You have resuscitated a corpse!, the doctor on duty from the ward “upstairs” scolded me.
I had just resuscitated a lady who collapsed and stopped breathing prior to reaching the Emergency Department of Hospital Alor Setar, Kedah. I was then a junior doctor who had just finished my houseman training.
The lady, brought in by her relatives, stopped breathing when she reached the Emergency Room.
With my team, we immediately started cardiopulmonary resuscitation (CPR), intubated the patient and gave medications. Soon after, I was able to get back her pulse and breathing.
In the usual manner, after a successful resuscitation, the patient would be admitted to the intensive care unit (ICU).
But this time, the medical on-call doctor was not happy with me. He believed that the lady should have been left dead – which would have meant less workload and less hassle in the ward.
The lady had multiple other diseases, like hypertension and heart problem. As the patient had collapsed for more than 15 minutes (according to a family member) without CPR on the way to the hospital, he thought that the outcome would be bad and that the lady would only wastefully occupy a precious ventilator in the ICU as the brain cells start dying after four minutes without breathing.
I reasoned with him that although it was more than 15 minutes, you never know – she might have just fainted and was still breathing until about a few minutes before arrival to the emergency room, meaning that brain function might still be salvageable.
He refused to listen to my reasons and later told me that he would not admit her to the ICU. He would only place her in the normal ward and wait for her to die. He repeated the words, “You have resuscitated a corpse a few times” in an apparent attempt to trivialise all my efforts to save the patient.
The patient was finally admitted. I followed her up and found that three days later, she was able to sit and move all her limbs.
She was discharged “alive” after that. That’s interesting – I was able to make a “corpse” walk home!
I was disappointed by my colleague’s high-handed manner and told my boss, who in turn asked me to write a letter to the head of the Medical Department.
Three days later, the doctor came to see me and apologised. I accepted his apology and we moved on with mutual respect as professional colleagues.
This is how we usually resolve professional disagreements at the hospital. Our departmental heads will try to resolve issues amicably wherever possible.
Working as a doctor in the Emergency Department actually exposes us to life and death situations more than any other doctor working in other departments combined.
Amazingly, each patient presents to the emergency room with interesting stories that make us think about people and life.
‘Oh, sudah mati, ka?’
In another instance, I tried hard to resuscitate a young man who was hit by a car as he was riding a motorcycle. There was a strong smell of alcohol. There was also an earring on his left ear and a tattoo mark on his shoulder. His hair was kind of “punkish”.
Our team failed to revive him and pronounced him dead 30 minutes later after rigorous resuscitation.
Subsequently, his sister came to the hospital. I did my best to explain to her that we had tried our best, offered as much sympathy as possible and was very tactful so that the sister would not be too sad despite the loss.
I took quite some time to do this so as to relieve as much as possible the pain she might have upon hearing the bad news.
Nevertheless, the sister, upon learning that her brother was dead, only responded, “Oh, sudah mati ka? Ok.”
There was no sadness on her face. No cries nor wails for the departure of a brother. On the contrary, she appeared somewhat “happy”.
About an hour later, the mother came asking about the patient. Again, I went through my explaining and consoling ritual.
Her response was similar to the sister’s, “Oh, sudah mati? Ok lah.” I could not help but sense a kind of relief, not a loss, in her.
Thinking back, the alcohol smell, tattoo, earrings and history of motorcycle accidents actually told a lot about the person. He must have been an endless troublemaker for his family in his life. His death meant the end of problems.
After years of working in the emergency arena and trained as a specialist in emergency medicine and trauma, I accepted the fact that I cannot save all the lives that appear at the doorstep of the hospital.
Eighty and a chance of life
One day, I was working in the resuscitation area when a man walked past and said, “Doctor. Thank you. You may not remember, but a few months back, you resuscitated my mother and she is well now.”
I remembered the case; it was an 80-year-old lady whose heart had stopped. I mana-ged to get her back after resuscitation.
Again, I received “resistance” when the patient was about to be admitted to the ICU as an 80-year-old patient should not “waste” the ICU beds.
I understand the notion that they may not have a good outcome, but for certain patients like this one, I had a positive feeling and persisted.
Some of our patients do arrive already dead for hours – blue, cold and rigid.
Those who arrive early would have better chances of survival. Early CPR and defibrillation (using electric shocks for cases of heart rhythm disturbance due to a heart attack) increases the chance of survival for such patients.
We depend on people to do CPR to buy time until the ambulance arrives for the patient to have a chance at life.
An ambulance does not have a “turbo” button that, upon being pressed, will make the team instantly appear in front of the patient. Therefore, the public can play this role of “buying time” as the ambulance makes its way as soon as feasibly possible.
These days, you can see “AED” signs at airports, shopping complexes and theme parks. These are automated external defibrillators, and when the device is opened, a voice-guide will help people place pads on the chest and deliver electric shocks correctly.
Nevertheless, I have told myself and my nurses that unless the patient is already dead for hours or will only suffer if life is prolonged, such as those having terminal cancer and poor social support, we must exhaust all efforts to save each patient that appears in the emergency room so that we can say not just to the patient’s relatives, but also to ourselves, that we did everything humanly possible to save a life.
Before death cometh
Nowadays, with experience, I seem able to sense which patients will die and which will survive. For those Muslim patients whom I sense will die even after rigorous resuscitation, I make it a point to call family members to come into the resuscitation bay and whisper the syahadah (the Muslim profession of faith) to the patient.
As they enter the room to do this, they will notice the efforts to save a life. The syahadah recited will give them a sense of satisfaction. Even my nurses and medical assistants made it a point to whisper the for Muslim patients.
For non-Muslim patients, family members are asked to come be with them in the last minutes of resuscitation. They are then gently asked to wait outside as we continue our last efforts to revive the patient.
This practice, which started initially just for a limited number of patients, has become widespread. It gives not just the family, but also doctors and nurses, a sense of “completion” and satisfaction, a sense that everything that can be done has been done.
Mat Rempits and messages by the dead
Some situations may even function as a great lesson. At one time, a Mat Rempit (reckless motorcycle rider) had an accident – his motorcycle skidded during one of his stunts and he hit a lamp post.
He suffered from a fractured skull, fractured ribs and pneumothorax (trapped air around lung spaces) in both lungs. After prolonged resuscitation, we knew that he was going to die as his response was poor.
We called the rest of the other Mat Rempits who accompanied him and were waiting at the hospital hall to whisper the syahadah during our final minutes of resuscitation. They came in one by one. Some of them actually cried. The patient finally died.
We do not know if all those Mat Rempits repented and stopped being Mat Rempits after watching how badly their friend was hurt, but at least some messages were sent across. The dead do speak and they try to tell us something.
Years of working in such situations have made me realise that we are often put in such situations – between life and death – perhaps for a reason. All the effort, intervention and hard work to revive patients may be successful some of the time, but not all the time.
Whether the patient lives or dies, there are always lessons to be learnt – the stories behind predicaments, hope for life and respect in death.
In the lull between the many emergencies in the Emergency Department, there is space and time to reflect and think: about our own lives perhaps, and the inevitability of death, and what we do in the time between them.
Dr Alzamani Mohammad Idrose is an emergency physician at Hospital Kuala Lumpur.