Iron and Irony

"I've been practicing CPR since I was was 12 and yet I have never done it on a real person." This was me this morning as I explained to an attending how all I really wanted to do on my ER rotation was CPR and how I was somewhat disappointed, and more than a little surprised, that I had yet to get the opportunity. I joked, "Maybe I'm a good omen, maybe as long as I'm in the hospital, no one is going to die."

Well, dreams do come true, or irony kicked in, because a bit more than one hour later I was wearing a trauma gown hunched over a patient sweating bullets as I pumped hard on his chest.

CPR is not easy. It is surprisingly difficult, exhausting really. You lean over someone (inevitably at the wrong height such that your back starts aching or you have to be on your tippy toes), you lock your elbows, and then you push down as hard as you can. And then you do that again, over and over and over again. Your arms scream out and when you don't stop, they scream out louder. You realize 2 minutes is an awfully long time. And every time your arms start to lighten up, you remember that you are the only thing keeping the patient alive. It is your hands on his chest, your arms pushing down, your body weight compressing his rib cage and simulating the heart beating and the blood flowing such that your colleagues can feel the pulse in his groin or neck. Your arms, your effort are differentiating life from death. And all the while, all you can think of in your head is, "Harder, push harder, push HARDER," and you sync your hands to the tune running through your head: "Ah, ah,ah, ah Staying Alive, Staying Alive." Or "Dom, dom dom, Another one bites the dust," which is equally effective in tempo, but perhaps a bit more macabre in message. (I tried to sing the former, but ended up with the latter stuck in my head.)"

At 37, this man was not your typical massive coronary artery occlusion leading to cardiac arrest patient. He did not make it. I'll break that news right now. When exactly it became clear that he was not going to make is hard to say. Was it when he collapsed? Was it after the hour they spent in the field trying to resuscitate him, performing CPR the entire time? Was it when he arrived to our ED, chest compressions in progress? Was it when he regained a pulse (albeit slow and irregular) and a pressure (low and nerve-wracking) and was being readied for the cath lab but the attendings for the cath lab could not be contacted - was it that delay? Was it when, after that moment of pulse and organized electrical activity, he slipped back into pulseless chaos? Or was it when, at 8:12, after an hour of CPR and resuscitation efforts and with the parents by the bedside, the code was called?

Codes are interesting things. They are rather gruesome events, but also incredibly well orchestrated, calm, and surprisingly easy to participate in. There are usually somewhere between 10 and 15, maybe 20 people involved in a code. Everyone has a job, and every job is focused and compartmentalized. The exception to this is the person running the code and, perhaps, the attending leaning over their shoulder like a good angel, whispering guiding words of wisdom throughout the code. It is the compartmentalization that makes the whole experience manageable. I knew that the only thing I needed to do throughout the code was step up to the patient, perform 2 minutes of good CPR, and then step away from the patient and get back in the CPR line (a steady, pre-selected rotation of 3-5 medical students and medical assistants). Occasionally I would do something like get a syringe or set up the patient for an ECG, but these were just part of my role in the whole effort - a doer, someone who did stuff.

And during the code there was almost this jovial atmosphere. This sense of, "Hey, yes, we are doing a good job. Things are working, it's all going to be ok because everyone is doing what they are supposed to and everyone is doing a good job of it." And the atmosphere is calm and aloof. We are airy in our approach. We are urgent, but only in the race to do our jobs well and defeat death. Not in the race to save the life of the patient. The patient. I don't think anyone knew his name until 30 minutes into the effort. Even after that realization, he remained exposed, face covered by the bag and mask and hands twitching at his sides (when the patient first came in he was making movements with his hands and fists, despite having no pulse). It was the ultimate dehumanizing experience.

