The Long Job

“Patient is suspended”

We rushed to the scene and the FRU arrived seconds before us. The patient, an elderly man, was laying on the floor. He wasn't breathing, he didn't have a pulse and he looked dead.

“He's dead, isn't he?”, asked his wife. I could tell by the look on her face that she knew he was dead.

I could only tell her the truth, “He isn't breathing at them moment and his heart isn't beating. We are doing everything that we can for him, but you should expect the worst”.

She nodded, she'd seen the colour of him and seemed resigned to his death.

My crewmate put the defib pads to his chest – he was in 'VF', a rhythm that we shock. So we shocked him and did some CPR, all according to our training. Then we shocked him again, gave him some drugs, breathed for him, shocked him again and eventually (and surprisingly) got a pulse back.

We all looked at each other – this sort of thing doesn't happen to us. Normally our dead patients stay dead.

We packaged him up for hospital, three times his pulse stopped but after a couple of minutes of chest compressions he'd get it back. Surely this wouldn't last, eventually he would die.

His wife seemed confused, but happy. Perhaps he wouldn't die after all.

We rushed him to the hospital, I think he lost his pulse twice more, each time we got it back. By the time we reached the hospital he was chewing on the breathing tube.

The hospital worked on him for a long time – still he didn't die. They tried everything, they even gave him a drug that costs more than £600 in the hopes that it would help stabilise him. They did everything, they thought that he may have had a chance as well.

His wife had hope. The last we heard was that he was transferred to another hospital where there was an intensive care bed. I'm guessing that I'll never learn what happened to him in the end.

I wonder if it was for the best that we saved him. My guess would be that, even if he does make a recovery, he will have some form of brain damage – he went without CPR for too long. The alternative is that he never leaves hospital. I wonder if his wife will continue to hope until he fades away in ITU.

From her acceptance that he was dead, to a probably vain hope that she would get him back, I wonder if it was cruel that our resuscitation was 'successful'. At the time we have no chance to make such decisions, we do what we do and get on with it. It's later, as you see the family around the patient, the monitoring machinery showing life but the patient making no movement, only then do you wonder if it is right.

I can't remember many of the people who die despite my best efforts (the cynical would suggest it's the sheer numbers I see that make it hard to remember). But this one will stay with me for some time.

26 thoughts on “The Long Job”

  1. Thank you for sharing that Dan. I really appreciated reading a parent's perspective and to know what it gives to them.My nan died in 2004, she had a heart attack. She had been unwell for years having had multiple strokes and she was no longer the same person. She was resuscitated once, and then she hung on for hours after that until all her children had arrived, and when her family were around her bed she drifted away.

    Despite what I said earlier, I really appreciate that extra time we had, I know all our family do, and that wouldn't have happened had she not been resuscitated. However, to me it highlights just how difficult a decision it is to make and how it varies considerably in each situation.

  2. It's those kind of situations that I was referring to earlier when I posted. I am all for giving relatives time to say goodbye, I've had personal experience with that. But as you say that man could have existed in a PVS for years, the lady I mentioned will live out the rest of her life dependent on others for everything.You have to do what you think is right, and what you're legally and professionally bound to do. We all have 20/20 vision with hindsight.

  3. It was the right thing in the job you're in. “THAT” decision can be made by family later. I once knew a guy whose 4 year old child had “drowned” after falling in the river. He was brought back, but has been in a vegetative state ever since. He is now 11 years old. The family has lost their medical insurance and the State (Oregon Health Plan) is now paying for his life support, but they are now going to court because the State wants to “pull the plug,” but the family adamantly refuses. I have to say I disagree with the family, even though I think the State just wants to save money…

  4. It was the right thing in the job you're in. “THAT” decision can be made by family later. I once knew a guy whose 4 year old child had “drowned” after falling in the river. He was brought back, but has been in a vegetative state ever since. He is now 11 years old. The family has lost their medical insurance and the State (Oregon Health Plan) is now paying for his life support, but they are now going to court because the State wants to “pull the plug,” but the family adamantly refuses. I have to say I disagree with the family, even though I think the State just wants to save money…

  5. I remember meeting a patient during my (4 day) adult placement in my first year. She had attempted suicide, not for the first time, and had been rescutitated and is now permanently hospitalised. She suffered brain damage that has left her unable to talk, unable to move and is oxygen dependent via her trachaeostomy. And it really makes you wonder… For who's benefit do we “save” these patients? To make ourselves feel good that we saved a life? For the family? Or for the patient?Look… I'm not even out of my training and I've become cynical!

