We Should Talk About This

I looked down at my hands touching her fragile skin. The warmth, all the little flaws, wrinkles, the pale network of translucent veins, and for one second I imagined her parents holding her for the first time—more than 80 years ago. My shirt started sticking to my body; beads of sweat ran down my forehead. I felt my pulse in my fingertips, but another one was missing. Thoughts of how a life begins and how it ends started to blend through similar layers of exposure and vulnerability, as the anesthesiologist commanded me to continue. The defibrillator had not delivered a shock, and I again compressed her chest, and again, defying the noise of a fracturing rib, rhythmically, speechless.

Thirty minutes earlier my day in the hospital started as usual. After going through some paperwork before the morning conference in our psychiatry department, I stopped by the acute inpatient unit. When I opened the door, I saw the elderly woman lying on a stretcher. She had been admitted yesterday, suffering from a depressive episode. Now the staff were performing CPR, and they had already called the hospital’s emergency team. The patient wasn’t breathing and her face was expressionless. One of our residents quickly explained how this situation had developed over the last few minutes, how the patient had suddenly become unresponsive while sitting in a chair. The emergency team arrived; other patients were guided away from the scene, many of them severely agitated, unable to understand the situation. One of our medical students seemed to hold back her emotions, as she looked at the patient, at all the people trying to save her life, at the intravenous lines, electrode cables, and vital sign monitors. The attending anesthesiologist administered another dose of epinephrine. Many people were already involved in the resuscitation, and all the student could do was watch us apply the knowledge and training we always hope not to need in real life. I suggested that she take care of a patient with dementia who was stepping out of his room for the third time, wandering toward us. She took him by his hand, and he followed her back inside the room, where they stayed together for another hour. The automated defibrillator again tried to make sense of the pulseless electrical activity, one of my colleagues and I switched positions one more time in taking turns at chest compressions, one more shot of epinephrine—and then it was over. We failed.

The next day our student didn’t come in. She called and told us that she was not feeling well. When she returned 3 days later, the psychiatrists on duty were sitting again in our office, discussing last night’s newly admitted patients and our tasks for the next several hours. She didn’t participate as usual; her eyes seemed to focus on some photos on the wall. When the other two physicians left the room, I wanted to follow them to bring my to-do list in line with the day’s limited hours. Then she asked me, “Can you get used to this?” “What do you mean?” I replied, as she started crying. “I have never seen someone dying, I didn’t know what to do.” I remembered asking her to take care of the dementia patient; “It is important to talk about your feelings,” I said. At the same time I realized that she should not just speak with someone. She should talk with a physician who was involved in the resuscitation, who could share her perspective; it was obvious that we should talk about this.

In my career I have seen patients dying. Although many psychiatric diseases share a high mortality rate, losing a patient in the hospital is something that we rarely have to cope with. We have debriefing meetings for inpatient suicides, but there is no formal debriefing for an unsuccessful resuscitation. I know that our hospital emergency team members perform such debriefings, that they have established a routine for something they have to deal with more frequently. However, debriefings often focus on procedural aspects rather than emotional burden. This could prevent us from thinking or talking about how our feelings may change our perception of patients and ourselves. We should be aware that the multifaceted tragedies we observe and how they resonate in us will influence our own mental health and our decisions.

“You can’t get used to this, you never should,” I said. “I know how you feel. It was painful for me to tell her son that she suffered an acute myocardial infarction.” The student nodded, and I told her how the images from that day, the conversation with him and his grief were still accompanying me. “I was feeling helpless,” she said, “The demented patient did not understand why there were so many people; he was restless and he wanted to go home.” “What did you do?” I asked. “He calmed down when we talked about his children.” “You were very mindful,” I replied. “You validated his feelings and made him feel safe. In situations like this, our ability to recognize our own emotions modulates how we establish a relationship with a patient.” “Don’t my emotions compromise my work?” “I don’t think so. Sometimes we may even have to remind ourselves to pause for a moment and to reflect on how we feel. I believe that this contributes to developing as physicians—learning to care for patients rather than to interact with diseases.” The student and I kept talking for some time, and it was clear that she left with a feeling of relief and acceptance, and I did, too.