Editor’s letter 2015 No. 13

[box] Our Editor-in-Chief recounts a recent clinical and emotional experience [/box]

me sqI’ve been trying to write this article for a while now, not because I’ve been busy (I have), nor because I’ve been lazy (I definitely have) but because I wanted to do the experience justice when I finally found the right words for it. So often an agent of whimsy, I sometimes struggle to convey trauma, real life, real pain.

Cardiopulmonary resuscitation is something that all doctors are trained to provide and that too goes for medical students in their clinical years. Basic Life Support (BLS) training is a brilliant skill to achieve for anyone – not just those in the medical profession. To some extent though you can never prepare yourself for actually doing it for the first time. Recently, I had that experience. I broke that ground.

The setting was resus in an emergency department, the sun only just risen, the staff only just awake. A fellow medical student and I, oscillating between bedside and nursing station, were waiting for something to happen – all seemed quiet. “Never say the Q word,” a staff nurse told me, “not here in ED, never ever ever say it.”

As swift as a brisk reflex, a patient was wheeled in under blue lights. They were acutely short of breath, tachypnoeic, tachycardic and hypotensive, but conscious. We set up the ECG leads, got them on the cardiac monitor and sent off the bloods. Things evolved quickly. No sooner had we asked the patient about their allergies, the team had to sedate them for cardioversion. There was no effect – the heart rate remained sky high. Amiodarone came next, similarly ineffective, and then the proverbial hit the fan.

As I watched the numbers on the monitor tumble, I remember feeling that sense of impending doom that the textbooks talk about. The patient was arresting. The alarms were going off. The consultant was sprinting across from the main body of the ED. The nursing staff began the compressions with myself looking on, flustered and fearful, counting down the two minutes before the next person took their turn. I was encouraged to have a go, I am BLS trained of course, and agreed that I’d take up position next. The registrar administered a shot of adrenaline to the patient but I certainly didn’t need any more.

Once you are there on the chest, time slows and everything around you dissolves. I tried to imagine Vinnie Jones in that advert, the Bee Gees in the music video, anything to get the rate right. “That’s too fast,” they said, “keep the rhythm even”. I kept going, I got better as the seconds crept on. I kept my eyes closed for the second minute, just concentrating on the depth and the rate and the rhythm in my mind. One. Two. Three. Four. One. Two. Three. Four.

After I’d had my go, we were encouraged to step back. The patient had a weak femoral pulse and a strong radial pulse. I’d succeeded or so I thought. Arterial lines were stitched in at the speed of light as I stood there dumbfounded, useless, all out of sync.

They crashed again of course, and again, and again, and again. The working diagnosis was a massive pulmonary embolism. The consultant gave the go-ahead for thrombolysis and so we had to commit to another hour of CPR. This was provided not by the sweating, shocked medical student but by the Lucas chest compression system, a machine with a fist-like appendage that thumped the chest when instructed. It didn’t have the same flaws that I had – it could actually keep time.

Patients don’t always make it, so it goes. I’m very aware of that and I’ve had patients die on me before, I’ve had patients die in resus before but not one where I felt like I had such an active role and not one where the decline had been so sudden. I remember that, as my arms thrust down onto the chest, my legs were wobbling, alien creatures concertinaing beneath my torso. It wasn’t just the physical draining that I went through though; the emotional distress caused by the situation will live with me forever. Compressions on a dummy will never prepare you for the feel of a real chest and the thought that you are the only person, a gatekeeper, standing between a patient and death. The emotional bond at that point was as intense a feeling that I had ever felt.

In the debrief afterwards I commented that it felt “too real” and I still stand by that. Life and death situations are traumatic and you never know how you’re going to react until it happens. For me, it was to volunteer and then to freeze. I was told that with each subsequent attempt it gets easier but for a while after I avoided resus, aware that constitutionally I had been shaken, my very foundations dislodged and my enthusiasm ebbed. I didn’t want to have a subsequent attempt, I didn’t want to feel that feeling again.

A month on and I feel better about it now, confident that I would be able to thaw from that frozen state and assume an active role once more. It is good that we are trained to administer such crucial treatment but I feel that the emotional response is one that isn’t often talked about. The syllabus is mechanical, it’s all algorithms – cogs and bolts – and doesn’t prepare you for how the real life situation makes you feel. We are medical staff, not automatons, and we react emotionally just like our patients do.

Perhaps, like a consultant told me afterwards, I have to toughen up. Perhaps I’m not cut out for the stresses of acute medicine. Either way, emotional responses to clinical situations should not be overlooked; holism not only applies to how we manage patients but for how we manage ourselves.

Rob

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