Obedience Under Arrest

There’s a torso at the front of the queue. Towards the back of the line, patiently waiting their turn, are several uniformed staff-members. Some of them are cracking their knuckles. They mean business. Well one doesn’t, but he’s a first year medical student with a sweat sheen on his upper lip and a hairy look in his eyes, clutching a wilting assessment form.  The current contender bouncing on the sternum has forearms like roo tails and there’s a quiet admiration from the entire team. She’s managed to get the end tidal CO2 so high Al Gore would be outraged.

Me, I’m just perplexed. I’ve lost count of where we’re supposed to be in the sequence. We’re somewhere in the midst of an alternate cycle, so, I think, we are drugless and ready to charge. I don’t want to announce my heresy by questioning the algorithms out loud (writing this I have realised how close the name Al Gore is to algorithms, and I wonder if there’s an essay in here? A sort of linguistic marriage between fame and medical terminology? No, sorry, you’re right.) I’m lucky though. It doesn’t matter if I am struggling to follow the ACLS recipe, because everybody else knows exactly how to count in the actions, like being the next one to enter a kid’s skipping game.

The correct person at the precisely correct moment dumps an unwanted charge. I wonder for a moment where the rejected electrons have gone, but then another command hauls me back and everybody rotates, cranking up another round of the chant.

I’m sure I’m not alone experiencing an odd derealisation whilst running an out of hospital cardiac arrest. There’s the human underneath it all, of course. The bone white legs, a bloodless hand hanging unheld off the bed. A husk of a person gilded by the twilight sun streaming through the high windows. I don’t want to make light of it, for that patient, for these final violent moments. For a family gutted to see their loved one on this precipice of life and death. But the ritual of CPR? What a strange biological liturgy.

Imagine the body as a theatre. It’s the heart only under the spotlight. The audience is transfixed by its monologue, unaware of what’s going on in the wings. We applaudingly compress the myocardium like a metronome, and every so often bathe it in a drug that doesn’t work and then shower it in sparks. Left unnoticed the rest of the body goes all Lord of the Flies. We have a fair idea what anoxia does to tissue – can you picture the anarchic storm of molecules billowing up offstage? The rest of the body’s going to hell in a handbasket, and we only have the myocardium in our sights, hoping to stop it progressing from flab to stone. We have a few blunt tools, but our ACLS teaching lulls us into thinking of them as fine instruments, wielded at exacting moments in a protocol. Eyebrows are forcefully raised if deviations occur.

It’s not that conventional CPR doesn’t work – it’s the most effective technique we have to keep the heart sated and blood trickling to the other organs like a drink in the desert, until the defibrillator delivers the reboot (the best ‘have you tried turning everything off, then turning it on again,’ method), or a reversible cause can be identified (the new spar and parry spectacle between echo and compressor), or, in the fanciest of places, a diminutive machine attached via the way of hosepipes which can do the living for a bit. It just doesn’t happen that often. Great that we’re all speaking a common language, but having confidence in what we’re achieving? Ah, therein is another matter.

And, like a thousand Shakespearean ways to die, each arresting heart comes at this grand finale via a different route, along different time scales, and, ultimately, different needs at this rather pointy end.

There are things we do know for sure – pauses are bad, so if you’re going to have any hope, do it well and do not stop. Pre-hospital, bystander CPR makes a difference. Defibrillation works for VF. Adrenaline? That argument is best had down the bottom of a rabbit hole.

It reminds us though, that we, like Socrates, know almost nothing. So much is ahead of us to discover, in so many areas. How wonderful that in the first half of 2017 we have learnt so many extraordinary things about such varied areas; that the mesentry itself is a complex organ (after so long considering itself just a yolky bowelhanger prone to embarrassing plumpness in middle age), lungs make the majority of our platelets, and there are taste buds in our lungs as well as testicles. It feels like being in medical kindergarten. Are we on the cusp of unearthing a subatomic explanation for bodily functions? After discovering that there are quantum effects in the way plants photosynthesise, scientists have become very interested in qubits in consciousness, or entangled quantum bits of information, and that perhaps our wet, mushy biological systems can be better understood by nuclear physics. Exciting times, for sure.

Which brings us back to ACLS. Basic in principle. Simultaneously brilliant and terrible. CPR, same (no cats in boxes jokes). For hearts whose futures are irredeemable (if only we could convincingly know, besides the obvious, which ones these are), it is uniformly awful. So one mustn’t feel too guilty about questioning the rigidity of the guidelines. Although they are currently based on best evidence, and give us a useful common parlance, the truly effective interventions may be many moons away. The heroes in all of this are not the providers in the queue, or the chef calling out the menu, but the scientists and researchers, beavering away, coming at solutions creatively. Until we have better, however, we need to go back to queuing up, modestly and mostly obediently, with our sleeves rolled up.

This post originally appeared on Life in the Fast Lane.

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About the author

Dr Michelle Johnston is a consultant Emergency Physician who works at an inner city hospital. Mostly her days consist of trauma and mess. Also, she writes.

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