Wherein I’m A Robot
They don’t call it the Emergency Department for nothing.
I’m sitting there, talking with a 40 year-old woman complaining of lower back pain who had a kidney transplant, and then she adjusts herself to try to get comfortable, and shakes a couple times. She starts gasping for air; she is unresponsive to my questions. I immediately call for help, and a nurse comes in. Neither of us can get her to respond, and her eyes are glazed over. The nurse goes to get the attending, who comes in. We’re having trouble getting a good O2 sat on her (that gives us a rough idea of the oxygen in her blood), and once we do, we realize she needs to be intubated to help her breathe. We intubate, and then have to start CPR; she now has no pulse. Her blood pressure is dropping. We code her for 11 minutes. Her pulse comes back, and she’s maxed on the medications for blood pressure support. Her heart on ultrasound is pumping, but barely.
I have my hand on her femoral artery. We lose her pulse again. We code her for 24 more minutes, and eventually the family decides to do comfort care and have some time alone with her. We lose.
I could go into all my analysis of how my resident did a great job and set a good example of following the basics–Airway, Breathing, and Circulation. But something scares me more than not knowing exactly what to do when this happens next time.
What’s really bothering me is how okay with it I feel. That we spent 2 hours trying to bring someone back to life, that she crashed right in front of me–basically died right in front of me–and I was totally okay with that. That 5 minutes after it was over, after I finished writing up what happened, I just went about my business and picked up the next chart. I moved right on.
I keep waiting for some delayed grief reaction or something, like I’m going to be just walking down the street and suddenly feel really sad or something, but it’s not happening. I mean, this person I just met died, but I’m not all that upset about it. Maybe I just didn’t know her long enough to need to grieve about her. Maybe I somehow knew that after the first code, things weren’t looking good, and I didn’t have much hope when the second one began. Maybe this makes me a great, objective, detatched doctor. Maybe this makes me a terrible, distant, detatched human. I don’t know.
I’m hoping that either my over-analysis of this event over the past week is my grief reaction, or that whatever part of me I think I’m currently missing can come back, because it seems pretty damn ironic if I’ve somehow lost my compassion and empathy during the practice of medicine. Never saw this one coming.
That’s one of the things they kept telling us during the first weeks of education: “Studies shows that med students on the first year often have the same or higher level of empathy compared to other people, but during the five years of education something happens and the level of empathy decreases to lower than average.” I believe what’s happening isn’t very strange. Firstly, the education is mostly about patients as objects, being barely more than the host of the diseases and processes we study. Secondly you _need_ a kind of objectiveness/distance to be able to work professionally, as well as to cope with the day. Still it’s scaring, and I guess the best way to keep it on the left side of the equation “great doctor/terrible human” is to keep discussing it and reflecting over it.
//Par, just finishing first year of med school in Sweden
Another note. The “Take action” link on /sp/whatissinglepayer.php seem to be broken.
Sorry, man.
You’ve met the enemy. That’s why we go into medicine, some of us anyway- to battle against him.
If you decide to go through with it and become a pedie you’ll see it a whole less often.
BTW, I’m sure you won’t be disappointed if your E.D. rotation reverts to the norm there, 84% non-emergent complaints.
best,
Flea
Well, there could be some shock there, or you might be getting desensitized. You might also have learned to “stuff” the reaction in a manner that may or may not be viable long-term. Or you may just be mature/experienced enough to realize that this was something you really couldn’t have prevented…
No shame in not feeling grief, Graham. People die, unfortunately regardless of what we do. I don’t grieve when my patients that I’ve known for 2 seconds die. Sometimes I feel sad that we couldn’t help, and sometimes, depending on the situation, I’m glad that we couldn’t help, and the patient is no longer suffering. Obviously it’s harder to swallow in a young person, but don’t be ashamed. Do your job, show empathy for the patient and family while you are with them and go on. We grieve only what we love and know. We feel a pang of regret for the others and move on to the next. I often get accused of being a “hand-holder” in these situations, but the way you carry yourself at or near the time of death can mean so much to the families of the patients. Good luck, and welcome to the “Dark Side” as I lovingly call the ER. Hopefully you’ll love it as much as I do. Steve
I’m a critical care nurse and a member of the code team, so unfortunately I’ve seen a lot of people die in my hospital. It’s always sad and it’s always tragic, but a lot of the time you do really dissociate from the horror of somebody dying in front of you and just see it as a job to be done, a body to bag and push drugs into and squeeze their chest and feel for pulses and look hopefully at a monitor for.
