The speed of how events unfolded that afternoon took me by surprise. I certainly did not expect it to happen, but then again doctors only rarely do predict these things accurately. My thoughts seemed to freeze as I sought to fully comprehend what was happening. For a brief moment, I wanted to believe that the nurse had made a mistake and was over-exaggerating, as some of the more inexperienced would often do. But this was no rookie nurse; Mary1 was the ward sister. And as I started to realize the gravity of the situation, my heart sank in horror.
Perhaps I looked the way I felt because it was then that my registrar, Mairead, screamed to me, “Get a cannula in him now! Go! Go! GO!!” as she began CPR. From then on, everyone’s thoughts and actions were very much automated. While Mairead frantically attempted to secure the airways, I somehow managed to insert a second wide-bore cannula into the last patent vein in Mr Burke’s left antecubital fossa and took over doing chest compressions from one of the nurses. My hypothalamic-pituitary-adrenal axis went into overdrive, releasing the powerful peptide hormones AVP (arginine vasopressin) and CRH (cortisol-releasing hormone) to activate the stress response. The cardiac arrest team arrived rather promptly, like the ‘back-up’ police officers would call for in movies. The medical registrar oncall appeared calm and unfazed, as they do, and listened intently to a rushed summary of Mr Burke’s history from Mairead. Fintan’s cool persona was in stark contrast to Mairead’s, and stood out amidst all the chaos and commotion. He looked comfortably out of place, like a man who calmly sips his soup while the restaurant he dines in blazes in flames. It was a reassuring image, somewhat bizarrely, in such a highly-charged emergency situation.
Amongst the ‘back-up’ team were two Malaysian interns. For a moment, as brief as it was, stress levels dropped a notch as I made eye-contact with Razif, three years my junior in college. In our bachelor medical student days, we shared late nights together embroiled in battles of wit and courage for the right to be crowned champions of Risk. But this was no game and there was no time for reverie. Mr Burke spluttered copious amounts of foul-smelling, horrible ‘black stuff’ onto my yellow shirt2 (and matching tie) as I held the face mask, rather loosely it suggests; most of the coffee-ground vomitus spilling onto the floor and onto my shoes. With each chest compression, more black vomitus leaked from his mouth. Things were not going well, despite the efforts of Fintan, who by now had taken over the task of orchestrating the ‘cardiac response’. The late arrival of the anaesthetic registrar did not change matters significantly, although he did expertly guide a large nasogastric tube through Mr Burke’s nasal passage into his stomach, allowing suction of his gastric contents and ending the vomiting of digested blood: haematemesis as it is called in medical jargon3.
I lost count of time and cannot say accurately how long we persevered in trying to revive Mr Burke. Mr Burke, who just a few hours ago was walking and talking, now lay pulseless with traces of black vomitus around his mouth and all over the front of his bare chest. Mr Burke, who a week ago walked into hospital to receive chemotherapy for his Dukes A4 colon cancer, will now leave the hospital in a brown wooden box.
That was perhaps my last participation in a ‘cardiac arrest’ situation as an SHO5 in Medicine before my switch to the wonderful world of Psychiatry6. But it was definitely not my last experience as a doctor, nor was it the most tragic.
To be continued ...
Dr Mas Mahady Mohamad
2 in Ireland, we are allowed to wear yellow shirts
3 not to be confused with haemoptysis: the coughing up of blood
4 Dukes’ system is the way we stage colorectal cancer – to indicate how far it has spread. Dukes A is when the cancer is only in the innermost lining of the colon/rectum – this usually (but not always) translates to the best prognosis
5 senior house officer is the grade between intern and registrar (best kept as short as possible)
6 a terrifying alien planet to other doctors
