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."