Thursday, 28 November 2013


I know I've brought up death countless times, over the previous posts. I also know that I've talked about it at length with friends who wonder how, as doctors, we're able to deal with death so casually. I guess this is a post that'll help maybe clear up the misconceptions or at least give people an idea of how we deal or rather, process death in the health industry.

Bear in mind this is all going to be coming from an unclear mindset. No drafts and second drafts will be made, so there is a possibility I might veer off topic, and if I do that, then I apologize.

The first time we're exposed to death is in the morgue during our anatomy lessons. This happens in the first year, within the first week of education. I remember that clearly but not vividly. The class is usually divided up to 20 people to one corpse (specimen is always the preferred word) and we're shown muscles, nerves, arteries and veins. That first class is always interesting. You're always able to differentiate the students into two, those that will stay the course and those that finally realize they have no business being a doctor. You're able to differentiate through attitude. There are those that are unfazed, those that are interested, and those that just freak the fuck out. The professors explaining on the specimens are usually relentless in the fact that they will try to gross you out as much as possible. I've seen girls faint. I've seen boys puke. I remember thinking how cruel those professors were sometimes with the more queasy students. I probably didn't realize how necessary this 'reality slap' was until much later when I became an intern. I realized that they do it because they know for a fact, that if you can't stomach a preserved corpse, drained of all its blood, then there can possibly be no way for you to handle what will come later.

The specimens were drained of humanity. They were more like the preserved mummies you see at the museum than they were actually human beings. Still, that was probably my first time seeing a dead person in front of me.

Much later when you become an intern. That's when you truly witness death. There is a difference between seeing a dead body and seeing a person die before your eyes. I actually don't remember the first time I saw a person die. I do remember the first person I performed CPR on though. I don't particularly remember which round it was in, but I remember being ridiculously anxious over the arrest. The nurses had shouted out that there was an arrest and I ran to start performing CPR. I remember being very anxious and nervous. This was it. There was a chance that, through some maneuevers and medication, this patient might very well survive. It was ----exciting.  I also remember the nonchalant behavior of the residents. It was more a chore to them. They had this air of  "Oh, here we go again." rather than "I hope this patient survives." I was very upset by the demeanor. After all, why become a doctor at all, if that's the attitude that'll prevail.

In retrospect, I realized my naivete.

I remember asking my senior resident about it. All he told me was

"You'll understand later."

He was right. I did understand later.

Arrests aren't portrayed very well on television. On TV shows, when someone arrests, there's a chance they come back at 100 percent ; that all that's necessary is bringing back that base line to a normal heart rhythm and suddenly everything will be okay again. That's a very rare thing. It might be true in trauma cases and sudden arrests but usually when a patient arrests in the hospital, it's because his or her body is giving out. Sure, you can do CPR and give them some adrenaline and they'll come back, but that only means that most likely, they're going to arrest again within a few hours. We call these patients Post Arrest patients. When you're looking for an ICU spot for these patients because obviously when they come back they need to be ventilated mechanically (something you don't see in the TV shows either) the resident in charge of the ICU will very rarely ever admit them. That's because they're hopeless. It's a harsh reality, but it's also the truth. When you're in charge of an ICU, selecting a hopeful patient over a hopeless patient is always the priority. The question usually asked is "Will his stay in the ICU actually improve his condition or just be a place for him to die in?"

It's a difficult question. It's also totally lost on patients' families.After all, they'd just been told that his heart stopped and now it's back. As far as they're concerned, there's still hope.

I hate false hope. I understand the need for it. Doesn't mean I still can't hate it.

I remember the first death that mattered though. That didn't happen until I became a resident. It was during my second or third month and I was on call in the ward. There was a kid, who had something called Fallot's Tetralogy (which was a congenital heart disease). It's not the worst cardiac disease a kid can have here, and there's a surgery that can correct it completely (given that they fulfill the criteria for it). This kid however, did not fulfill the criteria for the surgery (her brain was damaged, which was a complication for neglected Fallot patients and so her brain was basically mush which meant that even doing the surgery wouldn't bring her back to 100 percent). I remember always sitting down with the mother trying to explain to her, in the nicest way possible, that there was no hope.

That sucked.

Anyways, the kid had arrested during a shift and so, I nonchalantly started doing all the necessary things we do when a patient arrests. It didn't work. She didn't come back. The mother was out buying diapers so she came a few minutes right after we called the time of death. I remember telling her. She wore the niqab, so all I could see were her sad watery eyes. She was angry. She was angry that she wasn't around. She was angry with me. She was angry with the surgeons. She was angry at God.  She kept shouting that she should have been there. I told her there was nothing she could do. She told me it wasn't about that. She said,

"I just wish I could have spent those final minutes with her."


I say this story because during the CPR and during the arrest, I felt nothing. There was no empathy. If anything, I was glad. This was by all means a hopeless patient and it was time for her to no longer be in pain.

That all changes when you see the reactions of the parents.

I'd mentioned in a previous post that that's why I hated the good parents. That is why I hate them. That empathy you feel, it doesn't help in making you a better doctor. It's just a burden that comes with the job.

I think the issue is how routine it gets to be, and that's exactly the thing. Death, to alot of people, is something that's witnessed in the most trying of times. It's an event. But for us, it's no longer this catastrophic event. It's just something that happens that we deal with.

I think I hate that it's no longer this event though. I remember once I was sitting with friends (not doctors) and I had a shift the next day. I remember calling up the doctor who was on call that day and asking him how the ICU was.

"So how's the ICU?"
"It's alright, Patient A is dying though so good luck delivering the news to the parents tomorrow."
"Oh man, is there no way she's going to die with you tonight?"
"Doubt it. But tomorrow definitely."
"God damnit. Fine, but I hope she dies with you."

My friends were flabbergasted. All they could think about was how harsh and cruel I seemed to be. It didn't help that we were both laughing about it as we were talking about it. Keep in mind, I'm censoring how cruel these conversations can be. Jokes are usually made about how the on call doctor should just kill the patient now and things like that.

It is cruel.

But only if you're not a doctor, and it's not because we have the notion of being superior to non doctors.

It's because we have to cope.

Otherwise, we'd all just kill ourselves.

1 comment:

  1. well said, the cruel truth, dealing with it daily ...I am pediatric oncologist