recognizing our dependence of God is the first step in a long healing process which is our journey home. Pain is in a strange way then an angel of invitation to grace. No, I haven't been inhaling strange substances nor am I for a change sleep deprived. I write these words more awake than perhaps I have been for some time.
How can pain be an invitation to grace? What do we who have a relationship with God do when we or someone we love is in pain? We pray even if we are not commonly prayerful people. People who don't really believe in God much are willing to try Him out in prayer if they are in enough pain or need. We seek help when we are in enough pain; we recognize in some small way our dependence on God whether we call it by name or not. When we are in pain, we are aware of our inability to carry on alone. The beginning of our life in faith is our reception of the truth of our true neediness. We need God. We cannot really make the journey without Him. We cannot fix ourselves. pain helps us to hear the invitation God sends to all of us to be healed in His love. Pain helps us to hear by making a noise to express the depth of our woundedness. Pain is grace in a strange dress and a strange unwelcome voice, but grace nonetheless.
For me as physician, pain is a guiding light, without it I would be unable to help heal others. Pain helps me to know to some degree where the problem is and the intensity of the pain helps me in part to know how serious the problem is. When I medicate someone, pain's easement helps me to know the problem is improved or under control at least. Pain's persistence often tells me to look further. Yes, pain is a necessary ally. Dark angel he may be, but we should all give thanks to God for the call to grace and the protection Angel Pain gives us. Protection? Yes, if we are stepping on glass, pain lets us know to stop it. If we are having a heart attack, pain can get us to medical help that can help save our lives. If we have a broken bone, pain saves us from further injury by keeping us from using the injured limb. Yes, pain is a dark but blessed angel without whom we could not easily survive.
If we look at pain in the spiritual realm, he is even more of a gift. Only a spirit that is truly dead in sin can be impervious to spiritual pain no matter what. Even in our sinfulness, pain lets us know when we do wrong. Pain make us uncomfortable until we seek healing. Pain is the tender but ever so sharp knife with which God carves our hearts. Has someone hurt us, abandoned us, abused or used us? Our hearts explode in pain, we are hard pressed to ignore. We want out, we want to run away and we may choose to run away from a God who "let this happen" to run away from our pain. However the only way out is through: the only healing is in God, not away from Him. How long we hurt often depends on how stubborn we are. Angel Pain is a messenger of God's healing and so is more persistent, more enduring and faithful than we can ever be stubborn, hard-headed and/or hard-hearted. Yes, strangely pain is a dark angel of great and wonderful grace. Would that we recognized his voice as a song from the heart of God calling us home to mercy, forgiveness and compassionate healing!
Please understand I am not in any way glorifying suffering. Needless suffering I believe is an insult to God. God never rejoices in our agony. He is not pleased in our hurting. How could anyone imagine a bloodthirsty God who punishes us with gloating delight I will never know! God loves us so much that He made our pain His and suffered for us and with us on the cross.; He walks with us all the way. His love is incomprehensible for us; it is beyond measure such is its depth and passion and it is completely unconditional. It is a love freely given and never can be earned. It is given to all equally. (Unconditional passion is like that.) Yet this God of Love uses pain to heal us?! Why??
God uses the Angel Pain as instrument of deepest healing because there is no other way. Our ways are so far from His that the growth necessary to approach Him to draw nearer to His heart causes us an agony of pain. Should God then leave us alone? Isn't pain which passes after his purpose is served, even if it is excruciating, worth enduring if it is the necessary pathway to the Father's unfurled embrace? Should women stop having babies because the process of giving birth hurts? How much is life worth? Are we willing to hurt for love?
Often when someone dies in the ER,, family members want me to medicate the bereaved spouse or parent or friend. I almost always tell them the same thing: the pain is healthy and necessary. The only thing medicine does is postpone the pain, it does not heal it. The only way out is through. I didn't want to walk down that corridor anymore than anyone else ever does. But I have "lost" those I love through the great separation of death. We walk down the corridor of the pain of grief only because there is nowhere else to go. So we take the arm of Angel Pain reluctantly and walk into the chamber of mourning and grief where God perhaps first shows us the deepest measure of His love.
Julia's husband and family will find the same treasure on their journey through the strange land of mourning: the treasure of eternal love. They will be numb for a time; pain so intense cannot be felt all at once but must be broken up to be born. They will be angry and they will search for a reason to make sense of the sudden death of such a beautiful young woman at age 25. They will feel empty and know a loneliness that cannot be filled. It is a difficult journey.
When the fighting and wrestling is over (and this time varies for everyone), when they finish feeling guilty for what they did or didn't say or do, they are left with the essential question: what do I believe? Do I believe that life goes on, that death is but a door? Do I believe that love endures and is stronger even than death? Do I believe that love is eternal? Only when we come to this center of the maze and receive the grace to believe the truth, are we really set free by Love that is perfect and eternal.
Understanding doesn't answer grief. The mind has no equation to solve this mystery. Only the heart can embrace the darkness of belief that is the true light of faith. Only the spirit can receive the Love that cannot be comprehended or understood but can only be savored and celebrated.
We enter robed in pain, full of questions, full of anguish, restless in our search to find the meaning and so be in control of our reality again or at least preserve our familiar illusions of safety and security. Twenty-five year old women just don't' get critically ill and die despite all modern medicine has to offer. It isn't "right"; it isn't "fair." It just doesn't make "sense." Mystery doesn't make sense that is why it is mystery. No, it doesn't seem fair and it seems out of the order we have come to trust. We are shaken not only by the tragedy, but by its challenge to the illusion of our control of our own little world. We don't like to feel helpless and out of control. Everything must have a reason that we might discerning understand and in comprehending once again be in control of ourselves. Ah, the depth of our illusions!
Once again pain is the leveler. These tragedies hurt us. Pain is again our instrument of healing. Of what do we need healing? Are we afraid perhaps of our own vulnerability? Are we angry over previous losses whose wound has never healed? Are we challenged by the lack of answers we can understand? Pain is the strange but necessary gateway to wholeness. Pain is a dark escort home to the heart of the Father who alone knows the depth of our wound and our vulnerability. We leave reason behind. We enter the dark gift of grace and let go. The silence and the darkness heal us. Slowly we rise and see the Light over the dark horizon of fear and pain. It is the Light of Holy Love.
In the end all that remains is love: in this love is God for God is Love. In God alone are we at peace. Is peace without pain at all times? No, we will always hurt in this separation from those we love that is the veil of death. However, in the end the love is greater than the pain because in this holy love is union. The peace comes from this union; the pain remains because our union is not complete until our own journey is done and we are truly one unveiled before God who unites us all. We walk on however in love. The love of those we have loved who have gone before us carries us on and the pain itself becomes deeper grace for it is but a measure of the gift of love we have been privileged to know and celebrate. We walk on more deeply in the mystery that is the Love who is God. The Light of this Love transcends all darkness we may face.
Time of death? Never, rather the time of Birth was seven-fifty a.m. one strange and challenging January morning; for us a dark but graced moment never to be forgotten. Thank you, Julia, my sister, for challenging me to help you in your Birth. Thank you, my God, for your dark Angel Pain who guided me back home to your heart and hence deeper in faith and love of You through this strange passage on my journey home.
