Internal Medicine – The Compression Manifesto

Updated: Nov 25, 2020

“We have a pulse”

These are words that are unfortunately rarely heard more than a few minutes into CPR. When the hospital operator announces a code blue overhead it is more often than not a one way ticket to blue skys. I don’t claim to be any kind of expert in resuscitation management, but I’ve seen and been a participant in a few now and would like to make some insights.

I’m not actually sure between boy scouts, life guard training, working as a nursing assistant, and medical school how many actual classes I’ve had on CPR. All I know is that it,s taught with such a rigor that it would seem foolish to question its ability to save even the most dead of corpses. The truth of course is that the brain does not do to well without oxygen, even for a few minutes.

My first and most true example of this came during second year of med school. There was an optional extracurricular activity that involved going on ambulance rides with paramedics. Not having hardly any clinic skills at this point the idea was to follow the role of an observer. Most of my friends that had already done it said they saw some interesting things, but nothing too exciting. I wasn’t expecting too much. The excitement started about an hour into the night when the ambulance was called to an empty Wallgreens parking lot with a report of a downed female. The ambulance pulled up to a about two or three people standing calmly around a parked car. The paramedics got out and asked what was wrong. One woman replied “she had a seizure and now she won’t get up”. In the back set of the car there was a young 20 something girl slouched over. One paramedic shook the girls leg to wake her up, there was no response. They checked her pulse. No pulse. Then everything happened really fast. Before I understood how the stretcher even got behind me I was hoisting this girl onto it and rushing her into the back of the ambulance. I jumped in the back with one of the EMTs while the other one drove. He looked at me and said “you know CPR right?” I froze in a moment of terror, dozens of hours spent training and I couldn’t remember what the current guidelines said. Was it 30 compressions and 2 breaths, or 15-1, 30 breaths and 15 compressions. I simply answered “In Theory”.

I started pumping away at her chest as hard as I could. They teach you when you do CPR correctly you should hear and feel ribs breaking. Naturally I was not excited about this and was hoping I wouldn’t be too creeped out. Imagine breaking a branch off a tree, only you are pulling on the branch at the far end and it breaks at the end close to the tree, its not really underneath your hands, but you can still appreciate a distant snap. That's pretty much what it feels like to crush someone’s chest in your palms.

We had no idea how long this girl had been in cardiac arrest for, we knew it was at least 10 minutes. On the way to the hospital I switched on and off with the EMT between compressions and working the ventilator bag, we pushed epi, shocked her, and did whatever else he could think of.

When we got to the hospital I was trying to do compressions as we wheeled her in the front door. As we bursted through the front doors I saw one of my classmates standing against the wall who was riding in a different ambulance. He was wearing his white coat with his shirt tucked in looking as a proper med student should. I however was dripping with sweat, my white coat was probably underneath the ambulance, my shirt was untucked and somehow half way unbuttoned. As we rolled this poor girl into the trauma bay I was still doing compressions as three of four doctors crowded around, starting IV’s and what not. I suddenly thought to myself, what if I’m doing this wrong, what if these seasoned ER doctors think I’m an idiot and clearly killing this lady. Thankfully they didn’t, but I was replaced by one of the interns which I guess was just their protocol.

After about 5 more minutes of shocking, pushing different drugs, and chest pounding someone finally announced a time of death. Half an hour later while I was standing at the nursing station I heard screams of terror down the hall from a waiting room. Those screams put an identify to this Jane Doe that we had failed to save. The scream from a mother whose world has just been ripped apart by the very unfair death of her young daughter is something that sticks with you.

After exactly 29 minutes of pulselessness I was praying they would call the time of death and stop such hopeless activities. That was when I heard the words that are not to ever be heard, “I’ve got a pulse”. I couldn’t believe it, my skepticism about CPR threatened to be washed away. She was stabilized and quickly rushed to the ICU, I overheard some of the docs and nurses rejoicing saying how much they enjoyed that patient. I approached one of the residents that was basking in her glory and bashfully said, “Well Its great and all, but isn’t she going to be a vegetable? What did we just save”. She didn’t reply anything to insightful, I’m not sure if I caught her off guard. Later that evening I saw her again on the stairway and she opened up a little more by telling me that she was grateful that we saved her even if she clearly was going to be next to brain dead, at least this way the family had the choice to pull the plug, and the last chance to say their goodbyes.

I thought about this for a while, and I really appreciated the compassion in what she had said. A large part of me still values this kind of compassion and insight. But, there is a part of me that can’t help thinking about the money spent and dollars absorbed by the hospital to keep this patient alive in the ICU for the sole purpose of fulfilling a possibility that the family may want that. Looking from a different angle, maybe seeing this girl in the ICU with tubes and lines coming out of here, and eyes taped shut would only add to the scar forming on the family?

In the end we do what we can in modern medicine to save people, often times reaching for heroic measures, but do we ever stop and ask ourselves how much is heroic, and how much is damaging. Not an easy topic to teach in 9th grade after school CPR.

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