This business of caring

Hanna Bielawska

The morning shift in the emergency department is quiet. Suddenly, the charge nurse announces, “The paramedics are bringing in an 83-year-old male—vital signs absent. They will be here in 5 minutes!” I immediately perk up.

As everyone busies themselves with preparations, the attending doctor delivers yet another jolt of excitement: “Hanna, you are running the code, okay?”

Fantastic! For a junior resident, this is a great opportunity to practise the skills and leadership necessary to coordinate a resuscitation effort. Excitement and fear rush over my body, and my mind goes momentarily blank. After all, it is a mighty fight to bring a man back from the brink of death, and I am being given the chance to call the shots! As my exhilaration rises, I grow calm and determined again. In my mind I recall the ABC and ACLS algorithms. I can handle this.

Then the patient arrives and we begin: cardiopulmonary resuscitation, rounds of epinephrine, rounds of atropine … But there is nothing more than pulseless electrical activity. It has been 40 minutes since he collapsed at home, and we are getting ready to quit. Somebody asks, “Is his wife here yet?”

Hmm. Among the adrenaline rush I did not think of his family. I have no time to think about that now though, because the unexpected suddenly happens: In between compressions I think I feel the pulse returning. Sure enough, the attending doctor ascertains the faint yet undeniable beat of the femoral artery.

“All right, start a dopamine drip and call ICU,” he orders. “Hanna, do you want to put in a central line?”

My very bones are buzzing with excitement. Do I ever! I run to get the instrument tray myself. It is not often that this opportunity presents itself; it has been almost a year since my last. I set up my equipment, take a deep breath, and proceed with drunken confidence. The procedure goes smoothly and in less than 2 minutes we have central venous access—success!

I am still shaking inside with triumph and satisfaction when someone brings our attention to a new person in the room. The patient’s wife is here. The attending doctor explains what we have done and that the outlook is dismal. His heart was bad to begin with, and now only our ventilator and maximal doses of drugs are keeping her husband alive. If his heart stops again, we do not recommend further cardiopulmonary resuscitation.

I watch as she crumbles down into a seat beside the gurney and grasps the cold hand of her lifelong partner. They probably woke up beside each other this morning, ate breakfast together, and shared complaints of ailing health. I see her bright blue eyes fill at once with love, hope, despair, and disbelief. She sits by her husband’s side, stroking his white hair and crying in silence, and places a final tender kiss on his pale cheek.

The scene unfolding before my eyes is heartbreaking, and I am suddenly ashamed of the exhilaration I felt just moments ago. Although I am thrilled to have had the chance to practise a skill, I am also filled with guilt for neglecting to reflect on the context until now. So to make it up to myself, I let myself sample her sorrow. As I stand with my fingers guarding the weak femoral pulse that beats next to my central line, I imagine how I would feel if this were my love, leaving me forever, putting an end to a lifetime of companionship. The pain of this brief moment is paralyzing.

Coexisting emotions

In medicine we face tragedy all the time, and for a resident it can be all the harder to process. Not only am I new to this, but I am also torn between deeply respecting the human tragedy and fervently celebrating a skill learned—the ability to practise medicine. So, then, should I feel guilty for experiencing excitement when only sadness should be appropriate? Although it seems counterintuitive, I am learning that the 2 opposite emotions can indeed coexist. The thrill of the task at hand means no offence to the human tragedy. There should be no shame in eagerness, as long as care is patient-centred. In fact, without this manic energy that drives our learning, aspiring residents could not progress to becoming skilled independent physicians. The profound significance of a life passing must not interfere with efforts to work and learn, but both can be respected simultaneously.

So how do I learn to function as a competent yet caring physician in this frequently disturbing daily existence? How can I lose neither the profound enthusiasm nor the intense empathy? This challenge, not taught in any textbook or classroom, still lies ahead: to detach just enough so that anguish does not impede my work, yet never lose sight of the human side of each task at hand.