The Dying of the Light

Dylan Thomas penned the often-quoted lines “Do not go gentle into that good night…Rage, rage against the dying of the light.” As a Registered Nurse I often participated in the rage that was the battle between life and death, and let there be no doubt, Cardio-pulmonary Resuscitation is a brutal battle that, like most battles, occasionally blurs the line between winners and losers. I have broken the brittle ribs of a barrel-chested emphysema patient, a common and not unforeseen by-product of CPR in that population. I have assaulted the frail body of an elderly lady even though she begged to be allowed to die in peace--because her family wanted everything possible done to “save” her. Both died, the most common outcome of CPR in adults in my day. But nothing quite spoke to me as much as a case early in my career:

I remember the stifling Louisiana summer heat that seemed to press in on the squat, sturdily built Rhodes J. Spedale Hospital as I arrived for my evening shift as Nursing Supervisor that day. Thanks to the ninety percent humidity, my sweat did not evaporate until I got to my office on the second floor. The 1980’s afforded me (due to a nurse shortage), the opportunity of working weekends and getting paid for a full week’s work. Thought I had hit the jackpot until I came to discover that the sleepy little Iberville Parish health care center was a major hub for weekend bar stabbings and shootings from the surrounding small Cajun towns of Plaquemine, White Castle, and Donaldsonville, as well as some horrific auto accidents from the two-lane highways that skirted along the Mississippi River levee and snaked between large sugar cane fields. Since we only had one Emergency Room nurse, I was often pulled off my supervisory duties to pitch in with the incoming.

The usual order of business for the hospital wards was to care for the terminal ill or elderly patients in the area who either could not afford the more expensive hospitals in nearby Baton Rouge or simply wanted to remain close to home and loved ones as they died. And oddly, though R. J. no longer offered obstetric services, it was the hospital where I was born 28 years earlier. My mother walked to the hospital from a block down where her mother lived, where she grew up, and where the Mississippi River roared past on the other side of the levee. Yep, full-blooded Cajuns, so there was a bit of nostalgia attached to my accepting a position there. Not that I was a patient there ever again, for my father moved us all to Baton Rouge while he worked on a math and education degree at LSU. And my mother whisked her mom and dad to the Baton Rouge hospitals if they needed care. You see, there was little confidence in the care received at the R. J. The death statistics were rather high, but what would you expect since the institution was the end of the road for nursing homes in the parish and the place where many came to breathe their lasts?

By the time I began my tenure, top notch nurses had been seduced from Baton Rouge hospitals. I was offered and given a small car to make the trip from my home in Baton Rouge to the bayou town and hospital. New owners with larger purse strings were anxious to change local attitudes about the only health care facility for 35 miles. And I was proud of our small-town hospital Emergency Room though we could not offer multiple specialty or neurosurgery. We did take red blanket cases to the Operating Room with great success to pump in much needed blood and remove bothersome bullets.

I had just finished my supervisor rounds that day when I got a page to come to the ER. There were a few lingering day cases—a lanced underarm boil, a young screaming boy awaiting stitches—when the call came through the police radio that a family was bringing in a man who had been struck by lightning. Seems Iberville parish was experiencing one of Louisiana’s pop-up thunderstorms which occur many July afternoons. The rapidly forming system was sweeping through White Castle when the victim decided he had enough time before the deluge to finish mowing his lawn. Apparently, his wife was still haranguing him when lightning electrified the skies and a bolt crashed down upon him striking him in the back of his head. The family was bringing him in via the family car. They realized that our ambulance was too far away to get him there any sooner.

Our ER staff sprang into action, readying IV solutions, the CPR crash cart, and calling in respiratory therapy and our on-call doctor. We moved the necessary equipment and gurney outside to the receiving bay and stood at ready, paladins of the medical arts…or so we liked to believe.

The ferocity of the storm had died down to a strong wind, the last dregs of the dark sky slouching across the horizon, lightning slashing above the Mississippi River. Steam rose from the over-heated pavement in front of the covered bay like ghostly spirits wafting toward Heaven. Soon we heard the screams of the police escort that always ramped up my adrenaline a few notches. The group of us focused on the empty streets, watching for the tell-tale flashing lights.

