When bringing a dead person back to life doesn’t feel good
10/24/2020 Saturday 11:47pm
It wasn’t until this year (as a 3rd year resident) that I became the “leader” in major resuscitations. This means that whenever someone comes in SUPER sick or dying, or dead, I am technically supposed to be the one in charge of “leading” the resuscitation. This means assigning roles, calling out for meds, calling for specific procedures to be done, etc.
Last month, I had two very different cardiac arrest resuscitations.
One was a young guy who looked to be in his 40s (later found out he was only 39) who had been found down by a bystander. There was a questionable history of some drug use. He was given narcan by the FDNY without response and the paramedics started CPR. He never had a shockable rhythm (ventricular fibrillation or ventricular tachycardia) and he had been down for over 1 hour.
In my short time as a resident, I’ve learned that: long downtime + no shockable rhythm = likely no ROSC (return of spontaneous circulation-- basically the dead coming back to life). Nothing is impossible, of course-- but usually that’s usually how it’s been. It means there’s nothing you can really fix from a cardiac standpoint by shocking the heart back to a livable rhythm. The unknown or prolonged downtime means that the brain (and the rest of the body) has been without oxygen for a significant amount of time.
Miraculously, as we took over CPR and I gave my usual doses of epi, calcium, bicarb, dextrose, within a couple rounds of CPR this guy’s heart came back to life. Maybe he had come back with a very slow rhythm with the paramedics and the additional CPR maybe just helped to further resuscitate him, who knows?
Anyway, his pupils were nonreactive by the time he came to us and even though he was already intubated and had no sedation meds on board, he had no mental status (wasn’t fighting the tube, waking up, moving, etc). Essentially he was brain dead. His blood pH was 6.5 (not really compatible with life). I started an epinephrine drip for him and called the neuro ICU to start the post-arrest cooling process (which has shown to improve neuro outcomes for post-arrest patients).
I stalked his chart after he went upstairs to the ICU and found that his brother eventually came and identified him. He had a long history of drug abuse. Given the poor prognosis of him ever coming back as a functioning human being, he was made DNR (do not resuscitate)-- meaning if his heart were to stop again, we would not do CPR or give meds to try to bring him back.
This particular code stuck with me for some reason. I suppose all codes do in some way. It’s weird to be at the foot of the bed calling out orders as the patient is dead and in the process of being brought back to life. Just based on the history alone, I was very close to calling his time of death and ending the resuscitation efforts. What would have been the ramification of calling that time of death one CPR round earlier than what we had done? He would have been pronounced dead in the ED. His brother would have had to identify a body instead of a body being kept alive by medications and a breathing tube. Did I do right by his brother and the patient by keeping him alive? Or did I somehow prolong his suffering and put the burden on his brother to make the difficult decision of making his brother DNR? Even if this patient initially survives this significant physiologic insult of being oxygen-deprived for however long he was, is he now going to live indefinitely on a ventilator being turned every few hours to prevent pressure ulcers and eventually die from sepsis from UTI or pneumonia, or a sacral ulcer? Is this patient’s brother now going to be stuck with an enormous medical bill (actually not sure who becomes responsible for the bill when the patient dies or is incapacitated)?
I think the end result of the story would have been the same. The patient’s brother lost his brother, one way or the other. That is the tragedy. But did I cause further damage by bringing him back to life?
I know it’s not really my call. It is what it is. It’s not like I could have known that he was or wasn’t going to come back. There’s a saying that EM residents sometimes say to each other: People who are going to die will die. People who will live will live.
The second cardiac arrest… interestingly enough, was a corpse. I’m sure that comes off very crude. But there’s a certain difference between a recently dead person who may have a chance of coming back and a very clearly dead person receiving chest compressions. Maybe it was the color of her skin (gray). Maybe it was the fact that no one really knew how long she had been dead for. She was elderly. Morbidly obese. No shockable rhythm ever. None of that really matters. You still go on with the ACLS algorithm. There’s a moment when it becomes very clear in the resuscitation process that the person isn’t going to come back. The room goes very quiet. The person doing the CPR eyes me with the question “how much longer are you going to make me do this?”
It’s honestly the most ideal resuscitation situation because everyone looks to you and wants to know what your next move is. An actual “might-come-back-to-life” resuscitations tend to be very chaotic. Everyone wants to do their part: the nurses are fighting for an arm to get an IV, the resident is yelling for the monitor to be placed, the resus leader is yelling for next pulse check times or for meds… when it becomes clear that the outcome is death, the entire room goes quiet and no one says a thing.
I did one round CPR, followed by a round of all the meds, then another round of CPR to circulate the meds. Then I called the time of death. It took some time for our wonderful social worker to track down the “next of kin” who was just a friend of the patient. She was sad. I was sad. The friend told me that she called the nursing home when her friend didn’t answer her phone earlier that day. The nursing home staff told her that the patient was just sleeping. Maybe that’s when it happened. Maybe she really did die in her sleep. Maybe it wasn’t so bad.
I try not to carry around the guilt of patients dying. As I said before, people who are going to die will die, people who are going to live will live… There’s not a ton of life-or-death altering things that happen in the emergency department as long as we do our job the way it’s supposed to be done. Maybe that’s a pessimistic way of looking at my job. But it also relieves a lot of pressure. It is my job to try to bring someone back from the dead, but it is not my job to actually resurrect people every time. It is my job to try to prevent likely or predictable deaths, but it’s not my job to consider every possible death-inducing thing that could potentially happen to every single patient. The problem is when you do everything you’re supposed to do, and they do come back to life… sometimes you ask yourself: was that really the best thing for the patient? The answer is: it doesn’t matter, it’s your job to still try. And that moral conflict is something that I do carry around with me.