What follows is a powerful blog by @drphiliplee1. Please read and share. #notsafenotfair
“Can I have some help in here please?”
You look up from what you’re doing, recognising the special tone that question is asked by nurses and doctors that something bad is happening. Already half stood up you see a senior nurse you know run out of the bay and grab the emergency trolley. His eyes catch yours.
“Is it a real one?”
“Yep.”
You feel your heart skip a bit and pick up the phone in front of you, dialing 2222. As calm as you can, you say, “Adult Cardiac Arrest, AAU, fourth floor.”
“Cardiac Arrest, AAU, fourth floor.” The voice at the other end repeats back.
“Thank you” You hang up and walk quickly towards the bay. As you do, the emergency buzzer on the ward starts to sound, a two tone noise like an angry French police car, and the bleep on your waist blares what you already know. You feel your pulse quicken as you round the corner.
The male patient lies on the bed in front of you, as one nurse starts chest compressions, another attaches the sticky pads from the defibrillator to his chest. The man is ashen grey, his mouth open, his eyes wide as if he’s seen something shocking. You round the bed to the head end, grabbing the manual ventilator or Ambu Bag as you do so. You attach the oxygen tubing from it as you arrive at the patient’s head, turning the tap on with a hiss.
You put your fingers on the man’s neck and lower your face to his, lifting his chin up. “Stop for a second please.” You count out loud. “1…2…3…4…5…” up to 10. “No pulse, not breathing. Can we restart CPR and attach the monitor please.”
The nurse to your left carries on chest compression, counting it loud as she does so. “One…two…three…” You wait until she gets to thirty and give the Ambu Bag two squeezes whilst keeping the man’s airway open. The monitor is now on. “Ok. Can we hold compressions for a second and check for a rhythm please?” You ask.
A single flat green line with very occasional small spikes on the screen appear. You feel no pulse as everyone looks at you expectantly. This is pulseless electrical activity, where the heart does not beat despite having electrical signals. Not good.
“He’s in PEA. Carry on CPR please and can we give him a mg of adrenaline and hang some fluids? And can someone get the notes please” You note the time on the monitor.
Your SHO arrives, having run up from A&E. She nods at you and you nod back, “Hi Sara, can you get a gas for me please.” She nods and rummages for a kit to test arterial blood from the emergency trolley.
The urgent pattering of feet in the corridor signal the arrival of the anaesthetist, who arrives in a theatre hat and blue scrubs. “Sachin, good to see you, can you come get the airway for me please?”
“No probs.” He takes over from you as you step back. The Operating Department Practitioner (ODP) with him starts readying equipment to pass a tube to protect the airway. You hear the gurgling of the suction machine as he starts to clear the airway.
Someone passes you the notes. “Thank you.” No “Not for Resus” form you see. You read aloud so the rest of the team can hear. “78 year old gentleman, admitted two days ago with worsening shortness of breath, diagnosed and treated for heart failure. Background of high blood pressure, previous heart attack five years ago.” You look around, “Who found him first?”
A healthcare assistant answers, “Me doctor, I came to answer a call bell from the next bed and saw the gentleman was breathless. Then he passed out and I got the nurse.”
“OK, thank you. Sachin, I think we’ll tube on the next pulse check, you good to go?” The anaesthetist gives a thumbs up.
“Got the gas,” Sara calls out, “I’ll run it.” She hurries off with the syringe filled with blood.
The clock hits another two minute mark and you announce, “Alright, let’s stop compressions and pulse check. Anaesthetist is going to intubate.” You watch the monitor with your fingers in the patients groin feeling for a pulse, nothing, as Sachin passes the tube counting out loud. You both know that every second without compressions will impair survival and he has only 20 seconds to do this. “…14…15… OK I’m in, syringe please, balloon is up.” He hooks the Ambu bag back up and watches the chest rise. “We’re good”.
“Resume compressions please, uninterrupted.” Sachin listens with his stethoscope. “Equal air entry both sides, but very crackly.” This, you think, is pulmonary oedema, fluid on the lungs backed up from a weakened heart.
Your next thought turns to reversible causes of the cardiac arrest. The 4Hs and 4Ts every medical doctor knows by heart. One by one you try to exclude and treat these, low oxygen? Too little blood volume? Electrolyte imbalance? External pressure on the heart and lungs? As Sara returns with a slip of paper like a supermarket receipt, you read and absorb the result of the test. Nothing reversible, normal blood sugar, potassium OK, but his blood is very acidic now, from a build up of lactic acid.
Another two minutes pass. “Hold compressions.” The spikes on the monitor have disappeared, now replaced but just a flat green line. “Asystole, OK resume compressions, 1mg of adrenaline please.”
Sachin draws your attention to the breathing tube, pink frothy fluid is now backing up. You know there is little way that can be cleared off. He suctions as much of it off as he can.
Another two minutes, still asystole.
And another two minutes, more adrenaline, still asystole.
And another two minutes, still asystole.
You know from your training that on average, only around 18% of patients who have a cardiac arrest in hospital will survive. Asystole, a total absence of heart activity makes that number even worse. You don’t want to accept it, but you know that further resuscitation will not work and will in all likelihood be futile.
“Alright, we have a 78 year old gentleman with pulmonary odedma who has had a PEA arrest. He’s had full ALS protocol for coming up to seven cycles now. He has gone from PEA to asystole with no response to treatment. Ventilation is now difficult and there’s no reversible cause. I suspect he’s had a huge myocardial infarction and further CPR will not work. If no one has any suggestions then I say we stop CPR after the next pulse check.”
You look around, a sad silence. Sachin nods silently at the top end.
Two minutes. The monitor shows the same flat green line, signalling the inevitable.
You note the time. “We’re stopping resuscitation. Can we note the time of death please. Thank you team.” You announce.
The team begin to slip away, there’s other patients on the ward still. Two nurses and an HCA stay behind to clean up the patient. Monitors are detached, oxygen disconnected, and the detritus of your attempts to save is life is cleared up. Sachin deflates the breathing tube and pulls it out, discarding it in an orange bin bag. “Thanks.” You pat his shoulder as you walk off with the notes.
Returning to the desk you left, you’re grateful to find your pen still there. You open the notes and start to write down what happened. Half way down the page, you’re interrupted.
“Doctor, his wife is here.”
Wearily you stand, straighten your top and make sure you look presentable. You follow the nurse to the relatives room. Through the glass on the door you can see a grey haired woman, staring straight ahead at the wall, she looks frightened, but expectant. “She knows his heart has stopped and we were working on him. Not much else yet.”
You take a deep breath, knock and open the door.
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This is what junior doctors and NHS staff do every day. This is the heartbreaking reality of hospital life, resuscitation and being a doctor.
Would you want to do this, make these decisions, have these discussions after consecutive, unsafe long shifts without adequate rest?
Would you want someone making those decisions on you, or your family when they’re tired, exhausted?
If the answer is no, then please support the BMA and the junior doctors against their contracts. Please share this widely especially with non medical friends.