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Cardiac Arrest in A&E (II)

Posted Jan 31 2012 4:33pm

A number of doctors stood round in a semi-circle in resus, talking quietly but excitedly about the next cardiac arrest. ‘35 years old with no previous history of chest pain? Could be a stemi?’.What should they be labelled collectively? A Swab of medics? A syringe of doctors? It struck me that, although the incident was serious, nine medics was a little excessive. Just as I was counting them internally, a consultant came in from majors. He peered over his glasses: ‘erm, is it really necessary to have so many medics here?’ There was a silence and the sound of feet shuffling. Smiles were hidden behind closed hands. ‘Just to see the scenario, given how unusual it is’ said the doctor who lead the last resuscitation and would be leading this one. The atmosphere was charged. I was rearing to go, hardly able to believe my luck at receiving two in a day. Meesha was walking out, it was the end of her shift. ‘Oh no, today’s not a good day. Something’s different, I blame you!’ She said, wagging her finger at me.

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Like in a Spaghetti Western, just as she left the double doors the sister in charge came in on the opposing swing. She pointed at me. Why did everyone keep pointing at me? ‘Hi, are you the student paramedic? Could you do us a massive favour? Follow me, quick’. I was mortified to be leaving the resus room and reluctantly followed, my unformed complaint swallowed up in the humdrum of majors. ‘A nurse needs a hand with a patient, thank you so much, I owe you one’. I walked into the cubicle. ‘This patient, she need cleaning boss’ said an Asian male nurse. ‘She soil herself, it ain't nice. Which side you want to take?’ Poor love, I recognised it as the wife of the patient who had passed away earlier in resus. I log-rolled her towards me as the nurse on the other side of the bed got to work with soaked wipes and a towel. He grimaced. ‘I don’t like the job now, but when I go home I get satisfaction that I do a good thing’. I buried my nose in my shoulder sleeve as tactfully as possible. I was eager to get back to resus.
When the patient was covered up and the job almost done, Kermit Heimlich came through the curtain. He had a flushed face and animated eyes. ‘Jeromeo get yourself to resus, do you know what we’ve brought in?!’ So his crew had attended the cardiac arrest! What a great job it must’ve been. I looked at the nurse and he waved me away. We marched into resus and Kermit filled me in on the way. ‘We intubated him and started CPR in the shopping centre. He’s a big lad you know, like, really big. I was giving compressions in the back of the ambulance and going all over the place, it was brilliant. That’s what I’ve joined up for, things like that’. We walked in through the double doors. Kermit was right, he was a big lad, easily 25 stone. 
One of the paramedics was giving compressions whilst the others got to work cutting off his sleeves to gain cannulas for delivering drugs. His belly jigged up and down with each compression, as if he were jumping up and down lying in bed. One arm was folded against the trolley bed, the other was hanging limply out, a conspicuous wedding band on his ring finger. His naval was crusty with red, exzematous skin, and around the folds in his belly were bands of flaky skin.
‘Two minutes’ said the scribe, looking at her iPhone on the lectern that was especially for this purpose. The lead doctor called out some orders and looked intently at the monitor. ‘Stop compressions. That rhythm still looks like VF to me. Charging shock’. The defib made a comical tone that was rising in pitch from mid-tenor to treble signifying the charge. It sounded more like something you would hear in an arcade, followed by hitting the button with an over-sized hammer and watching the thermometer jump up. The defib rang. Everyone away, oxygen away, shocking now’. The man’s pudgy frame jerked on the trolley-bed, shaking it in a way I’ve not seen before. Shock delivered. Carry on with compressions’.
The patient’s trousers had been cut off and he was completely exposed, the scraps of his clothes trapped underneath him. Medics were finding lines wherever they could to get drugs into his veins. He had one in each arm already, but they were trying for the ankles. One was plunging an arterial blood gas [abg] needle into his groin, trying to find an artery to get a sample of blood and see its acidity. It’s the gold standard assessment of how oxygenated the blood is and what the chances of survival are. It’s not a pretty sight, a needle been stabbed into the groin and moved from side to side.
A few cycles later, I got a chance to give compressions. ‘Nice and deep with this one’ the paramedic said under his breath as I stood on the footstool. The patient’s moobs were comparable to a females, swinging in a circular motion with each press on the chest. I could see straight into his eyes which were half-open and bulging. His face was cyanosed, acquiring a purple haze as his blood slowly became deoxygenated. ‘Two minutes up, stop compression. Oh, looks like we might seeing PEA [pulseless electrical activity]’ said the lead. ‘Feel for a pulse please’. There was a medic at each wrist feeling for the pulse. They shook their heads ‘can’t feel one’. ‘Ok, charging shock’. That was how it went for the next few cycles. There was a faint glimmer of hope for a while at the thought of clutching victory from the jaws of the cardiac monster, but it was short-lived. Ventricular fibrillation was showing up repeatedly on the monitor. A sample of arterial blood had been gained and the results were printed on a receipt-sized piece of paper. The prognosis was not good: acidotic blood. Forty-five minutes had gone by. ‘The family are outside, I’m going to let them know what’s going on and give them the option of coming in and watching’. A nurse got a blanket and covered up his bottom half. The doctors were no longer fishing his groin for blood samples but were stood round self-consciously. Three family members came in, lead by the wife. She was a mess, sobbing into her hand, her face impossibly scrunched and very well perfused. ‘Oh Micky, please come back my Mick, we’re here darlin’. She touched his foot, protruding from under the blanket. I felt emotion that originated from my stomach rising into my neck. My eyes teared up slightly. I was glad to be standing slightly back at this time. The posture of many of the others was the same. This was a husband and a son that was being lost. There would be a Micky sized hole in their lives now, and what a substantial hole that would be.