And then, it wasn't. His mom and dad entered the room and suddenly all of the humanity that had been stripped away from the patient came flooding back to engulf him like a shroud. Suddenly E. had a name. The mom asked to hold E's hand and E became a young man with a partner and 2 children at home. The father shouted, "E, don't leave, you are needed HERE E, we need you right here," and E became a 37 year old with a troubled past who had spent the last year successfully picking up the pieces of his life. With each sob that was cried, E became a banker, a student, a runner, a food service worker, an alcoholic, a brother, a lawyer, a vagrant, an abused child, a husband, a father, a son. Each tear shed was a story; each plea to stay was a relationship. And with E's sudden humanity, the train that was our resuscitation effort derailed. We increased our efforts, put on a better show, but our hearts were heavy with the reality that when we stopped CPR, which we knew we would, it would be to pronounce this human, this person, dead.

And a heartwrenching moment, a reminder to watch your mouth:
The code leader says, "Well, we will continue CPR until the priest arrives."
The father said: "What you meant to say was until our son wakes up."

Death Bear

I really like this story.

I think this is similar to one of the duties those of us in healthcare professions are lucky enough to have. We are semi-anonymous professionals in front of whom individuals bare all. We are rarely members of the same community as our patients and, as such, we are, essentially, blank. I've talked about this before - this blank slate concept - but this is a new and beautiful incarnation of the idea. In truth, almost anyone who has ever been in the service industry has, at some point, been a Death Bear to someone else. By listening to, absorbing, or even just witnessing a stranger's pain without judging it or engaging with it they are able to help that person start the healing process.

Minimize

The ER is unlike any other place in the hospital. Tragedy, disaster, shock, pain, agony, fear linger unchecked around each patient bed. There is little room for comfort, reassurance, paced improvement, or doctor-patient relationships. Those can be found on the upper floors. The ER is not a place for healing, but rather for the stabilization and "packaging" of patients before they go to other places in the hospital. As such, the arc of illness is rarely completed in the ED. For sure, more people are discharged from the ED than admitted, but those people were rarely very sick to begin with. And, without a doubt, lives are saved every day in the ED, but saving a life is very different from healing one.

Because of this, and because emergent situations are best dealt with using algorithms, it is easy to dehumanize patients in the ER. Not only is it easy, it is expected and, to some extent, necessary. If you know that no matter what a patient looks like, where they come from, or what their name is you are, first and foremost, going to evaluate their ABC's (airway, breathing, circulation), the larger picture of who they are becomes less important. For certain you want to hear the story of their main complaint - their signs and symptoms - and a few important details about their social situation - where do they live, do they drink alcohol or use IV drugs, do they have anyone to take care of them when they leave here. This information, however, is not used to build relationships, but rather to determine the diagnosis of the patient and expedite the discharge. Doctors are often criticized for minimizing the patient and maximizing the disease, but in the ER, this actually makes sense. Here we are taught to sort sick from not sick. Names make less sense, so you remember patients by their diseases.

This dehumanizing runs counter to most of what I am drawn to in medicine. But I also find something very appealing, and almost comforting about it. The ER is, to some extent, the most socialist, egalitarian place in our country. Without a doubt, the people who see the ED as a place for primary care and urgent care needs come from a certain underinsured, underserved demographic, but they aren't the only people who come to the HX ED. Trauma knows now boundaries and as the major trauma center for the state and several surrounding states as well as a world-reknowned orthopedic and burn center, people from all extremes of society pass through HX ED. And everyone gets care. As they pass through the ED doors, they (more or less) become their condition, and they receive whatever care their condition asks for. In determining what a condition calls for, no one asks, "what is the patient's insurance," and that is a beautiful thing.

That said, the flip side of not asking "what is their insurance," is that no one is asking, "is this test really necessary." Actually, that's not entirely true. Everyone asks that question, but everyone follows it up with, "It's very low yield, but we might as well do it to rule X out," or "It's not necessary, but it is standard of care, so. . ." Clinical judgement is a dying art and we, as medical professionals, need to revive it if health care reform is going to stick.