End of the Road

Some days, when I least expect it, certain calls mow me down in ways I never thought possible. People ask me sometimes what the worst call I have been on is. I don't usually entertain their morbid curiosity.They are usually looking for grotesque stories that exceed imagination. But most of the time, the gory, blood-filled calls or the cardiac arrests really aren't my worst calls. They are perfunctory and by-the-book. I usually have little, if any. time to interact with my patients on truly critical calls. My worst calls usually are borne from the depths of despair of humanity. The patients who know and are conscious of how awful and hopeless their situation is and yet are unable to do anything about it. Those are the ones that pain me long after I have walked away.
We had one such call the other day. And I want to share it with you, not to wow you with some tale of heroism or adrenalin-fueled lifesaving. I share it with you because I want you to understand the truly tragic calls that never cross anyone's mind when they ask what the worst call ever was.

It was a glorious sunny morning. I had barely clocked in when the page came through. When we heard the address, we all recognized it. At some time or another, we had all responded to the little old man's house. Sometimes he took a ride to the hospital and other times he just needed help getting out of his chair. The tiny house looked old and neglected from the outside. The inside was no different. It sat on a small corner lot with huge trees that must have been planted when the house was built. I had never asked but I'm pretty sure the man had moved into the house when his kids were still small and the paint on the house was still fresh and bright. I wondered how long the house had been in such disrepair and why I had never seen any of the man's children in the multiple times we had been to his house.
We arrived onscene that morning and parked in our usual spot. We clambered through the back door of the little house as we usually did. As our feet crossed the threshold, we were met by stifling darkness and the pungent odor of urine, feces and rotting food. A tiny dog charged at us, making up for its size with ferocity. My partner pushed the dog aside with his foot.
“In here,” a small voice called from the bedroom.
My partner made his way toward the sound of the voice as our captain opened blinds and searched for a light that worked. I quickly grabbed the dog and searched for the bathroom so I could lock the dog out of our way. Then I returned to my partner's side.
The little old man had been lying on the floor of his bedroom and my partner was already helping him sit up.
“I was there for about an hour. I couldn't quite reach the phone,” our patient explains. He is relieved to see us but obviously ashamed.
“Let's get you stood up and into your chair,” my partner warmly offers. The old man is thin and frail and it doesn't take much effort to get him standing.
When he is on his feet, his sad eyes meet mine. He is wearing only a soiled Attends and a filthy white t-shirt with several holes in it. He has lost a ridiculous amount of weight since the last time I was at his house. “I'm sorry you have to see me like this,” he apologizes.
In spite of his sadness, there is a twinkle in his eye and for more than a brief moment, I want to fiercely hug him and take all his pain away. I refrain and, lugging my equipment, follow him and my partner into the adjacent room.
Once he is comfortably seated in his well-worn recliner, I began to check his vital signs while my partner does the rest of the assessment. Halfway through, our captain loudly blurts out, “What's wrong with your leg?”
Everyone's attention fixates on our patient's red, swollen, lower left leg.
“They told me I have blood clots,” he explains.
“Have you gotten them checked out lately?” Our captain has now taken over the conversation.
“I was at the hospital a few days ago. And the hospice nurse is supposed to come this afternoon.”
HOSPICE. The very word breaks my heart. I understand it and appreciate it for what it does. But it also is the final option for terminal patients who are simply waiting to die comfortably and dignified. I envision most hospice patients tucked warmly and safely in their bed surrounded by loving family and friends. Our patient is not comfortable, nor dignified, and there is no mention made of family or friends.
“Well, do you think we should call hospice and see what they think?” our captain offers.
“Sure. Let's do that,” the little old man agrees.
Our captain grabs a hospice information sheet off of a nearby cluttered end table and makes his way to the far corner of the room. A long, heated conversation ensues in which there is much arguing made in favor of our patient being seen immediately at the hospital. Hospice refuses. While our captain tries to convince them otherwise, my eyes wander away from our patient to the memorabilia that decorates nearly every surface. Several beer steins are arranged neatly along the top of an entertainment center, all of them inscribed with German writing. Hanging nearby is an insignia with a bald eagle, wings spread wide. Next to that are several framed photos and documents from an obviously extended military career. On a wall near our patient is a carved wood hammer with the word “Persuader” engraved in the handle. Everything is covered in a heavy layer of dust and cobwebs occupy more than a few places in the room. All of it suggests a life fully lived but, on so many levels, is now sad & dejected.The man before us was once a proud, vibrant, hard-working man. Now he is a hollow shell with only his memories.
Our captain finishes his phone conversation and addresses our patient, “They don't want you to go. They're sending over a nurse right away to see you.”
Our patient seems disappointed with this news. The caveats of hospice. When a patient agrees to hospice, the majority of decisions regarding their medical care are handled through an assigned nurse and, generally, a comprehensive team of other medical, social and religious professionals. Receiving medical care through other means can actually jeopardize the patient's eligibility to receive benefits through Medicare. Hospice knows this and I'm pretty sure our patient does too. And so, he is at the mercy of a system which can both help and hinder him.
Our captain is unimpressed with the entire predicament and actually makes a second call to hospice to debate the matter. Inevitably, they will not approve an ER visit and are insistent a nurse is on her way, a line we know isn't true.
Begrudgingly, we have our patient sign a refusal form, double check that he is comfortable in his chair, and bid him farewell...probably for the very last time.
A few hours later, we hear a page for the neighboring private ambulance service to respond to his address for a non-emergent transport to the local rehab center/nursing home. Apparently the hospice nurse has finally showed up and decided his fate. We all briefly share a knowing look and our hearts sink a little bit. We know that he will never go home from there. He will never again feel the warmth of his feisty little dog lying at his feet. And he may never end up being surrounded by his family.

These are the truly tragic calls that I see almost daily. The dead do not bother me. Their suffering is over. It is the tragedy that lies between life and death that tugs at me. I hope that none of my family or friends has to deal with such pain. I don't mean it to sound cruel but if/when the time comes, I hope that it is swift and painless and their last thoughts are how loved they were in their lifetime and that it was full of joy until the very end.