#medstories #intraining

Lights. Sirens. Action. In almost every Hollywood medical drama, there is a scene in which a patient crashes. Usually, it is an obvious event, with a nurse immediately calling a Code Blue and hordes of doctors quickly painting the room white. Suspenseful music keeps viewers holding their breath as providers burst into action and give life-saving CPR. Thanks to their heroic actions, the patient takes a deep, life-affirming breath once again.

Although a 2015 study showed these lucky Hollywood patients survive to discharge 71.9% of the time, real life is not so forgiving. A National Academy of Medicine-commissioned report published the same year noted that only 24.4% of patients who undergo CPR while in the hospital survive to discharge, many of whom battle devastating neurological outcomes after resuscitation.

Despite knowing that Hollywood’s portrayal was a far cry from the realities of medicine, there was absolutely nothing in my preclinical education that could have prepared me for my experience with a man I saw in my hospital’s Medical Intensive Care Unit (MICU) during my second week on the wards. New to the clinical world, my fresh-faced excitement to see and learn about everything I could was obvious. And when I was sent to help with a Code Blue alongside my resident, my enthusiasm resounded with every light-footed step I took as we ran to the MICU.

“Have you ever done CPR?” my resident asked.

“Only on a dummy,” I responded, out of breath after running up the stairs.

My resident watched me mirror him, putting away my white coat and grabbing a pair of gloves so that I could be of use if directed to help. He was clearly weighing my apparent lack of physical fitness against the adrenaline-driven enthusiasm reflected in my eyes.

“Okay then. This is different. Compressions on real people take more force,” he warned me, “Go ahead, stand in line.” He directed me to the line of blue scrubs waiting to do chest compressions on the rotund middle-aged gentleman lying on the bed in front of us.

I understood the gravity of the situation. Yet, the exigent atmosphere around me clouded my ability to fully recognize the fact that the human being in front of me no longer had a pulse. It was as I stood on a stool, leaning over the patient’s body, that it finally occurred to me that my compressions could keep this patient’s blood flowing to the rest of his body; or they could deprive him of the oxygenation he needed to even have a fighting chance at life.

The moment of clarity that followed was paired with a laser focus I can neither describe nor recreate on command. The room disappeared around me, along with its people and its noises. I disappeared. My line of sight fixated on my hands, which were layered over one another, sitting firmly on the chest in front of me. My elbows locked. “One,” I counted to myself, channeling what felt like my entire body’s weight through my palms and past an already cracked breastbone. In those moments, all that mattered to me was that I push down as hard as I could for as long as I could.

A resounding crash outside the patient’s room, accompanied by howls echoing down the hallway, finally severed my focus. I saw a woman banging at the glass door, begging to be let in, as I switched with the next provider in line who had earlier congratulated me on seeing a code so early in my career.

The room looked different now. As the woman’s friend pulled her away from the glass door, I noticed all the lines, wires, and tubes running into the patient in front of me. I noticed his gown, torn open in the center, falling off of him. His wife outside was now calmer and sitting in a chair with her hand grazing her forehead, peering through the glass doors at what must have looked like a savage scene before her.

The next time I stood over the patient, I knew he wouldn’t make it. After a few more compressions, he was pronounced dead.

Providers dispersed as quickly as they arrived. My resident had left earlier, urging me to get as much from the experience as possible by staying until the end. A kind nurse used some sheets to cover the patient up before leaving the room. It shocked me how everyone could just move forward without a glance back. Walking out of the room I had so eagerly rushed into, I noticed the patient’s wife had gotten back up and was wailing while beating on the floor, her friend now sitting on her to restrain her.

“Please, dear God, just come by here and bring my husband back to me,” she cried as I walked past her to pick up the white coat I had so hastily discarded. My feet felt like lead, and my coat, now heavy on my arm, felt futile, for all I could say was, “I’m so sorry for your loss.” At the time, I was too young to understand that medicine is as much about caring for our patients’ families when they have suffered a tragic loss as it is about caring for our patients when they are alive.

Every provider remembers the first patient they watched die. I’m no different. To this day, as I sit here and write about this man whose name I never had a chance to learn, I can visualize his face, his chest, the last teardrop that rolled down his cheek as if to apologize for not having a chance to say farewell to his family. All of it comes back to me and I am transported to a time when I was shocked into silence.

For days afterwards, I couldn’t sleep. Was I wrong, I wondered, to let the situation affect me for so long — was I weak? How many codes must one see to move on without feeling anything at all? When I finally asked those questions of my mentor, he smiled empathetically. “I think, in some way, you’ll always feel that sadness when a patient dies. I still feel it,” he said, “In fact, it’s when you feel nothing that you know it’s time to stop practicing medicine.”

Medicine, I soon came to learn, is as much about death as it is about life. Yet, there seems to be a culture of bravado in the field, passed down through generations of doctors who have lived up to a perception of never having to shed a tear. The man in the MICU will certainly not be the only patient I see die, but the compartmentalization of sorrow that must occur in the aftermath of death doesn’t require a complete disregard for the emotion.

We talked about this in 2015 when we made a hero of the emergency physician in a viral photograph for grieving in private and putting himself back together before caring for his next patient. We discussed the heavy emotional burden that comes with Medicine.

Yet, only recently do we see the culture of Medicine start to catch up to the conversation; and we still wait for the profession to create robust support systems to encourage providers’ emotional resilience. In the meantime, while collectively mourning physician suicide, we have abolished work hour restrictions, increased uncompensated documentation hours, and talked extensively about self-care without giving providers the time or resources necessary to follow through.

We still view tears as unprofessional and, in some specialties, take pride in depriving ourselves of food and sleep, expecting of ourselves efficiency levels that are difficult to ask of a human being. All while the very human existences of real people, like the man in the MICU, extinguish in front of us every day.

Medicine is a career I chose despite the sorrow of losing patients, because every life saved or positively impacted makes the challenges of training and practicing completely worth it. But, it is entirely up to us to fuel the culture we want to practice in and set the stage for a new generation of providers to practice safely and happily in a field racked with emotional challenges.

Lights. Sirens. Actions? I can’t wait to see what we will do next.

Pavitra Krishnamani is a medical student with a background in global health interested in innovating how we deliver healthcare to our patients at home and abroad. To learn more about her and her work, check out her website.

*Publish dates for articles discussing patient encounters are disparate from when the encounter actually occurred in order to protect patient privacy. Names, ages, and other encounter details are also modified to protect patient privacy.

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