The lead consulted them. We’ve gone through 19 cycles now, 55 minutes, and the paramedics were working on him for 40 minutes before he came in. We’re doing all we can, but the chances of him coming back now are very small. We’ll do five more minutes, then we’ll call it’. Two of the relatives went out, leaving the wife. The paramedic touched her arm, and she gripped his hand thankfully, her eyes streaming. What else can be done to comfort someone? If you ask them, it pretty much is the end of the world, and no words will bring their departed back. Touch, the most basic of primeval of human interactions, is the most appropriate and powerful methods of communication.
‘Still VF. That was the last cycle.’ He turned to the wife. His face was heavy with the burden of the decision. ‘We’re terminating the resuscitation. We tried all we could. I’m very sorry’. Kermit’s stood next to me: his eyes were wide. I had to swallow another bolus of emotion that started to rise. The wife touched her husband’s foot that was poking out of the hospital blanket. His dark sock, turned inside out, lay next to it. ‘I love you Micky’ she gasped, and stumbled out. ‘That was really slick, you did really well, well done’ said the anaesthetist to the lead as she walked past with the others. He gave a humourless, pursed smile and followed the late patient’s wife into the visitor’s room opposite resus. The paramedics followed him in, with Kermit standing just inside its threshold leaning against the door frame. He had the same wide-eyed look fixed on his face. I walked passed and through the open door heard a panicked ‘No! No!’ of another woman emerge from the room. It sounded like emotional carnage in there, I don’t think I would’ve survived it. ‘It’s good to see how the paramedics break the news’ said Kermit later. ‘I’ve had to do it once before and it was the hardest thing I’ve had to do in my life’. 
I was dressing the second body that day in a shroud. It was put into the thin paper night dress before being wrapped in a Hospital sheet and taped shut, leaving the head exposed. The family were about the come in, so the resus nurse and I made it extra neat. We tidied the medical wrappers up and cleaned the blood from the floor with wipes. It felt like the audience and actors had departed the theatre and we, the caretakers, were switching off the lights. All the signs of the struggle thirty minutes ago had been erased. Maybe ghosts do exist after all, the memories of people and events that swirl round and round the spectral washing machine between our ears. 

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