There had been deaths under the care of my team before, but they were always just names that disappeared from our list overnight. Perhaps a brief comment in the morning, then onwards to the patients that remained. There are some patients I suspect might have died, but they might just have been transferred or discharged — the team often doesn't have time for my questions. Once we had a very sick and demented old man for several weeks, who hung around getting neither better or worse, and was strictly not for resuscitation. He died while I was eating lunch. I came back to the ward to find that his section of the room was hidden behind curtains, and by the next morning it was occupied by someone new. I was too embarrassed to ask where his body had been taken — that’s the kind of thing I should know by now.
I am not sure when a medical student normally sees their first death, but I saw mine in my third year, after almost ten months on the wards. I was on the sixth floor of the hospital, in the staff area, leaning against the doorway, staring at my shoes, while my team was talking about antibiotics. Macrolides, beta-lactams, aminoglycosides — I know the facts about them but they still don’t mean much to me. I was trying to listen, to engage, but failing. Instead I was thinking about what I would to make for dinner.
Amidst the babble of the many conversations occurring around me, a dozen pagers at once began beeping in anxious tones, and everyone twisted to check theirs in its its little plastic holster at their waist. My team's intern, Josie, held hers up and asked the room, "I'm not the only one supposed to go to the ED, am I?"
The doctors in the room, perhaps six in all, piled up their clipboards and their patients' files on the desk, then wove through the crowd of nurses to the corridor. They formed a mob moving along along the corridor towards the Northern stairwell. I trailed a few paces behind. Nobody spoke. I was reminded of something that a grey-haired male nurse had told me after a moment much like this: "There's only two reasons why you should ever run in the hospital, and that's if your patient is having a massive arterial bleed, or if you're about to shit yourself."
In the booming concrete stairwell I looked over the railing as we clattered downwards, and halfway down the shaft I counted three other young doctors heading down. It's strange how easily you can spot a doctor in a hospital, always conspicuous in their mismatched uniforms — dark chinos and button-up shirts, mid-length skirts and plain cardigans. "So it's a CPR thing with Dr Vaisey?" "Yeah, he did this last month too. He doesn't like anyone doing compressions for too long and fatiguing."
We reached the ground floor and marched single-file through the branching corridors of the ED's deep end, merging with the three others ahead of us. The air was alive with the ever-excited sounds of monitors, alarms, and buzzers, all calling out for the attention of the staff, who had become de-sensitised to them. Through curtains and doorways I tried to see what we had come here for — a shirtless old man lying breathless on his gurney, a small black girl lying half-asleep, a pair of doctors laughing with a man in two full-arm casts, a trio of middle-aged nurses sitting silently in the staff room with heads bowed over their mugs of coffee. The others in my troupe looked straight ahead while I twisted my neck to and fro.
Suddenly the group darted sideways through a gap in a set of blue plastic curtains. As I fumbled for the opening I could hear the rapid beeping of a heart monitor, and the croaking of a ventilation bag’s valve every few seconds. Sounds that could be recognised anywhere, like the slamming of a car door, or the groan of old plumbing. When I got through the curtain I found a handful of people dressed in scrubs whose colour indicated their rank, and who seemed strangely calm as they vigorously worked upon a grey mass of a man. His head and shoulders were covered by a dark blue surgical drape, with only a window of skin visible at his neck. A plastic sheath emerged from within that oval portion of his neck, through which a thick black wire was being fed and twisted by hands gloved in ivory latex. A tube poked out from beneath the drape, connected via a fluttering valve to a melon-sized bag, being squeezed by more gloved hands, to force a gust of air down his throat every five seconds. An ultrasound probe was pressed hard against his chest, showing his flailing heart valves upon the snowy little LCD screen. And leaning over him from high up on a footstool, there was a young red-headed nurse, panting heavily and with a face shiny with sweat, bearing down upon his chest with her arms locked straight. With each thrust into his chest she forced a huge cavity from where his sternum usually sat, his flabby abdomen ballooned up and down, and his flaccid penis was thrown from on hairy thigh to the other.
The group ahead of me lined up behind the nurse on her footstool, without asking what they should do. I stood at the curtains and stared, before remembering rule number one of a code: Put gloves on. The beefy, bearded intern at the back of the line was already tearing gloves from the box on the wall and passing them to the people ahead of him. I walked around the edge of the room, twisting through the spaces between trolleys of equipment, to reach the box of gloves myself. But once my gloves were on, I couldn't remember rule number two.
