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Once the Compressions Stop

White gloves on black skin. The fingers of my gloved hands still interlaced, still resting tensely over her sternum. Elbows still locked. Frozen in the position endlessly refined during CPR training. It turns out that blood flow is important for catheter angiography, which presents a challenge if your patient has no heartbeat. Correction: has not had a heartbeat for 45 minutes. You cannot image without moving dye and you cannot image during forceful compressions. The patient had been transferred from another hospital and none of the doctors and nurses who periodically injected epinephrine and faithfully followed orders from an automated defibrillator had the privilege of ever seeing her smile. Or was it better that we had tried to save a complete stranger rather than a person we had known?

Is there a “banality of chest compressions?” What would Hannah Arendt say? The death rate in the U.S. reached 729.5 deaths per 100,000 this year — and many of these deaths undoubtedly involve doctors, at least to some degree. Doctors who are expected to be empathetic in the face of tragedy 729.5 times per 100,000 if necessary. In her op-ed, “How to Tell a Mother Her Child Is Dead,” Naomi Rosenzweig lays out how it should be: both physician and mother emotionally invested and both following familiar, expected roles. “You do not ever say ‘the body.’ It is not a body. It is her son.” Rosenzweig reminds us. Patients and physicians expect emotional commitment; both want death to be unique and meaningful, both want the emotional experience to be worthy of the moment. The next patient expects the same as the first, and also expects a physician who is focused and not emotionally drained.

My gloved hands were still resting over her sternum when I was told to back off. The physician who now stood by her side tried to insert what seemed like a mile-long needle into her heart. He was wearing tennis shoes, which is standard practice in a busy ICU. He soon called out in frustration, “Where the hell is her heart?” It turns out that 45 minutes of bone crushing chest compressions makes it difficult to find the heart. Instead of more injections and compressions, she was pronounced dead. The man in the tennis shoes moved on, maybe to find her family, maybe to get another cup of coffee, maybe to see his next patient. It was going to be a long day for the man and his tennis shoes. Or had it been a long night coming to an end just now? Her family was waiting somewhere in the maze of corridors. Waiting for the tennis shoes to arrive. Waiting for her doctor to give them the news and to be empathetic.

“Treat each patient like a family member” is an impossible standard to meet. Who could lose a mother 729.5 times? There has to be a certain drift into the banal and there is. Routine provides us with banality; the setting provides us with banality; our colleagues provide us with banality. But not in the moment. In the moment, when death is first acknowledged, the best of us hide all flickers of banality and try to follow Rosenzweig’s “how-to” of empathy. When asked the worth of a life, we answer unequivocally that all lives are equally priceless. We know this not to be accurate, just as we know what Arendt’s work suggests about the human condition. It does not matter in the moment. In the moment when death is first acknowledged, we forget that the average condolence payment for an Afghan civilian is $3,426 (the worth of a human life) and we forget the banality of 729.5 per 100,000.

The next patient was waiting. It was time for the next moment. Following our didactic routine, the resident recited how a proper code is run. How to take charge. How to do compressions. Reminding me to always switch with the next person before fatigue sets. “Are you okay?” “Yes.” “Are you?” “Yes.” The one deviation from our routine. The next patient was waiting. Would it be fair to bring along the emotional baggage from the last one? In the moment, we focus on the next compression, once the compressions stop, you need us to move on.

Tim Beck (4 Posts)

Medical Student Editor Emeritus

Drexel University College of Medicine

I am an MD/PhD Candidate at Drexel University College of Medicine/Fox Chase Cancer Center. My research focuses on cancer cell signaling, drug resistance, cancer cell invasion and discovery of prognostic biomarkers. Politics (national and international), foreign affairs and healthcare policy are additional topics I am particularly interested in.