1. Whited, Cynthia M. RN-BC, CCRC


Did Ethel have a premonition about what was going to happen to her that day?


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My new job of starting a clinical research department for a growing cardiology practice was just getting under way. It had been a day of paperwork and calls, and I was still digging out from all the work on my desk when one of the secretaries came to me and said that Dr. Hansen was sending a patient over and would like me to set her up in an exam room until he arrived.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Neil Brennan

I asked for more details, but all she could tell me was that the patient was 83, her name was Ethel (not her real name), and her family would be bringing her soon. "You never know," she said, raising her eyebrows. "It's a Dr. Hansen patient."


Dr. Hansen was a compassionate physician and had many patients who were real characters nobody else would care for or whom he'd been seeing for years-despite exhausting most standard treatments and beyond.


When I heard the door open and Dottie, one of the medical technicians, greeting the patient, I emerged from my office and approached a well-dressed elderly woman in a wheelchair. There were two women and one man with her, all in their mid-to-late 40s. I introduced myself. "Hi there, Ethel. We're going to bring you to the exam room to check your blood pressure and do an ECG."


Though Ethel seemed responsive, the daughter pushing the wheelchair looked concerned. She quietly said to me, "You should know that she's terminal."


This isn't a term usually used in cardiology, so I whispered, "Terminal? What do you mean-does she have cancer?"


"No, aortic stenosis."


I knew that if Dr. Hansen had used that term, it was for real. We brought her into the exam room as the tech took the family into the next room. I noticed that Ethel had slumped in the chair and wasn't responding to my voice. I shook her a bit and loudly said her name, then called for help.


Dottie and a research assistant came in, and as I told them to help me get her onto the exam table, Ethel picked her head up and said, "Oh dear, I keep having these spells."


I was relieved to see that she was still with us, but thought: There's something bad here. She must be barely perfusing her brain.


"It's OK, Ethel," I said, trying to reassure her, "we need to take off your blouse and trousers and get you onto the table now." Dottie and I quickly stood her up, pulled down her pants, and took off the blouse. We paused for a double take at her lovely silk matching bra and briefs-black-and-gold leopard print.


"Wow, Ethel, that's some pretty hot underwear you've got on!" I said. She looked right at me, blinked a few times, and said, "Nice underwear always makes you feel better." And then, "Oh dear, sometimes I have accidents-I'm so sorry!" as some urine slid down her leg to puddle on the floor.


Ethel was getting foggy again as we lowered her onto the table. At my first glance at the ECG I saw a wide QRS with runs of ventricular beats between.


"Forget the BP. Call 911 for an ambulance," I told Dottie. "And call for help." The secretaries called for the emergency response team as I saw that Ethel was becoming unresponsive again, this time with ventricular fibrillation on the ECG, then, surprisingly, some of the wide QRS pattern-an agonal rhythm, close to the end of life.


I gave her a couple of compressions, which made her moan and mumble, "I feel so weak[horizontal ellipsis]" I stopped, remembering her daughter saying she was "terminal." Telling Dottie to stay with her but not to perform CPR, I dashed to the room where her family waited.


Looking at the daughter who'd spoken with me earlier said, "You told me she was terminal. I need to know if you want resuscitative measures done." In unison, her family responded "No!"


"Well, then," I said, "you need to come and be with her because it's happening now." Dottie had covered Ethel cozily with a blanket and put a towel over the puddle. I pushed the ECG machine aside. "She can still hear you," I told them as I closed the door.


As I turned from the door, the adrenaline-filled emergency response team rushed up. I put up my hands. "Sorry, never mind, no resuscitation by the family's request."


A quick conversation about the patient and family helped disperse the team. Then Dr. Hansen finally arrived.


Did Ethel know what was going to happen that day? I think she had a premonition. Never had my assessment skills, cardiac knowledge, and technical, emotional, and spiritual balance been tested so quickly and at the same time. And yes, I think Ethel is right-nice underwear does make you feel better, and I wish I'd known her longer than the 12 minutes or so that she gave me.