“There were a lot of poor prognostic features from the start: unknown down time, no initial bystander CPR, initial rhythm was a PEA, 10 rounds of epi in the field.”
I stood there during the debrief from the code, feet away from a warm, lifeless body, reckoning with the first time I’d watched someone die.
Or did I? Was she dead when she came in? When someone else’s hands are responsible for the push and pull of a breath and someone else’s arms are responsible for the perfusion of a mind, the only moments we have to define that elusive term “alive” are a q2 minute pulse check.
“No pulse. Resume compressions.”
I wanted to be involved in the code but had initially been preoccupied with staying out of the way of those who knew what they were doing. When I finally inserted myself in the line of people ready to do compressions, reminding myself of the principles of high-quality CPR, I tried not to think about that episode from The Office.
Finally, we finish the first round of CPR. The tech steps down. Someone calls for a pulse check.
“No pulse. Check the rhythm!”
I wait for someone to tell me to start compressions. Nobody does. A nurse jumps up in front of me and resumes CPR. I missed my chance; I hesitated.
I wait patiently for another q2 minute opportunity in hopes that I can feel useful, so that I can say I’ve done compressions on a real person. “I’m behind you for the next round of compressions,” I squeak out. This is my time to shine, a chance to really prove I can contribute.
Good gosh, is my ego this fragile?
Suddenly, I’m above the patient’s bare chest, fingers interlaced, arms straight, bending at the hips. The weight of my torso plus a branded Patagonia lands on her bare chest at approximately 100 bpm. The occasional “Staying Alive” flits through my head. The stethoscope around my neck swings wildly.
Note to self: take that off next time.
Her emaciated chest feels so soft with each recoil. I can barely feel a solid sternum. I wonder if they already broke all her ribs. I wonder if it matters.
“Remember to breathe. We don’t want a second body on the ground,” my attending calls out to me from the side of the bed.
Without missing a literal beat, I respond, “Thanks. Just let me know if I can do the compressions any better.” I say a full sentence to prove I’m not out of breath, to prove that I’m not weak. We exchange a smile.
One of the techs had been politely reprimanded by the computerized compression monitor to “push harder.” But no such robotic chastisement has been uttered to me. “Staying Alive” plays through my head again. I can do this.
My Fitbit buzzes.
I’ve reached my activity goal for the day. A human body in cardiac arrest teeters on the precipice of death beneath my fingers, as this device on my wrist applauds my cardio for the day. I feel both exasperation at the device and embarrassment at the fact that I’m wearing it.
Note to self: take that off next time.
“Pulse check in 30 seconds.” My attending looks at me, directing me to act. I nod.
Wait, where exactly are the femoral pulses? Aren’t they near the aortoiliacs or something like that? I think I felt them on a baby in the newborn nursery once. Note to MS1 self: pay better attention in anatomy.
“Pulse check!” The attending shouts. Once again, it is my moment.
I feel for the pulse. I feel nothing; I say nothing. I move my hand and continue to search. I feel something small. Is that my own pulse?
“I got a pulse,” the tech on the other side yells.
Still nothing for me.
“I don’t feel anything,” the nurse on the brachial pulse says. I step back and give a look to another nurse, signaling a deferential request for help. He steps in and feels for the femoral artery. “Me neither,” he says. I feel validated.
Validated that this patient doesn’t have a pulse? Is my ego so fragile that I would rather this patient remain lifeless than look wrong?
“No pulse. Resume compressions.”
The nurse graciously shows me how to find the pulse as compressions continue. He marks it with a Sharpie. You know, for a university with a writing instrument in its name, those things really are tough to come by around here.
“No pulse. Resume compressions,” I state. Did those words really just come out of my mouth? I say it confidently. I know exactly where to feel for the pulse, as of a few seconds ago.
So, is this how teaching hospitals work?
Ok, not the time to think about that. Shouldn’t I be thinking about the H’s and T’s or something?
