By Jason Ha

2018 Auricle Writing Competition: Clinical Winner

The Emergency Department had had a quiet Friday evening, and as usual, no-one
dared to actually utter the ‘Q’ word unless they were ready to face the wrath of some
veteran Emergency staff. Just a few broken bones, a few cases of pneumonia, and
the typical bread and butter glorified GP cases – just the usual.

It was a quarter past eleven, and I had just finished documenting the details of my
previous patient, when the ANUM appeared at the door of the hub, straddled the
door frame and announced, “10 minutes before our urosepsis gets here. Get
everything ready.”

I had always wanted to see a resus in action, to feel the adrenaline coursing through
my veins – it had only been a few weeks earlier that I had taken part in a simulation
session. There were certainly recounts about how an effective resuscitation would
ensue: clearly defined roles, a steady stream of communication, a strong leading
clinician who were the eyes and ears of a smooth seamless operation. Patient
saved. Simulation session successful.

I’d been strongly encouraged to take part in a real resuscitation, to put what I’d
gained into practice, to refine those skills and to see the ED clinicians in their
element, so when I was asked if I wanted to be involved, I seized the opportunity.
By the time I’d gathered my belongings and opened the curtains, I was greeted by a
flurry of activity: putting on gloves, drawing up medications, powering up the
defibrillator and monitoring system, checking the oxygen, readying the resus
paperwork.

“Ready? Ever done CPR before?”

“A few times. But never on a real person before.”

“Well, now’s your chance.”

It was all I needed to understand the gravity of the situation: this was a grandmother
who only just half an hour ago had been at home, laughing at a TV show with her
husband, on the phone with her two children, or Facetiming with relatives from her
native home country.

And as she was wheeled in by paramedics, I could see her laying on a stretcher limp
and spread-eagled, devoid of the pink flush of life, with each passing second
punctuated with the pneumatic hiss of an automatic chest compression system.
Even among the clamour of the beeping monitors, the clatter of medication vials, and
the cacophony of voices, I could just pick out a few snatches of the conversation.
“82 year ol—yes, from home with her husb—”

“—ext dose of adrenaline ready!”

“—vious history of a UTI, felt unwell after dinn—before she collaps—”

But it seemed that this was no easy resus.

As I alternated in and out of hovering out of the way and performing a cycle of
compressions, I was aware of the hiss of oxygen as two airway doctors managed her
airway at the head of the bed. I could vaguely hear the drill of an intraosseous port
being inserted into the head of her tibia by a nurse, who had only shown me the
technique earlier that morning. I glanced over and saw that the senior registrar, who
had only earlier that week single-handedly managed cases of ruptured ectopic
pregnancies and trauma, had beads of sweat collecting on her forehead, as she
positioned herself to place an IV line amidst the jostling of the arm, dangling
precariously off the side of the bed.

I hadn’t noticed that an hour had passed, nor the fact that my stethoscope had fallen
off my neck during CPR and lay forlornly on the resus bay floor. It hadn’t occurred to
me that I was drenched with sweat, or the fact that it was now a Saturday. And as I
returned to my umpteenth cycle of compressions, I felt a hand on my shoulder.
It was over.

It didn’t matter now that the paramedics had arrived at hospital within just 20 minutes
of her collapsing at home. It didn’t matter that we were a well-oiled team, rehearsed
to the very last detail. In fact, it didn’t matter that we’d done everything we could,
given her all the right medications (even gone for an intraosseous line!) and placed
lines, ports, and leads in nearly every part of her body in our unsuccessful attempt to
revive her.

I gathered my belongings and was ushered out of the cubicle by a nurse. As I turned
back to look, I could see her husband cradling and sobbing into her left hand, and I
realised that—despite all my training, the numerous tutorials, simulations and
drills—nothing had prepared me for this.

My medical training could train me to mechanically recite the DRSABCD algorithm,
and practise advanced life support until it was imprinted in my memory. I could tell
you the number of times that I’d practised and even taught the correct technique for
compressions, even list out every single MET call situation when I had been a
bystander.

Yet this was controlled chaos – the only way to describe the choreographed and
calculated way each clinician moved through the resuscitation bay, directed by a
consultant standing at the foot of the bed, with hands in his pockets. Everything was
orchestrated, thought-out, planned – no miscalculations or missteps, a symphony
without a baton, a performance without cues.

Ultimately I wished I hadn’t been so naïve and that I could have prepared myself
better. But there was no way I could have. The gruelling nature of the operation, the
futility of the whole exercise, the difficult decisions to cease resuscitation, the ephemeral nature of human life, and the emotional aftermath: these were all things
that I could have only learnt by being present. These were lessons learnt the hard
way.

But despite it, there was nothing I could have done anything differently, and perhaps
in some ways, it is a rite of passage for many of us in medicine – an emotional
catharsis of sorts.

As I left the ED, I bumped into the ANUM at the exit, who gave me a weak
exhausted smile.

“Now what you saw back there—that was a good resus.”