As a medical student, you're exposed to death from day 1. I still remember going to get my headshot taken for an ID card five years ago: we'd just had our "Welcome to six years of medicine at Cambridge!!" lectures, and we were marched out in alphabetical order to get our photos taken. A few students at a time, we walked into a clean, white, windowless room containing little other than 48 stretchers, neatly lined up and covered by white plastic sheets. It was only when I was being told "Smile for the camera!" that my brain fully processed what was going on: we were in the dissection room, and the dead outnumbered the living by 10:1. I look pretty uncomfortable in that photo.
It is a part of human behaviour that when you are repeatedly exposed to something you gradually become more accustomed to it, desensitised even. You progress from the cold, stiff embalmed bodies of the dissection theatres, to seeing sleeping bodies in the morgue of patients who had died only a few days prior. You go from learning about how diseases cause the body to fail, to talking to patients with those very conditions and hearing from their doctors a few days later that they passed away. You may even see CPR being performed after a patient is found to have stopped breathing, and the harsh reality is that the vast majority of these patients never wake up again. However, I still felt there was one final step in a patient's death that I had not experienced: seeing the moment someone goes from alive to dead. That moment came last Friday.
***
We arrived in time for the morning ward round (like every other day, we promise) and one man was explained to be someone who had previously been in resus a week before, was sent to recover in the hospital wards after being stabilised, but had then developed severe antibiotic-resistant meningitis, gone into a coma, and was back in resus again. This was pushed to the back of the mind as a hectic day soon followed. Alex and I found ourselves helping doctors to treat three patients in quick succession who all needed the full works: fluids, bloods, hooking up to the monitoring, intubation, chest drains, central venous lines, whatever. All the while there would be other patients in neighbouring bays vomiting up bile or screaming in pain with a bone sticking out of their leg - just another day at Bara.
At one point that morning I found myself talking to one of the hospital staff helping us to treat these patients, someone I had not seen around before. She explained that she was popping in and out of resus using treating our patients as an excuse to come to the department. She was actually coming to see her brother - the comatose man with antibiotic-resistant meningitis. She spoke to me matter-of-factly, telling me she had been informed that his prognosis was poor, and that she wanted to see him even if it was just in glimpses as she attended to others in neighbouring beds.
In the afternoon, I was observing a doctor doing an ultrasound scan to look for blood in a patient's abdomen when I heard alarms ringing behind me. The drill for this tends to be to look at the monitor, confirm that the monitor is in fact lying to you, silence the alarm for a couple of minutes because it's annoying, and go back to what you were doing. In this case, I looked behind me to see the monitor panicking for good reason. The heart tracing was severely abnormal.
According to an Australian elective student, it was called a sine wave pattern (at the time all Alex or I could tell was that it "looked bad"... hooray for a top Cambridge education) - this leads to ventricular fibrillation, where the contraction of heart muscle becomes disorganised to the point that blood is no longer pumped around the body, inevitably leading to death if left untreated. My eyes darted around the room to see which doctors were coming to help, ready to have orders barked at me to aid in the resuscitation... but nothing happened. Doctors and nurses looked at the monitor, looked at the patient, and went back to what they were doing - it was the meningitis patient, and it turned out a decision had been made beforehand "not to resuscitate" should this situation arise.
[For non-medics: "Do Not Attempt Cardio-Pulmonary Resuscitation" (DNACPR, DNAR or DNR) is a legal order not to attempt CPR on a patient should the need arise, either under the patient's informed wishes or because the healthcare staff in charge of managing the patient deem it not in the patient's best interests. It takes into account many factors including the health of the patient, the chances of CPR being successful should it be needed, and what state of health the patient is likely to be left in if CPR were in fact to be successful. However, it is important to note that it has no impact on any other treatment the patient receives - they will still be treated fully in every other respect, it is not "giving up on the patient" as sometimes perceived. For our patient, the DNACPR order meant that he was being treated fully but if his heart or lungs were to stop any attempts at resuscitation were likely to be futile, and even if they were successful the patient would likely be even worse off than they were already: severely brain damaged, needing to be connected up to even more needles, tubes and machines to keep them alive, and likely to arrest again in the near future. It was therefore deemed in his best interests to allow him to pass away from his coma peacefully should his heart or lungs stop working.]
I had an extremely bizarre five minutes as me, Alex and the Australian elective student all watched the monitor helplessly. The rest of the room continued working on other patients as the cardiac tracing gradually petered out to a flatline. I walked over to the patient and felt for the radial pulse... nothing. Carotid pulse? Nothing. Put my stethoscope on his chest - no heartbeat, no breath sounds... just empty silence.
And what about my emotions? Nothing there either.
It wasn't as I had imagined. There was no holding the patient's hand as they slipped away, no tear shed or head bowed down. Simply a matter-of-fact end to a life. Had five years of medicine completely desensitised me to death?
Before I could really ponder over what had just happened, I turned around and saw the patient's sister walking into resus. Alarm bells going off in my head, I looked to the registrar in charge of the patient's care and asked whether the news had been broken. She responded impertinently, "I don't know, you can go do it. I'm too busy for the next half an hour," and walked off. Alex and I looked at each other in disbelief. It was too late though, the woman had already seen her brother, and was looking at the monitor. She knew full well what it meant. I didn't know what to do... I instinctively pulled the blanket up from his shoulders to cover his face, and moved away to give them a moment alone.
