april fools?

A&E can either be boring, busy or horrible. April 1st probably fell into the latter. It wasn’t because we had a multitude of patients (with varying degrees of illness) waiting to be seen – that was normal, it was what was about to happen that turned it from busy to horrible. Normally it’s the unpredictability of emergency medicine that keeps me going. The knowledge that I have no idea what is going to come in next and then on the spot, usually with little or no information, one has to make management decisions, which often can be life or death. Sometimes this fact can (as is often said back home) ‘Bite you on the arse…’

The first cardiac arrest came in mid-morning. A 65 year old man, who had been ‘down’ (meaning without any pulse or breathing) for about 25 minutes before he arrived in A&E. He was Asystolic. We went into cardiac arrest mode. Intubate (i.e. put in a breathing tube), obtain intravenous access, take bloods, check for any blood abnormalities and start giving drugs like Adrenaline and Atropine in a vein, an almost certainly futile attempt to get some electrical activity in the heart, all the while performing chest compressions. We continued for another 20 minutes with no success. Just before we decided that we would cease the resuscitation another call came in…’31 year-old female, cardiac arrest, 4mins’

Generally, when we have an arrest call, it is a patient who is elderly or has been ‘down’ for a while. This time it was someone around my own age who had been down for an indeterminate length of time. For this one we mobilised some more troops. In young people the causes for cardiac arrest can be very much different compared with someone of advanced years. We might have to decide to take her for emergency Angiography or even give some clot dissolving medicines. Hence we needed some people from other medical specialities involved to help decide management.

She looked young, she looked dead. She too was Asystolic, a bad sign. We ran the arrest again; breathing for her, performing chest compressions and giving drugs. All the while the patient from the prior cardiac arrest in the bay immediately behind us – his family sitting in one area of the department, the young girl’s brother and friend in another, all waiting to hear how their relatives were. We continued for an hour on the girl to no avail. She too died. In the space of an hour and a half there were two deaths and two families whom I would have to face.

I went in to the family of the young woman first. Her brother and her best friend were there. They looked like people whom I would go out to meet for a drink on a Sunday afternoon. In short, they looked like any number of my friends, they looked like me. He couldn’t believe it, he wouldn’t believe it and I suspect for a few days hence, he still wouldn’t. There’s no way of finessing a family whose relative has died. You don’t use euphemisms like ‘They’ve passed’, ‘They have moved on’ – it’s nonsense and ambiguous. You have to muster the courage and say ‘I’m sorry, but they have died.’ It sucked. She was young, pretty, intelligent and there was no good reason why this had happened. What made it worse was her parents were still on the way to the hospital, her brother looked at us distraught and asked if he should call them…we said ‘no, wait till they arrive and we’ll be here with you.’

We left that room and walked straight out the back to the other family of the 65 year-old. I hate the expectant look of families as you walk in. The last time they have seen their relative is when the ambulance door closes, CPR underway, they expect magic, they expect the miracle and sadly, more often than not, there isn’t one. Again, I had to tell them all (a larger group this time), I had to tell them their husband and father had died. Nothing can sugar-coat the news and nothing can assuage their grief; except I always, always, tell families that they have done the right thing and there was nothing that could have predicted or changed what happened. This almost certainly is the case. Sometimes it helps. I remember one wife breathing a huge sigh of relief and sitting back in the chair when I said it, her relief was palpable, the guilt shifted perceptibly. Most of the time it makes no difference.

I walked out of the room emotionally drained and went out of the department to sit by myself for a while. A bad hospital coffee and some time off the floor, then back for the remaining 10hrs of the shift as if nothing happened.

It would have been nice if someone had jumped out and yelled ‘April Fool’s!’

~ by Dr Ben on April 11, 2007.