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Emergentology

Sometimes Patients Die, Sometimes Doctors Can't Save Them

Walker, Graham MD

doi: 10.1097/01.EEM.0000581472.19375.b3
Emergentology

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Do you remember the first time you did CPR?

I was a medical student. I remember going too fast and the attending telling me to slow down. I remember pushing with my elbows and learning to bend at the hips. I remember holding compressions, ready to resume on command.

But I remember most of all how much I wanted it to work. I remember looking down at his flaccid, cyanotic, 26-year-old face and trying to conjure something inside me, wanting to pass some of my life through my hands into his body.

I envisioned movie magic and special effects: Time slows down, and a bluish-green wispy glow of particles slowly pours down my arms into his chest. I'm momentarily weakened by it but still strong; it's just enough to bring him back and make his heart beat again.

There's no need for epinephrine. Or defibrillators. Just the Lazarus powers inside of me, wanting—needing—them to work. Needing so badly for this life to return that I think I can somehow make it so. Then there's the next movie moment, where we see the monitor start to blip rhythmically and realize we saved him. My attending yells, “Hold compressions!” We hear gasps, then cheers. Something magical has just taken place. And I'm the only one who knows it.

Then I snapped out of it.

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Gone Too Soon

Back in the real world in 2007, we continued CPR. Round after round. Epi after epi. Asystole after asystole. We switched out chest compressors as everyone grew tired, but no one was ready to stop. Hope faltered and faded. You could feel the mood in the room starting to change; people were in a rhythm, but after 30 minutes people started looking at each other silently, wondering, “When do we stop? How long do we go?” No one dared speak these words aloud. It would make them true.

My attending decided we should needle decompress both chest walls for tension pneumothorax because it was his final stab in the dark. The senior resident inserted one 16 g IV, then another. Everyone desperately hoped for a whoosh of air that would reignite our hope, but there was none. We stopped 30 seconds later, and checked for a pulse one last time. But there was none. The last ray of hope faded, replaced immediately by sadness. Emotion finally filled our bodies, whiplashing us from medical algorithm to the overwhelming loss of human life. The attending muttered, his voice cracking, “Time of death, 12:18 p.m.”

We wiped the sweat from our bodies. Our breathing slowed. We covered his body with a sheet, and allowed his family in. Cries and tears reverberated through the room. We bowed our heads, eyes filled with tears of our own, and walked out in silence. Shame, regret, and doubt intruded our minds for days and weeks afterward, wondering if we could have or should have done something differently, something more, something first, something last.

Twelve years later, I think I remember the details of this case: the timing, the location, what happened, who was there, what the young man looked like. I'm sure he was 26. Or was it 27? He was certainly young. Too young. That I remember. My age. He was skinny. My build. I'm pretty sure it was a he. I know he could have been me.

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An Epicenter of Sadness

My memory questions many of those details, but it is piercingly clear about others. I know I remember the screams, the cries, the sounds of that day. They were guttural. Animalistic. Limbic, even. They were angry, sad, remorseful, confused, lost, longing, and questioning in one terrifying, anguished sound. Somehow these sounds were a high-pitched screech, but at the same time, they were deep and low. Like the siren song, these sounds of loss trigger something in anyone who heard them, sealing them firmly into memory for eternity. Everyone in the ED knows this sound, and we can all easily recall the last time we heard it—and probably the first time as well.

Gone too soon. Gone unexpectedly. Gone unfairly. We exist in a world where there's crime and punishment, where there's some semblance of equality and fairness. You work hard? You're supposed to be rewarded. You treat others with kindness? Kindness will be returned to you. You exercise and eat right? You'll live a long, healthy life.

But the universe doesn't work that way. We humans try to make sense of it, wrap our brains around it, process it, understand it. But we can't. In the same way we try to digest large numbers that our brains can't really understand (a billion seconds is nearly 32 years), we come up with rationalizations just as ridiculous: “It was his time.” “He's in a better place now.” “God doesn't give us more than we can handle.”

In the end, all we're left with is an epicenter of sadness and grief that echoes and reverberates through everyone it touches, with aftershocks lasting for days, weeks, years, or lifetimes.

That was the first time I did CPR.

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Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.

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