From a distance, I watched the woman's eyes, and the hustle and bustle of the resuscitation room suddenly fell silent to my ears. The stressed doctors, shouting nurses and groaning patients all became blurred as a bubble formed in my mind around me, the patient, and his sister. This was the true moment of death: not the last breath, not the final heartbeat, not some transition from a sine wave to a flat line, but instead the impact on those left behind.
It is a part of human behaviour that when you are repeatedly exposed to something you gradually become more accustomed to it, desensitised even. You progress from the cold, stiff embalmed bodies of the dissection theatres, to seeing sleeping bodies in the morgue of patients who had died only a few days prior. You go from learning about how diseases cause the body to fail, to talking to patients with those very conditions and hearing from their doctors a few days later that they passed away. You may even see CPR being performed after a patient is found to have stopped breathing, and the harsh reality is that the vast majority of these patients never wake up again. However, I still felt there was one final step in a patient's death that I had not experienced: seeing the moment someone goes from alive to dead. That moment came last Friday.
***
We arrived in time for the morning ward round (like every other day, we promise) and one man was explained to be someone who had previously been in resus a week before, was sent to recover in the hospital wards after being stabilised, but had then developed severe antibiotic-resistant meningitis, gone into a coma, and was back in resus again. This was pushed to the back of the mind as a hectic day soon followed. Alex and I found ourselves helping doctors to treat three patients in quick succession who all needed the full works: fluids, bloods, hooking up to the monitoring, intubation, chest drains, central venous lines, whatever. All the while there would be other patients in neighbouring bays vomiting up bile or screaming in pain with a bone sticking out of their leg - just another day at Bara.
At one point that morning I found myself talking to one of the hospital staff helping us to treat these patients, someone I had not seen around before. She explained that she was popping in and out of resus using treating our patients as an excuse to come to the department. She was actually coming to see her brother - the comatose man with antibiotic-resistant meningitis. She spoke to me matter-of-factly, telling me she had been informed that his prognosis was poor, and that she wanted to see him even if it was just in glimpses as she attended to others in neighbouring beds.
In the afternoon, I was observing a doctor doing an ultrasound scan to look for blood in a patient's abdomen when I heard alarms ringing behind me. The drill for this tends to be to look at the monitor, confirm that the monitor is in fact lying to you, silence the alarm for a couple of minutes because it's annoying, and go back to what you were doing. In this case, I looked behind me to see the monitor panicking for good reason. The heart tracing was severely abnormal.
According to an Australian elective student, it was called a sine wave pattern (at the time all Alex or I could tell was that it "looked bad"... hooray for a top Cambridge education) - this leads to ventricular fibrillation, where the contraction of heart muscle becomes disorganised to the point that blood is no longer pumped around the body, inevitably leading to death if left untreated. My eyes darted around the room to see which doctors were coming to help, ready to have orders barked at me to aid in the resuscitation... but nothing happened. Doctors and nurses looked at the monitor, looked at the patient, and went back to what they were doing - it was the meningitis patient, and it turned out a decision had been made beforehand "not to resuscitate" should this situation arise.
[For non-medics: "Do Not Attempt Cardio-Pulmonary Resuscitation" (DNACPR, DNAR or DNR) is a legal order not to attempt CPR on a patient should the need arise, either under the patient's informed wishes or because the healthcare staff in charge of managing the patient deem it not in the patient's best interests. It takes into account many factors including the health of the patient, the chances of CPR being successful should it be needed, and what state of health the patient is likely to be left in if CPR were in fact to be successful. However, it is important to note that it has no impact on any other treatment the patient receives - they will still be treated fully in every other respect, it is not "giving up on the patient" as sometimes perceived. For our patient, the DNACPR order meant that he was being treated fully but if his heart or lungs were to stop any attempts at resuscitation were likely to be futile, and even if they were successful the patient would likely be even worse off than they were already: severely brain damaged, needing to be connected up to even more needles, tubes and machines to keep them alive, and likely to arrest again in the near future. It was therefore deemed in his best interests to allow him to pass away from his coma peacefully should his heart or lungs stop working.]
I had an extremely bizarre five minutes as me, Alex and the Australian elective student all watched the monitor helplessly. The rest of the room continued working on other patients as the cardiac tracing gradually petered out to a flatline. I walked over to the patient and felt for the radial pulse... nothing. Carotid pulse? Nothing. Put my stethoscope on his chest - no heartbeat, no breath sounds... just empty silence.
And what about my emotions? Nothing there either.
It wasn't as I had imagined. There was no holding the patient's hand as they slipped away, no tear shed or head bowed down. Simply a matter-of-fact end to a life. Had five years of medicine completely desensitised me to death?
Before I could really ponder over what had just happened, I turned around and saw the patient's sister walking into resus. Alarm bells going off in my head, I looked to the registrar in charge of the patient's care and asked whether the news had been broken. She responded impertinently, "I don't know, you can go do it. I'm too busy for the next half an hour," and walked off. Alex and I looked at each other in disbelief. It was too late though, the woman had already seen her brother, and was looking at the monitor. She knew full well what it meant. I didn't know what to do... I instinctively pulled the blanket up from his shoulders to cover his face, and moved away to give them a moment alone.
From a distance, I watched the woman's eyes, and the hustle and bustle of the resuscitation room suddenly fell silent to my ears. The stressed doctors, shouting nurses and groaning patients all became blurred as a bubble formed in my mind around me, the patient, and his sister. This was the true moment of death: not the last breath, not the final heartbeat, not some transition from a sine wave to a flat line, but instead the impact on those left behind.
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