Guest Post - I Can Still Hear the Crying

Still have a lot on my plate at the moment, so this is here courtesy of Will (@bungeechump on Twitter). Having not long seen my first in hospital death, this was something that was something that I could really relate to. It's a well written piece and something that I wanted to share.

As graduation races towards me, the knowledge that I will be a "real doctor" in a few short months has made me pause for reflection on my time in medical school. Death is something that medical students are expected to deal with easily. Often this isn't the case. They say you never forget your first cardiac arrest as a medical student, but in practice I found this not to be true – I will never forget my second.

The first cardiac arrest I participated in was fairly uneventful and as morbid as it sounds, unremarkable. An eighty-two year old gentleman who has suffered an out of hospital unwitnessed VF cardiac arrest. He was not a well man to start with, his swollen legs indicative of heart failure and the mere fact that he was over eighty put him at a disadvantage. I stood in the resuscitation bay with one of the SHOs and the registrar. The ambulance was about five minutes out. I noticed the two doctors were wearing gloves and had donned aprons so I followed suit. I knew that statistically the chances of surviving to discharge following an unwitnessed out of hospital cardiac arrest were less than five percent, so I wasn’t expecting miracles. I wasn’t sure what to expect.

A slam on the double doors and in rolls the patient, the paramedics pushing and a nurse pumping on his chest as they wheeled him into the bay. He was already intubated and had good IV access, so that was one less concern. I took over the chest compressions. The sensation of ribs cracking beneath your hands and vibrating up into your shoulders is horrible. It sounds like somebody breaking a large wooden branch in the next room. After each crack, the chest becomes easier to compress until eventually it is soft like an old chain link fence.

The defibrillator was attached. A familiar broad complex, irregular waveform tachycardia emerged – ventricular fibrillation. Stand clear, oxygen away, shocking! The man’s entire body tenses up, his arms come up in the air – but then instantly flop back down as the electricity subsides. Continue chest compressions. This cycle continued for about ten minutes with adrenaline injections interspersed. The man’s Grandson arrived and said an emotional goodbye and we stopped resuscitation. I calmly left the room and went back to trying to insert a cannula into a little old ladies forearm.

I was remarkably unbothered by what had just happened. I was suddenly dubious of what they say about your first arrest and how it always sticks in your mind. That was until my second arrest, several days later.

The man had walked into the department. He was a hospital porter and felt unwell and so had wandered down to A&E. He was in his mid-fourties. He looked awful and was complaining of a several day history of headache, breathlessness and general malaise. It was quickly decided that this guy was far too sick to just be sat in majors, and he was transferred to resus.

His level of consciousness was falling and he became unresponsive. His respiratory rate shot up and he was gasping for air. This patient was very unwell, and the anaesthetist was paged so we could get a definitive airway. All of a sudden, he doesn’t have a pulse. Chest compressions begin, and the anaesthetist is here – but the intubation is proving difficult. His oxygen saturations are falling and all the machines are beeping. Finally the tube is in, and compressions can resume.

His chest was very hairy - far too hairy to get a good contact for the defibrillator pads. One of the nurses scurried off to find a razor while somebody else had the bright idea to try and wax his chest with one of the sticky defib pads. This didn’t work. The razor turned up and the pads were on with good contact. The heart trace showed sinus rhythm. Oh shit. Pulseless electrical activity – a bad thing to have if there is no obvious reversible cause, because it is an unshockable rhythm and you just have to keep pushing adrenaline and hoping for the best.

Time flashes by and we still don’t know what has caused the arrest. The most likely culprit was a massive heart attack, or a pulmonary embolus. However we can’t give clot busting drugs because of his history of a headache – if he has a subarachnoid haemorrhage the thrombolytics will turn his brain to mush, but his pupils can’t be assessed because he has had so much adrenaline and atropine so it’s impossible to rule anything out and therefore impossible to really treat anything. Vigorous CPR was attempted to try and bust up a clot mechanically if one was present (cue more ribs cracking, and my arms aching the next day).

This all happened at the weekend, so none of his relatives were in work and they all turned up rapidly until there was a gang of about eight of them in the resuscitation bay within twenty minutes. His wife and sister are holding his hand, sobbing into each other’s embrace, calling out to him and asking him to wake up. His son turns up and stands next to his head, intubated with eyes wide open and staring, flopping around lifelessly as we jump up and down on his chest, telling him to pull through so they can go to the match next week together. His elderly Father stands at the foot of the bed. He fights back the tears, occasionally slapping his son of the legs and telling him to ‘pull through’ and stop messing around.

A pause in the CPR and suddenly a familiar rhythm emerges on the screen. Pulseless ventricular tachycardia. One of the nurses pulls the family off him, and a shock is given. His wife nearly falls to the floor watching her husband convulse off the bed as 120J of electricity pass through his lifeless body. They huddle back round him. I am taking turns doing the chest compressions with one of the nurses, in short cycles so we don’t get tired and therefore not push hard enough. The A&E consultant is talking quietly to the anaesthetist at the head of the bed. CPR has been on-going for 45 minutes and there was been no real improvement. A pause in chest compressions to check the monitor reveals a very irregular agonal rhythm.

The consultant turns to the family and introduces himself. He tells them what we are all doing to try and save their beloved. He tells them we have done all we can but he’s not showing any sign of improvement. He tells them he doesn’t expect the patient to recover. His wife pleads with him, please, just keep going for a little bit longer, he’ll pull through - I know he will.

We all know he won’t pull through. We all know that he has been receiving CPR for so long that all the centres of his brain that make him the person his relatives know and love, are dead. Even if he did get back to sinus rhythm, he would be a vegetable and would end up in intensive care (also known as the cabbage patch) for several years, just waiting for the pneumonia that will kill him.

The consultant looks round at all of us involved in the resuscitation attempt. Then he turns back to the family. I’m sorry, there’s nothing more we can do, we have to stop. The monitors are turned off, the oxygen is disconnected and chest compressions cease. We all take a step back, the sound of multiple pairs of gloves snapping off spells defeat.

His family rush towards him and hold him, all of them sobbing. All we can do is stand and watch. I slip out the side of the room and walk back towards the main area of the department. I walk past an angry young woman shouting at one of the nurses about how she’s been waiting for four hours, and I feel angry. If only she had a clue as to why she’d been waiting for so long, I’d bet she’d go and sit down and shut right up.

I can still hear the crying in the background. I sit down in one of the cubicles and gather my thoughts. Now this was an arrest that I will never forget.