    It's hard to predict the outcome and what the right thing is to do, and right by whom (or possibly even who!). It makes you consider what you would want were you in the patient's situation. I'm still troubled by the memory of this patient 2 years on, and I met her only briefly. I know that I will be faced with similar dilemmas in my future career choice (A&E nursing).

    By the way, received your book in the post this morning, looking forward to tucking into bed with it tonight.

  6. We do what we do for the sake of the family as well as the patient. Every patient is different.Some stay dead even after CPR/defib/tubing/drug therapy/open chest cardiac massage.

    Others respond well with little or no brain damage, and with minimum interventions.

    For some it is fate/karma call it what you will, when its time to go….its time to go.

    But we live in hope and we take care of the wife/husband/partner/sister/brother/mum/dad by doing our best for them as much as for the patient.

  7. Part of me considers any life saved to be a good thing, considers it a victory of a sort, considers the very fact of death an unfortunate and abhorrent fact of life (oh, what a contradiction!) and applauds any effort to postpone that final moment.Another part of me wonders – not the first attempt to end it, and unable to move or talk. Is this *really* what she wants? Were she able to clearly communicate now, would she thank her carers, or curse them? If it was me, having resolved to cease but fluffed it, how would I feel?

    I have nothing but the utmost respect for the people who face this (and more) each day; I've talked with one or two suicidal friends in my time, and it's *hard*, and left me messed up for days; I can't imagine it being part of my job.

    On a lighter note, da book is truly an excellent read – it had me beaming and screaming inside by turns. Well worth the money (and more) even with the contents being freely available in the archives here.

  8. Hey Reynolds, been reading a while now but figured I should add my two pence on this one :)Last year, we lost our 4 year old daughter, Bethany. She was diagnosed in-utero with multiple congenital heart defects. She grew, she developed, she was tiny, and she had cardiac surgery.

    The second stage of the surgery was tricky, but it was that or should would die. She was in Guys Hospital for four weeks, and there was complication after complication. At the end of the third week, we knew, right there, we were not going to be bringing her home. The doctors and nurses ressused her each time she suffered a cardiac arrest, managed to get her “numbers” back up to acceptable, and continued to try and treat her.

    On the Monday we lost her, they told us she had suffered a stroke of some degree, and despite the fact she was only just clinging on to life, we would lose her. But, before we made any decisions, they push for a CT Scan to be done. They nearly lost her twice while moving her and performing the scan, but she held on.

    In the end, the damage was too severe, and if she survived, she would not be anything but a shell, and we had to make THAT decision. We held her, we cried, and she left us.

    I've rambled on here, I know. My point is that by saving the life of this man, as the doctors did with Bethany, we were able to say good bye properly. Family was able to come up and say goodbye, and hold her close in her last moments. We didn't get a phone call saying “Come up, we've lost her” and didn't have to say goodbye after the fact.

    Even if he survives for a few days, people will be able to say farewell to this man as they want to. So my hat off to you.

    -Dan

  9. You do what you have to do. If you arrived at a job then sat down and spent a bit of time having a good think about the pros and cons of saving the individual then the death rate would soar. Besides, even if does fade out in intensive care, even if he doesn't regain consciousness you gave his wife the chance to say all the things she wants to tell him and to say goodbye and so you've done something to help someone even if it isn't the person you originally set out to help. Besides, there's a chance he will get through it ok. You really shouldn't beat yourself up over this, what you people do is amazing.

  10. Hey Dan,Your post moved me as a mere reader….. “No parent should outlive their children” is a phrase which cuts (me) like a knife, so my hat off to you for having the courage to write your post. I was thinking about the “is it right…?” question for some time and the best answer I can see is that which you wrote – I agree that saying goodbye is important, we seem to need completion in some way…..so applause to you for an insightful and very personal viewpoint.

