I recall my first Christmas Eve as a recently qualified doctor. I was oncall that night, a task that has fallen onto my shoulders consistently every Christmas period since then. Medical intern oncall in that particular hospital was usually extremely testing with frequent cardiac arrests and medical emergencies. But strangely that night, for the first time in 6 months, the hospital was unusually quiet. Doctors were watching TV in the res7; some (unable to believe that no nurse was looking for them) were bleeping themselves to check if their bleeps8 were working. I went to bed early that night, wishing it could always be that quiet.
But good things come to an end9, sometimes at 4 a.m. in the morning. At first, you think you are dreaming. Then comes the realisation that it is not a dream, although you try to convince yourself that it is (so that you can continue sleeping). Finally, the responsible part of your brain wakes up and forces you to open your eyes and look at the arrest bleep10 to see where you have to run to. And at 4 a.m. that Christmas morning, the arrest bleep told us to run to A&E.
Most of us got out of our oncall rooms at about the same time, except for Ali, the lanky medical registrar who had sprinted down the stairs a few moments ahead of us. But when we arrived in the A&E department, there was no patient in sight. What greeted us instead were three A&E nurses, the A&E registrar and Ali, all standing around an empty trolley. We immediately understood what was about to happen.
This was not a prank, nor was it a surprise Christmas party. A few seconds later, through the glazed windows by the side of the A&E, we saw the dreaded blue lights of an ambulance as it made its way into the ambulance bay.
I was not prepared for what came in through the A&E double-doors that morning. A twenty-one year-old man was wheeled in, unconcious and barely breathing. His skin mottled, purplish and covered with thick ash. The smell that came off his clothes and body is something I will never forget.
Kevin was at home alone that Christmas morning after his parents left to stay with relatives just a few hours earlier. The house caught fire and he was trapped inside. Cork City Fire Brigade managed to save Kevin from the fire but not from the smoke.
Like with Mr Burke almost 2 years later, I inserted, first-time, a grey cannula in a large vein in Kevin’s left antecubital fossa. The medical SHO oncall did the same on his right while the surgical intern started chest compressions. As I fumbled with the T-connector11, a stream of blood spilled onto his forearm, washing away a superficial layer of ash as it trickled to the floor. We were otherwise an efficient team; this was after all a hospital with frequent cardiac arrest calls. But efficiency alone does not translate to successful resuscitation12.
I remember thinking that we were persisting with the resuscitation much longer than we would usually do. Perhaps we were conscious about Kevin’s age and the manner of his presentation. But we were only delaying the inevitable. Even with our best efforts, we all knew that Kevin’s hopes were slim. After checking for Kevin’s femoral pulse one last time, Ali looked up at the rest of us and finally indicated that he was discontinuing the resuscitation effort. He scanned our faces for any opposition and, as there was none, called the time of death.
As we took off our gloves, we knew our task here was done. But it was not over for Ali. He still had to break the bad news to Kevin’s parents in the quiet room.
Sadly, the extent of my exposure to death and dying do not end with the above two examples. My short three months in a palliative care hospice meant I was forced to witness the passing of many much-loved family members or friends, in a place where people were expected to die13. Till this day I have decided not to recall some of those memories. Even in psychiatry, you will sometimes find yourself being the first and only doctor at an emergency situation14 where invariably, the outcome is death.
Unfortunately, in medicine, death is as commonplace as bedbugs in an old mattress. You are constantly (uncomfortably) aware that it is lurking, and every so often it springs out to bite. Most of the time, it is expected, even welcomed. Sometimes they come as unexpectedly as Kevin’s or Mr Burke’s; more often they are much less dramatic but never less tragic.
And therefore, as doctors, you would expect us to be more aware of the certainty of death. You would expect us to be humbled by our experiences with death from our safe vantage point. You would think we would be more grateful for our lives and the time that we still have with our loved ones in this world.
Instead, we fail to learn from our experiences at work. We become desensitized to death and the sufferings of others. Although we see people dying, pronounce them dead and sign their death certificates, we fail to reflect on our own ephemeral existence in this world. Perhaps to shield ourselves from raw emotions, we opt to instead employ various defense mechanisms to protect us from the pain.
But ultimately we only deceive ourselves. We somehow forget that we could very well be next.
Dr. Mas Mahady
8 there is no piece of hospital equipment more despised by doctors than this
9 the way hardship gives way to ease
10 there is no piece of hospital equipment more feared by doctors than this
11 this is connected to the cannula once it is in the vein; medicines can be administered intravenously through this connector
12 the average success rate of cardiac resuscitation is around 15-30% (unlike the terribly misleading 77% in popular medical programs like ER and Chicago Hope)
13 that said, the discharge rate at the hospice was actually much greater than their death rate
14 this is because most psychiatric units are positioned as far away as possible from the medical/surgical wards and in some cases are on separate sites altogether (as I’ve said, other doctors are terrified of psychiatry!)