Occasionally you do have a patient, even if you just met them or you’ve been caring for them for days, whose death drops the bottom out of your world. It doesn’t happen every time, but occasionally I need to leave the unit and have a good cry downstairs when we can’t get someone back.
Call me weird, but I’d be okay with that too. It’s probably because, yeah, you didn’t know her well enough to grieve. And yeah, you somehow knew that things weren’t looking good for her too. As long as you did your best by her, and you evidently did, then it’s alright.
It’s ok…….consider it destiny…..the part you were meant to play in this case was very little……in that part….you did the best you could…..you could not have done more…it was her destiny to leave us at that moment….and we cannot change that.
Graham, Thank you for remaining human. I believe that in your education to become a physician it is simultaneously the most difficult and most important thing you can do. It is a shock to go through an event like that and not allow yourself your grief. You have an important job to do, and you must carry on in the face of pain and death. We need people who can face “The Enemy” as Flea said, and do battle. And in that battle many lose some of the connection to those they’re fighting for, because if they let themselves feel it all, it would be overwhelming, and the job would be left undone.
It is clear that even though you didn’t give yourself the chance to grieve right away, you have dealt with the event, the emotions, the life that was lost, and you’re holding on to your connection, even if you had to postpone its expression. Please keep that connection, it’s the best tool you have as a physician who truely wants to make things better for those he serves, and if you feel yourself losing it, take a break, give yourself some space, change something so that you can regain and maintain it. We can’t let our human connection be a casualty in the war.
Salud,
~losrivas
After thirty years of codes and their sequelae, I have to ask – to whom did you lose? Is this a win/lose situation? Or is it our job to provide the best chance for a meaningful life to those who come to us? And having done so, whether the patient survives or not, should it be considered a win/loss situation? We “win” when we have provided assistance to the maximum of our ability, regardless of the outcome. We have fulfilled our purpose. We “lose” when we brush off the need for assistance, whether it is a resuscitation or the holding of a hand while the patient dies without extreme measures. So – what is your true definition of winning and losing in this profession?
Graham,
I agree with several of the other comments about this situation. I think one of the most important thing that medical students, interns, and residents can learn is that when you are dealing with a situation that seems hopeless, you do your best in treating the patient and accept the end result with empathy but not necessarily grief. It is appropriate to grieve then one loses a close friend, a relative, or a patient that you have been treating for a long while but not every death that occurs in the ER. The other fact that young physicians need to learn is when to give in to the inevitable. The second attempt at resuscitation, that lasted 24 minutes, probably should not have been attempted.
Your case reminds me of a situation my wife and the chief of surgery at OHSU, faced a number of years ago. My wife was an associate professor of anesthesiology and was called to the ER along with the chief of surgery. The case was similar to yours, i.e. a patient brought in to the ER in extremus. The residents were trying to resuscitate the patient, and were willing to go on for hours. After maybe 15 minutes of CPR, with minimal response, my wife and the surgeon said that it was over but the surgeon said they should allow the residents to continue for a few more minutes, to gain experience, but then both of them intervened and told the residents to stop because it was hopeless.
Don’t scold yourself for not feeling grief, in this situation,because as has been noted in other comments, if you really grieve for every patient whose death you witness, you are going to have your own emotional problems. Be sympathetic when dealing with the family of such a patient, but realize that these things happen in spite of the best efforts we can make.
It sounds as if she had a massive PE and in most cases resuscitation fails.
I’ve been at many neonatal resuscitations. Most succeed, some, blessedly, do not. Death is not the enemy. Death is inevitable and grief at each death is not necessary to remain fully human. What is necessary is to do your best to give appropriate care – and that includes knowing when to stop in a resus. It is also necessary to be empathetic to the families, whether the patient succumbs or moves on to the ICU for further treatment. It sounds to me as if you are on your way to accomplishing those things.
So I’m quiet Intimidated by all the “MD titles” above… but my 2 cents is this – doctors are all amazing and you do amazing things. If you got emotionally attached to every suffering person you saw you wouldn’t be able to do your job! That’s why we pay you to do all the stuff you do, because the people who love us most couldn’t do what you do (‘specially ER) You picked your job because you love humanity – that’s better then most. Most of us love only the select few that love us back.