  11. In 20 years, I've only got 3 back – and one of those was during a fast inter-hospital transfer with an CCU nurse on board. (Strange feeling, doing CPR/Resusc alongside someone whose patients normally live, and who expects this one to do the same!)Re the “time to say goodbye” comments, though: – it's not always the case. About 12 years ago we responded to a man in his 60s who had suffered cardiac arrest outside the house of a lady who happened to be a nurse tutor. She and her mother were in the garden at the time. The mother raised the alarm, whilst the tutor started highly-effective CPR; she was joined shortly by a shepherd (good at resusc on lambs), by us, and by a GP. The man's heart re-started at the third shock. He subsequently survived for three weeks in Persistent Vegetative State.

    I work in small-town Scotland where everyone knows everyone else and, during those three weeks, the patient's family and friends made it abundantly clear to myself and to my colleagues (in the street, in the pub, in the supermarket, etc) that they did NOT think that we had done a Good Thing. Seeing the patient in PVS, with the possibilty of his living like that for years, was NOT a good outcome, so far as the family was concerned, and the guy who had been at the incident with me was offered the opinion in the pub one afternoon that it would have been better had we just minded our own f****ng business.

    Give my mate credit, though, he finished his beer, picked up his shopping, said “That's exactly what we did do”, and left.

    If you do the right thing, you can never be wrong – but 'tain't always easy.

  12. What about people who are found at the bottoms of swimming pools after having been immersed for lengthy periods of time? They make a recover even though they've been deprived of oxygen. This guy you saved might be just as lucky and have no brain damage.I'm wondering about the drug that costs 600 pounds (don't have the symbol to use) in the UK. Clearly, it's being rationed by what you say. Is this because of the NHS cuts and I'm wondering who exactly make the decision to administer it? Does it have to be okayed by the 'suits' as opposed to doctors?

  13. I'll never forget the gentleman in the first bed on the right. H'ed been a cantakerous old git during his visit, and he decided that he was going to walk off the ward for a cigarette. I don't know how long the walk to the main entrance took him as it's a good 150 meter walk. He was 85 (but looked older) and usually walked with a stick.We didn't know he'd walked off the ward, so security and myself searched the hospital, and he was found outside on a bench enjoying a cigarette. We chatted, i told him he'd need to come back to the ward. At that point he went a bit vacant and started leaning to one side. 'SH*T he's having a cva'. We got him into the chair and rushed back to the ward. He was thrown onto the bed, as he was starting to deteriorate in front of us. We quietly got the crash team in place, and we stood around and waited for him to arrest. He stopped breathing, we bagged him, he started breathing again, we put up some iv fluids, we tried some nalaxone in case it was his painkillers that were causing the problem.

    Amazingly the on call reg managed to get a CT scan done, so we went down to CT, had him scanned, and on the way back to the ward he started to die, we'd seen it time and time again, the breathing alters, the patient starts to look different. So we ran full pelt back to the ward so this patient would have the dignity of dying on a ward, and not on a corridor.

    Staff were suitably fed up. We moaned at how we were too good at resuscitation now, and that all dignity this guy would have in death had been taken away.

    Relatives were informed (who lived a long distance away) that we werne't hopeful for his survival.

    Then things didn't go to plan.

    4 hours later he turned over in bed.

    6 hours later he sat up and asked for a drink.

    We weren't too concerned as we thought this was just one little pick up before the inevitable fall.

    Then the next day he got transferred to a stroke ward.

    Two weeks later he got transferred to a rehab ward.

    Three weeks later he went home.

    We were shocked. I was very shocked. But i also learned an important lesson – we have to give people a chance. We were convinced that this person wouldn't see out the night, let along leave the ward, or even go home. We were wrong. If we had done what we 'thought was best' rather than what we were trained to do, then this guy would be dead. It is not up to us to make decisions like that, we just have to do everything we can in our power for the patient.

    If you're going to take a fatalist view of things, then his heart was clearly not meant to fully stop that day as cpr, and ambulance, and you were put in his vicinity. It may not seem the best thing, but it is the right thing.

    As an aside, i saw my first VF arrest on saturday. He got up after 5 minutes because the floor was uncomfortable. Isn't electricity marvellous.

  14. Had some feedback a couple of years ago following a “successful” resus of a prime-of-life adult male who had suffered a cardiac arrest resulting from trauma.We had managed to get a pulse back on scene, but the patient was making no respiratory effort. The patient was transferred from scene by helicopter to a hospital specialising in trauma, about 25 miles away.

    He died in intensive care four days later, having never regained consciousness.

