Thursday, October 21, 2010

Losing the Battle for My Soul

"Man is the only animal that laughs and weeps; for he is the only animal that is struck with the difference between what things are and what they ought to be."

Lectures on the English Comic Writers (1819)
by William Hazlitt

Two fingers' breadth above the xiphisternum. Place heel of one hand and interlock fingers. Arms straight. Pressure two inches deep. One hundred compressions a minute.

I positioned myself beside and over the old woman with my hands on her breastbone. With my waist as the fulcrum, I levered my weight onto her heart. The idea was to squeeze the blood out of her non-beating heart into her system to keep her organs - her brain, in particular - awash with whatever little oxygen we can feed into the lungs. The idea was to do it for as long as necessary.

Let's backtrack a little. She had no pulse. For a short moment, the cardiac monitor showed her heart flickering between ventricular tachycardia and asystole before it decided on flatlining persistently. A house officer zoned out for a second, stared at the brilliantly green horizontal axis and then said, almost with robotic disinterest: "Asystole. Start CPR now."

It's not like in television when all personnel manning a hospital's casualty unit would snap to immediate attention and swarm around a dying patient in an excited bid to save a life. Reality is a far more sedate affair. No one ran - they walked briskly. One house officer produced a bag valve mask and started pumping air through the old woman's airway. Another house officer, in his second day there, appeared a little undecided on what he should be doing. I can identify: it was only the second day of my A&E posting too, but as a medical student.

"What are you waiting for? Start chest compressions," a colleague of his chided, and he obeyed. There's no panic, which was good. There's no sense of urgency either, which was unsettling. I suppose that that's only natural. In the emergency department, emergencies are routine.

"I'm tired," said the house officer, smiling sheepishly after performing five minutes of rapid and furious calisthenics on the old woman. He met my eyes. "Hey, med student. Wanna take over? Put on some gloves." I did. And that was how I ended up helping to keep a geriatric in her 70's hang on to the tatters of her ghost.

Two fingers' breadth above the xiphisternum. Place heel of one hand and interlock fingers. Arms straight. Pressure two inches deep. One hundred compressions a minute.

I felt sweat beading on my forehead and under my shirt in the chilly, air-conditioned resuscitation zone - it was hard work maintaining the rhythm and pressure, to be sure. As the minutes trickled by, I took to thinking more and more that the human being under my hands was a CPR practice dummy. It occurred to me at that time that it's pretty hard to tell if a person's really dead. Sure, I understand death in theory but on an emotional level, when I personally created and held every beat of the old woman's heart in my own two hands, the distinction became a lot less clear. Was I helping a person stay alive or was I making a corpse appear alive? Five minutes passed without my notice before I was asked to step down and another newly recruited med student was put on the case. We took turns.

"Just another fifteen minutes," said a house officer, checking the clock on the wall and writing in some case sheets. It was a countdown. It was admitting that there's nothing further which we could do besides maintaining her body a little longer for her, just in case she decides to come back. There's an empty spot in the room which optimism usually occupies, but not today.

Arms straight. Pressure two inches deep. One hundred compressions a minute.

"Alright, stop," someone told me, but I can't remember who. I promptly let her go and was surprised at how ridiculously easy it is to do so. I just let a human life go. Wow. I snapped my surgical gloves off and began washing my hands at the sink. Someone opened the double doors and walked outside.

"We did our best. Come in and see her one last time,"
I overheard him say his rehearsed lines. "Come in one at a time."

Unbeknownst to me, there were at least twenty kinspeople of the recently departed who have been waiting in the exterior the entire time. They filed in solemnly wearing various states of grief. Some remained stoic. Some were crying. There were looks of disbelief, defeat and confusion. For them, what transpired in the past several hours - hidden from their view - was certainly outside of routine. As I dried my hands, I watched as they surrounded what's left of their beloved matriarch and perhaps wondered as I had, how diminished a person looks after she had left her broken shell behind. "Ma... ma..." one or two of the women called feebly and mechanically because they have ran out of rational responses for what was laid before their eyes. A weeping grandchild asked her grandmother to wake up, but no one told her she's being naive or stupid.

I walked into the adjoining yellow zone, separated by some screens. Every once in awhile, the heart monitor gives out an orphaned beep - residual effects of adrenaline in her system. I imagined that it could easily be misinterpreted by someone unschooled in the science of medicine as a sign of life. "Shouldn't they have unplugged everything? Make her more presentable before letting the family see her?" a colleague of mine wondered out loud but out of earshot. Another colleague of mine, a girl who was helping with the bag valve mask, was visibly shaken and was crying. I think it was the first time someone died in her hands. Died. Poof. Just like that. It was the first time someone literally died in my hands too - but I was so detached I was barely there. Analyse and rationalise. Empathise, but not too much.

The doctors, nurses and medical assistants left the little clan alone to grieve and with pragmatic indifference, continued to function and man the casualty machinery - because someone's got to do it. The cries, the sniffles, the halfhearted conversations with the dead in the next room were relegated to background noise. Other patients required attention. Forms and case notes needed filling. Blood needed to be taken and sent. And someone dying in the department necessitates its own slew of paperwork, I'm sure. Being human is not a luxury that a person working in medicine can freely afford to indulge in.

It's a lesson I need to learn and a sacrifice I am expected to make. It's a job that requires me to be more than human to perform. Or less of a human. The distinction was never made clear to me.

Ever so slightly hollower,
k0k s3n w4i


Lukey Luke Phang! said...

that's life, right? or what is it?

mg said...

i would say less a human most of the time so that we dont get attached to our patients too much but, somehow i still do so. it's a tough job.

Zzzyun said...

i think it would be less of a human. to be unfeeling. to be mechanical. cause there is still so much work to be done.

i have seen a few resus-es done, but i have never had to do it myself yet so far. as we have a specialized team that will come running for a med call.

so to be honest, i can't really tell.. but death is part of a doctor's job.

May Lee said...

=( is there another way of coping that doesn't involve you getting hollower?

i'm sure that being less emotionally-affected doesn't equate less humanism.. after all, adapting emotionally to suit one's surroundings is a very human characteristic! having someone's life in your hands seems like a very scary thing =/

k0k s3n w4i said...

Lukey Luke Phang!: that's some kind of life.

mg: i heard it get better with time as your insides become stone cold hard.

Zzzyun: it's funny how everyone automatically thinks that an unfeeling person is less of a human. one can make an argument that the ability to rationalise above one's own emotions to be a superhuman feat. are we giving ourselves too little credit?

May Lee: it's not so much scary as it is uncanny. i think it's not conscious choice but an inadvertent erosion of our ability to empathise. a lot of doctors are capable of keeping a semblance of empathy throughout their careers without actually giving too much of themselves away. i may be wrong but at some point, i think they are all just pretending to care.

Zzzyun said...

you do have a point there... maybe less like a normal human being and more of a emotionless superhuman? XP

im sure Superman has his days too.