A n elderly woman has difficulties walking and uses an assistive device to get around. Her gait is typically unstable and she has been advised several times by her family to “take it easy”. In addition to simple walking this woman has tremendous problems navigating steps. She has recently traveled north to be with her family after a recent hospitalization for a fall in which she fractured one of the bones in her cervical spine (neck). Clearly a frail woman, but one that has been toughened by her life experiences as she frequently engages in risky activities like walking up and down stairs, ignoring the pleas of her family not to. A woman that is aggressively reluctant to bow to the effects and limitations of an aging body, she is stubborn.
This winter day after a recent snow fall, rain and ice producing temperatures she slips on the steps outside her home while letting her dog out, a task that most of us with animals do several times a day without even thinking about it. It is an activity fraught with peril for this woman. In an instant she loses her footing and falls down the concrete steps with her face taking the full force of the blow. She is alone, no one is home, it is cold outside and she lays there. She is stunned; her forehead has a large gaping wound that is actively bleeding. Her left wrist is clearly broken by the way it is deformed and swollen. There is an accumulation of blood under the skin already. She lies there alone. Time passes, and a neighbor notices her outside on the ground. Realizing what has happened the neighbor dials 911 for help and within a few minutes fire department paramedics arrive and take the woman who is still moaning in pain to the emergency department.
Her head wound is extensive and is bleeding at a concerning rate. Within only a few minutes of arriving at the hospital her neurological status deteriorates rapidly. She has to be placed on a breathing machine. She is rushed over to the CT scan to determine how badly she is injured. Her family arrives at the hospital during her scan which shows devastating injuries. Her neck is broken in two places, a C-1 and C-2 fracture, she is bleeding into her brain, and the tissue around her eyes and her left ear are filling with blood – raccoon eyes and Battle's sign as they are called. She has a significant skull fracture.
Shortly after coming back from CT her condition worsens. The family is informed. Her daughter pulls out the woman’s advanced directive – DNR, do not resuscitate. No heroic measures. Time is of the essence now, the healthcare team is losing ground in an effort to mitigate this woman’s injuries. A decision is made to withdraw care by the family in accordance with the woman’s advanced directives.
Over the next four hours the woman is surrounded by her family and she is made comfortable with IV pain medicine. The resuscitation efforts are stopped. The rest of the emergency department is bustling with activity; ambulances are arriving with patients, phones ringing, people talking, some crying of small children, the usual sounds of an emergency department.
It is 9:15 in the evening the woman who just wanted to let her dog out to pee is dying. Her breathing has become shallow and slow. She takes her last breath. Over the next few minutes her heart still beats trying to hold on but it is too late. Her pulse is gone, the cardiac monitor shows only a few blips on it until there is nothing but a straight green line.
Her daughter and other family members are crying. They are angry that she is dead. “Why did she have to let the dog out” her daughter said. “I have told her not to over and over”.
While this story tells the tragic tale of a patient I recently took care of it highlights the importance of all of us having some sort of advanced directive and or a healthcare proxy - a person who can make medical decisions for us when we are unable.
The other part of this story which I briefly discussed with the woman’s daughter before the woman died, was the extensive costs that her family had been saddled with from her last hospitalization in which she fell and broke her neck only a few months ago, and now there would be more bills.
More than anything else, a story like this which plays out countless times a day all across the country shows us how fragile life can be and is. In the span of only a few seconds events unfold which will change our lives and the lives of others forever.