    Following this job I had the same kind of thoughts that you write about in this post: should we have bothered in what was a pretty hopeless situation; were we wrong to give his wife false hope; should we just have let him 'go' on scene; etc.

    A couple of weeks later the patient's wife contacted the Service with a message for everyone involved in the case, thanking us for our efforts and saying something like “thanks to you I had him for four more days”.

    Questions all answered – we did the right thing.

  15. Sometimes it's a shame you don't know what the outcome is. Or maybe it isn't. How about that little girl who there was all that arguing about ressucitating – she's going to foster parents because her parents have split up and now neither of them can cope with having her.Yet another moral dilemma.Like you, I have no religion, just believe in fate, nature, whatever.

    Just carry on doing a bloddy good job oops that should be bloody, it's all you can do

  16. Not only did you do the right thing, you did what you had been trained to do. Ultimately it comes down to doing your job and letting the fates decide. We're not allowed to 'call' codes in this country as EMT-Intermediates or Basics, so we'll perform CPR for long periods of time on essentially dead people en route to the closest hospital (sometimes a transport time of 30-40 minutes where I live). Despite the fact that we know that unless we'd arrived as the patient hit the floor we have no chance of resuscitation, we still go through the motions.I know if my loved one had an AMI, I'd want the responding personnel to put some effort in, no matter how much they may think the pt. is unsalvagable.

    As an EMT, I need to come away from every job feeling that I did everything I possibly could for the patient – otherwise I'd be haunted by doubt at every turn.

  17. Metaplase – it's used to 'bust' any clots that had formed in his heart (which may have been what caused his heart to stop in the first place).

  18. I recently attended a 'suspected death', and the gentleman was indeed very, terminally dead. He was found by his neighbours who will remember the shock, and how undignified his last moments of life and first 24 hours of death were. He was seen sprawled on the floor naked in rigor mortis by his neighbours, and a bunch of strangers – community responder (me), 3 paramedics, policeman, police surgeon, etc etc. His family had no chance at all to say goodbye – he had no medical history, no warning for them.I wish I had been able to do something that showed that we wanted to preserve his life, and that we had some respect for him, and something that would have given his family time to say goodbye.

    But maybe that is selfish – it was a very swift end, the kind most of us hope for. Maybe he would have been happy to trade a bit of dignity and shock for a very swift and conclusive end

  19. I understand the resuscitation attempt and the wife was happy that you both made an attempt and got him back. But once you had him inside the wagon why did you keep resuscing him? The wife had originally accepted his death, you gave her a good feeling getting some response, but if he'd died in transport she would've understood and thanked you for your efforts and he wouldn't be a good PVS candidate.I'm not saying you did the wrong thing; I'm a pragmatic armchair quarterback these days. I'm just curious about the decisions and what motivates them. Do you make them based on a prescribed protocol (i.e., If you've had a pulse and lose it, you continue to try to keep it for 20 minutes) or on gut feeling (“I'm bloody well not ready to let this one go”) or some combination?

  20. Behave with decorum. Take control of the situation, and treat him as you would were he still alive. Restore his dignity and his modesty by covering him completely with a blanket or duvet. Once the police have seen him, close his eyes and mouth, and cradle his head on a couple of pillows or cushions; you'll be amazed at how different he will look. Leave his face exposed if the family so wish. Tell them how sorry you were at being unable to do anything – and mean it.

  21. Got it in one – “because the protocol says so.”There are circumstances which allow us to give up – or not even attempt – resuscitation. There are others which offer us no option (eg: CPR in progress when we arrive, cold water drowning, victim is pregnant). When in doubt, though, we do it. It is the defensible option. What Tom and his mate saw here on the ECG was VF in a pulseless patient; that is a shockable disrhythmia, and, from there on, you are commited.

    If the effect of shocking such a patient is to turn the VF into asystole, we are expected to make heroic efforts on behalf of the patient, but are permitted the discretion of eventually giving up. This is not a decision we make lightly; unfortunately, though, it is the one we make most often

  22. So sorry for your loss Dan. I was going to post something along those lines, that this gave people time to say goodbye a bit better, but you speak from experience and me, I speak from wishful thinking where I wish I'd had that chance with someone.On a brighter note, it's not over until it's over – this guy just might get better, and if he doesn't, where there's a medical chance there's a medical responsibility to keep trying – economics, religion and everything else don't enter into it as long as we're dealing with physical facts IMHO.

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