My mind wavers, unable to remember the mnemonic in the chaos, and defers responsibility to my resident running the code. I take solace in absolving myself of the responsibility, and in placing it in the hands of a PGY2 running only her second code. Surely, she doesn’t feel the turmoil and foibles I do.
“No pulse. Resume compressions,” the resident calls out.
We begin to have conversations about “calling it.” Is that just a euphemism for “letting someone die?” If there’s a smidgeon of a chance this woman makes it, shouldn’t we be willing to go for hours?
“There were a lot of poor prognostic features from the start. One more round, and then we’ll call it,” my attending tells the room.
So, this is going to be it. We’re just going to stop. We’re going to let her die so that we can go click through billing codes.
No, we’re going to admit that she’s dead, that she’s been dead, and that all my studying and training don’t make me a miracle worker. We are still finite. And sometimes being a healthcare worker means a front row seat to the realities of brokenness in this fallen world and requires that I call it what it is. “Call it”, there’s that phrase again.
“No pulse. No compressions.”
I call the final pulse check; time of death announced, a moment of silence.
For the first time, I feel emotion rise up within me. Tears well up just behind my Stoggles, far too small to be distinguished from my sweat. To this point, I had not felt. I had done. And I had done well.
There’s that ego again.
The moment of silence ends and I push the tears back down. They won’t come back up until we tell the daughter and son that their mother has died. They won’t come back up until I see the daughter fling herself into the corner of a consultation room, with a sound that can only be described as “wailing.” They won’t come back up until I extend distanced professional sympathy to this woman in acute grief. They won’t come back up until I imagine if this were my mother.
I cry.
The chaplain takes over. She seems collected; she’s done this before. I remember back to the article we read in Doctoring, “How to tell a mother her child is dead.” I remember I was supposed to sit, not stand. I did, thank goodness. Did I do the rest of it?
I walk back. The psychiatry intern goes and grabs ginger ales so the team can catch our breaths before the debrief. It was her first-time doing compressions too, and I’m thankful for her.
“Did you see the goiter on her? If not, you should go back and feel it – it’s massive,” my attending tells me. She’s providing a learning opportunity for me, but it feels a bit detached.
Following her instructions, I re-enter the room. For the first time, I notice the patient’s hair, her eyelashes. Did she have a nose ring this whole time? I see the prominent goiter and poke it tentatively.
What am I afraid of, that she’s going to suddenly jump up and grab me? It will take a long time for Hollywood to leave my ACLS framework.
“Great compressions by the way,” a burly nurse says in passing.
I beam with pride. This was my moment, a chance for me to prove my quality. And apparently I did, but to what end?
I walk past her lifeless body and return to my workstation. I breathe. I’m not sure if I’ve been tachypneic or apneic this whole time, but for the first time I notice my own breath.
I look in my patient encounter list to document the last hour so that Penn can remain accredited.
I look for “providing CPR in a code.” Not on the list of required encounters.
“Feeling a goiter.” Not on the list.
“Thinking about the fragile boundaries of life and death.” Not on the list.
“Crying behind an N95 and Stoggles.” Not on the list.
“Femoral pulse check.” Not on the list.
“Noticing eyelashes.” Not on the list.
“Wrestling with the subjectivity of ROSC.” Not on the list.
“Awareness of the fragile ego of a student.” Not on the list.
“Closed loop communication.” Not on the list.
“Reflection on the role of trainees in emergencies.” Not on the list.
“A cold ginger ale during a hot debrief.” Not on the list.
“Staying alive.” Not on the list.
We suspected hyperkalemia-induced arrhythmia, so I log the encounter as “Renal/Electrolyte-Fluid/Electrolyte Abnormality,” one of my final clerkship requirements. And in doing so, I reduce the moments I held someone’s final heartbeats between my outstretched, locked arms to an accreditation checkbox.
My Fitbit buzzes. It’s a pulse notification.
Chip Chambers is an MS3 at the Perelman School of Medicine.
Art by Montita Sowapark, an MS1 at the Perelman School of Medicine.
