Archive for July, 2012

Please email your story to Tracy Napper at tnapper@acep.org

A Piece of Humble Pie
It was not just another day in the trauma resuscitation area at our tertiary referral center. We had just received a call from dispatch that a cardiac arrest was on its imminent arrival from a close scene. As the second year resident, I was in charge of the resuscitation and I assembled my team. Unlike other medical resuscitations where it’s just you as the only resident on hand, a cardiac arrest meant all-hands-on-deck. I quickly called my fellow residents working in the department and gave them all distinct tasks. The intern had the airway with the other second year as their backup. The senior resident would work on vascular access. I stood outside the resuscitation bay waiting for the electronic doors to automatically open and tried to gather my thoughts. I knew how to run a code and could recite ACLS with my eyes closed, but I just felt this cardiac arrest would be different.

The automatic doors flew open and I was glad I was wearing a face mask to hide the fact that my jaw had just dropped. The patient received one-handed chest compressions as a paramedic walked briskly next to the EMS stretcher. The patient was easily over 500 pounds. I started to assist with chest compressions as I realized the petite female paramedic was barely making an indentation in his chest, let alone anything adequate for perfusion. I began to listen to EMS’ history as I continued compressions to the metronome in my head. They had been called to the patient’s house by his mother and found him seated/propped against the couch on the floor tachypneic and diaphoretic. He reportedly walked to the ambulance and subsequently collapsed in the rear of the truck. He became bradycardic and then went into a pulseless, non-shockable rhythm.

As I continued my chest compressions the patient was moved to the hospital stretcher–sort of. Even though there were no less than six people transferring this patient from the EMS stretcher, his lifeless body only made it halfway, then his girth abruptly pushed the entire mattress askew. After some quick maneuvering (and more help) the emergency department resuscitation began. The airway was difficult so an LMA was placed. Vascular access was also formidable, so an IO was placed by an emergency medicine resident who was rotating on orthopedics. Talk about all hands on deck! Although our efforts were valiant, the patient never had return of spontaneous circulation and was declared dead. Following the customary thank you to all who had participated, questions started swirling. What happened to this patient? Who had more answers?

After allowing me to gather my thoughts, our social worker approached me and asked me to speak to the patient’s mother in the family waiting room. But there was a catch, she knew nothing. She was not even aware the patient had collapsed, let alone had just been pronounced dead after arriving lifeless to the emergency department. You can go through lectures in medical school on “How to break bad news” or receive a “pep talk” from your attending, but telling a family member their loved one is dead is one of the most difficult aspects of residency.

I started with the customary, “What do you know about ____’s condition?” His mother began to paint the picture of a normally healthy obese male who had just been discharged two or three days ago from another hospital for pneumonia and called her that morning saying he did not feel well. When she arrived to his home, she found him in the same position that EMS reported. After she had finished with her description and sequence of events her eyebrows raised and she gave me that look like, “Is my son okay?” I shot a quick glance to the social worker and she slowly nodded her head as if cajoling me to tell her. I did. Aside from the normal shock and denial, the patient’s mother said something that will stick with me for my entire career. ”But his father is a doctor here and he is upstairs right now. We have to tell him.” The social worker let out a gasp and gathered his name so she could try and bring him down to the family waiting room. The patient’s father was an internal medicine faculty member who was still rounding on the floors above the emergency department with his residents.
When he arrived and saw his wife, he knew something was inexplicably wrong. Before I could tell him the news, his wife broke down and began sobbing. She kept on saying, “He’s gone, he’s gone, he’s gone!” As the patient’s father attempted to find his bearings and make sense of his wife’s sorrows, I stepped in to tell him the news. He asked for details, and I gave him what I could. He thanked me and began the grieving process with his wife.
Who could be prepared for something like this? I have two small children myself, and placing myself in the shoes of that physician, that father, was a real eye-opener. These are the servings of humble pie that life and emergency medicine can hand you. When I got home from that shift, my daughter was watching the Lion King. I sat next to her and held her hand as I started to reflect on the day and how that experience (now in the past) would affect me and mold my career. I “zoned” back in to the movie, and heard wisdom as only Disney can bestow, “The Past Can Hurt, But The Way I See It You Can Either Run From It or Learn From It.” ~Rafiki

Brandon R. Allen, MD

University of Florida-Shands Emergency Medicine Chief Resident