The police cruiser pulled in ahead of a blue/gray station wagon splotched with rust in places like bleeding sores. The whole auto seemed to drunkenly list to the passenger side where, windows down, an assortment of arms like extra appendages in some malformed beetle, extruded and waved. Frenetic activity could be seen through the back windows as CPR was administered to the loved one by friends or family—the assembly resembling a huge misplaced piston. The engine had a distinct wheeze like a patient with agonal breathing and belched out noxious fumes that quickly became trapped under the bay. I momentarily lost my focus and thought that perhaps the automobile should be declared DOA (dead on arrival).

But that passed as the back door was flung open and manly family members began to drag their half-naked patriarch out by his legs. Our emergency techs along with the police officer took over and transferred the patient to the gurney. One jumped up on the moving stretcher, straddling the nonresponsive man and began chest compressions while the respiratory therapist used an ambu-bag (a bellows-type breathing apparatus) to deliver much needed respirations. Even as the gurney raced toward the entrance to the hospital, I began to prep one arm for a large bore IV as the regular ER nurse did the same to his other arm. I also had the difficult task of directing weeping family members to a waiting room across from admissions.

As we rolled the gurney to a cubicle in the ER, we had both “lifelines” (IV’s) running and I began my assessment for later charting. The middle-aged man was about 200 pounds and heavy in the chest making chest compressions more difficult than someone with a less-muscled frame. No independent pulse, no respirations, pupils fixed and dilated (a grave sign). He had blood coming from his groin where (I was told) the lightning exited his body for the more conductive metal handlebars of the lawnmower. All in all, he was clinically dead.

But the team was all in…and like a well-oiled machine we continued chest compressions, inserted an endotracheal tube into his airway to facilitate more efficient breathing, and administered life-saving medications to combat systemic failure. Every several minutes we performed that tag-team exchange that replaced the person delivering the difficult chest compressions with a fresh set of muscles. It also gave us the opportunity to look at the monitors for a few moments to see if there were any spontaneous heartbeats or respirations. Each time—nothing, though we watched in anticipation like an old lady at a slot machine in Las Vegas. I don’t know what kept us going except a steady supply of adrenaline and that need to win/succeed.

X-rays, arterial blood gases, epinephrine, more medications…for a full 35 minutes we fought against our nemesis, death. We were all sweating profusely when we made that last exchange and heard an unrhythmic “beep” from the monitor. All got profoundly quiet and eyes were leveled at the heart monitor. A few unsteady blips and then the EKG tracing was apparent. The respiratory therapist stopped delivering breaths long enough for the once moribund patient to take a shallow breath. After a few tense minutes of evaluating the patient’s stability, we took a collective deep breath and began to realize our accomplishment and revel in success.

We cleaned our patient and readied him for transfer to the better equipped ICU at Baton Rouge General Hospital. I finally spoke with the family and they were relieved, elated, shocked, grateful…and spoke of the long drive, the difficulty performing CPR in the close confines of the station wagon and losing hope. I began to think of the implications and the fact that the man’s pupils remained fixed and dilated.

My fears were realized when I heard from the receiving hospital, Baton Rouge General, that our patient may have had a beating heart, but his brain was dead on arrival and he had a flat brain tracing for 5 successive EEG’s (a measure of brain activity). Such was our “miraculous” save on that day. BR General allowed the man to die surrounded by his family and friends. Peaceful at last, though in reality he was dead when the lightning struck him.

*****

I suppose we took comfort in the fact that we did what we felt was right and went to the ropes for this victim of mother nature’s wrath. But why did we press on when so many others would have arrested the process much sooner and declared the patient’s time of death? Why didn’t we stop to think of the outcome rather than the battle? Take into consideration how long his brain had been without Oxygen? Was it our hubris? Our belief in “life must always prevail”?

I have not whole-heartedly embraced Dylan Thomas’ assertion to “Rage against the dying of the light” for many years, especially when my parents were dying. At 82 years old each, they both died peacefully with loving family around them. No heroics. No CPR. Are there times for extreme medical intervention? Of course. But there are also times of simply letting go. I feel that going gently into that good night might be the best many of us could hope for and a grace from God that I, for one, sincerely pray for.