Josie waved me over to her spot in the line, and said I should go before her. Two of the interns ahead of her had already had their turns on the man's chest, and were joining the back of the line again. I said I had never done CPR on a real person before, and she said that was a good reason to practise. The intern ahead of me looked over her shoulder and counted out her last five compressions, tacitly asking if I was ready. I put one foot on the stool and pushed myself, just up as she stepped off away from me.
Beneath my hands his chest felt formless, yet resistant, like a half-inflated air mattress. His ribs had been broken for me, so the work felt easier than I had expected. He was a hairy blob beneath my weight, bouncing back up each time I lifted off. I tried to keep time and push deeply, locking my arms out straight, counting one, two, three, four, five … Then a man's voice yelled out, "The M-A-P is falling, you must be getting tired. Next one up!" I knew that whoever was speaking, they must not have seen me take over from the last one in line, but that they were also not to be argued with, especially at a moment like this. I looked over my shoulder at Josie’s eager face, we nodded in agreement, and I stepped sideways off the stool as she slid into my spot and took over. I walked around the edge of the room and stood in the corner by the sink, to watch the rotation continue. I looked at my gloves by the window's light, and they were still spotless.
Perhaps it was only a few minutes later that Dr Vaisey called out “Everyone stop!”, and as the room fell silent he stared intently at the ultrasound screen and twisted the wire in our man's neck. We all watched as he pushed the bulbous tip into the layer of cardiac muscle on the screen, and the ECG on the big monitor lit up with a textbook 60-BPM trace. But the blood pressure still read as a flat line, and on the ultrasound monitor there were only the weakest of movements. "OK, I’ve got electrical capture but barely anything mechanical, I think that's all we can do. Any objections if we call it off?"
There were no objections, and the ED consultant thanked us all for our help. Josie got a round of applause for reaching the highest end-tidal C02 reading. She smiled and hummed proudly as we walked back to the lifts, tossing our gloves in the bin as we went.
We debriefed at the top of the stairs.
"You know how deep your compressions should be, right?"
"One-third of the chest depth."
"You know the target rate?"
"100 per minute."
"Yeah, so yours were one the slow side. You know the song Stayin’ Alive?"
"Yes, I was singing it in my head, and I felt like everyone else was going a lot faster than the song."
"Well, my rule is to just press down as soon as the chest come back up to full expansion. As long as I'm letting it come all the way up, I know I'm not going too fast."
"And in the end he was being invasively monitored, so it's all about the mean arterial pressure, not the rate."
"I don't think so."
"The most important rule is just don't cry, mate. Hahah! You'll be alright."
The next day I said nothing to anyone about what had happened. I didn’t know how to talk about it without it just being another grisly story that we might share for curiosity’s sake. For a while I didn’t feel like talking to anyone, and it's hard to say why. Perhaps it was just because I had seen a life disappear before me, a man going from living to dead. But I don’t know why this man’s death should have bothered me so much. I never knew his name, never even saw his face. I knew him as an inert body for ten minutes, at most. He was probably just as close to death when I entered the room as when I left it, and what I had seen was more of a legal death than a biological one. What I felt much more clearly, in the foreground of my ever-circulating thoughts, was that I had let my team down. They had given me a chance to be a part of the effort to keep someone alive, and I had failed to be any help.
The next night, I called my mother, and when I told her about what happened, I began crying. She said to me, "You shouldn’t feel responsible. Do you really think that five extra seconds of myocardial perfusion would have saved his life?" She was right, I wasn’t at fault. CPR rarely saves anyone’s life. I tried to explain the heavy guilt I felt about the team, how I couldn’t help feeling like a failure and a burden to them. With obvious frustration she said, “You’re a student, you’re not there to be helpful! Teaching you is part of their job, and be it on their head if they try to make you work for them.” Again, as always, she was right. I had no real reason to be upset. I silently wiped my eyes and my dripping nose, and tried to hide the croaking of my voice as I buried my guilt. I didn't cry for the dead man, but for myself, because I wasn't sure if I would ever stop feeling like a failure and a burden. Then I went to sleep, and woke up early the next morning for class, and told no-one else about it.