Stepping into a hospital for the first time as a clinical medical student is a strange dichotomy. There is still so much you have to learn before you will become a physician, but you are quickly thrust into life-and-death situations. One of my early rotations was in the emergency room. As a student, you have no actual authority and must be closely monitored at all times. Many times you will need to step back and observe and stay out of the active personnel’s way.
In one of my early shifts in the ER at our large downtown hospital, I found out what it’s really like to work in medicine. It was near the end of my shift when an ambulance brought in a man to the trauma bay. He was rolled in on the gurney with the EMT kneeling over him doing chest compressions. The ER staff swung into action. He was transferred from the gurney to the table, and a dozen personnel were in a flurry around the bed. One nurse was doing chest compressions while another was trying to place a peripheral IV line and several more were gathering medications and supplies. The ER resident and doctor were at the head of the bed intubating the patient in between the violent rhythmic jerking movements of his body with the chest compressions. Another resident was at the patient’s groin, trying to get a femoral IV line in place. The patient was a healthy man in his 50s who had collapsed suddenly at home while mowing the lawn. As it sometimes occurs, his bowels had evacuated, so the room smelled of feces initially and soon the scent of blood from an unsuccessful femoral line attempt blended in the room. Occasionally the flurry of activity would pause as the team checked to see if any signs of life were present, looking for a pulse or signs of cardiac activity. The patient’s heart was in ventricular fibrillation, so the attending doctor yelled “all clear” and a jolt of electricity shocked through the patient. His body jerked, and then the staff resumed their compressions.
Trying to revive someone is messy, physical work — and the staff needed more help. I was called to the bedside to do chest compressions. Standing atop a small metal stool, I concentrated solely on the strength and rhythm of my compressions. Activity continued all around in controlled chaos as medications were found and administered, the breathing tube was secure in place, and blood samples were obtained to send to the lab. While securing the patient’s airway, the doctors had caused some trauma to the airway tissues, so blood was filling up the tube and bubbling out with each compression. The respiratory therapist suctioned to try and clear the bloody secretions and allow for air to move. Blood was splattered on the staff and the room. Time seems to slow down during a code blue. We each know how precious every single minute is, as with every passing one, the brain is deprived of critical oxygen. This patient had been down for approximately 10 minutes before the ambulance had arrived at his home. By the time our ER team was working on him, he had been without oxygenation and cardiac activity for 25 minutes. As time in a code goes on, it slows down even more. The rhythm of the team is established, and everyone is perfectly in place doing their role. At a certain point, the attending will call again for time. It had been over 45 minutes since the patient was found down in his yard. “Hold compressions and check for pulse,” said the attending. Silence. No electrical activity of the heart, no pulse, no breathing. In those last seconds, silence overtakes the room. “Time of death 1746.”
The doctors cleared quickly from the room; they had other patients they urgently needed to attend to. In the quiet, the nurses went about removing the invasive medical equipment from the patient’s body and cleaning the body fluids and debris. They worked with quick efficiency but showed small compassionate gestures like closing the patient’s eyes and resting their hands on his forehead for a moment. I stayed in the room and helped tidy up. As I was disposing of some used medical equipment, the attending physician was speaking to the family in a holding room next door. I could hear wailing seeping through the walls. The sounds grew louder. And when the nurses had finished making the body presentable, the patient’s family was led in. His wife and several children huddled around the body, overcome with grief. A nurse stood close by, keeping her arm on his wife to steady her and offer support. Simultaneously as the family came into the room, the other unneeded staff members and I exited. The family, who had last seen the patient lying dead on the front lawn, were reunited to spend their last moments together in the ER bay.
At this time, the end of my shift had come and gone. I quickly touched base with my attending and walked to the parking garage. I sat in my car. A wave came over me. I started sobbing in the garage. I had just witnessed my first patient die. I couldn’t forget the sound of the wife’s wailing screams. The violent physicality of the resuscitation attempt with the forceful chest compressions, the invasive devices being inserted into the patient, the body fluids commingling in the room was traumatizing to witness. This patient had been a young, otherwise healthy father and husband. To know his life was gone in an instant and that his family would never see him alive again hit me like a truck as I sobbed in the garage. And then I did what everyone in medicine does, I went home, and I came back the next day and did it all again.
Jenny Hartsock is a hospitalist who blogs at Doctor of a Certain Size.
Image credit: Shutterstock.com