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January 31st, 2011

The Real Breathless CPR

Greg Bratton, MD

hospital food
Residency is hard. The hours are long, the work is grueling, and, simply put, hospital food is not good. Many days, we, as residents, walk the wards in a lifeless haze – coasting on the wings of our white coats, our fuel tanks pointing way past empty.

During these times, we find ourselves sitting in wheelchairs that are stored in dark remote corners, questioning whether or not all of this is worth it. For years, our nose has been to the grindstone, and our minds have been focused. Back in high school, our internal compass always pointed towards the Mecca of Medicine. And no matter how hard our roommates or fraternities or coworkers tried to veer us off our path, we stayed true to the course. In one way or another, most of us have followed the standard pre-med algorithm to medical success:

Step 1: Convince yourself that high school grades matter and study hard.
Step 2: Go to a good college. “Good” being based on the science department and not the social scene or sports.
Step 3: Sacrifice fun (parties, vacations, dates, etc.) so you can maintain a 4.0 GPA.
Step 4: Do research because you hear “med schools like it.”
Step 5: Nail the MCAT by staying true to Step 3.
Step 6: Never lift your head from a book while in medical school, even if you’re in the bathroom.
Step 7: Convince yourself to postpone marriage and family because there is “no time.”
Step 8: Nail Step 1 and Step 2 by placing Step 6 on steroids.
Step 9: Get into a good residency program.
Step 10: Don’t sleep. Convince yourself that it’s a sign of weakness and failure.

Then, when you allow yourself a second to take a break, you see your friend who graduated from college with a 2.0 GPA is running his own business; the guy who cheated off you in biology class has now graduated from law school and is driving a Mercedes; and the girl who was clearly in college for her “Mrs.” degree has opened her own boutique and has a home decorating show on HGTV. Moreover, you see yourself: tired, unshaven and in need of a haircut, pale from not seeing daylight, 20 lbs heavier – thanks to late-night McDonald’s runs – and $200,000 in debt.

And just when you think you can’t take it anymore, you meet the patient in room 533.

Mr. 533 is a 59-year-old man who presented to the hospital with a past medical history of diabetes mellitus type II and with the chief complaints of chronic diarrhea and 55-lb weight loss during the last 6 months. Mr. 533 is a self described “pain in the ass” who refuses to go to the doctor “unless I am dead.” This time, though, he presented at the insistence of his wife and is not happy about it.

On admission, Mr. 533 was a well-appearing man who looked older than his stated age. His skin was wrinkled from years of sun exposure, and his hands were calloused from the wear and tear of manual labor. Other than that, his physical exam was completely benign. His labs were negative, but a CT of the abdomen and pelvis showed “enlarged lymph nodes involving the retroperitoneum, pelvis, and the inguinal regions bilaterally; possibly due to a metastatic disease or lymphoproliferative disease such as lymphoma or leukemia; thickening of the rectum possibly neoplasm.”

He initially refused a rectal exam, so it was not until he went for colonoscopy that his rectum could be examined. To make a long story short, Mr. 533 was diagnosed with stage IV metastatic prostate cancer to the colon.

Staying true to form, Mr. 533 was resistant to treatment during his 3-week hospitalization. He refused insulin for his hyperglycemia, refused IVs, and never complied fully with physical exams. However, somehow we did get him to agree to begin treatment for his cancer with Lupron. “But once I receive the injection, I am leaving,” he said.

Mr. 533 received the injection, stayed the night and the next morning, and started to get ready to leave. But, while leaning over to tie his shoes, he fell to the floor in ventricular fibrillation. ACLS protocols were run, and Mr. 533 was shocked twice. Subsequently, he underwent bare-metal stenting of his left anterior descending artery for a subtotal occlusion and had an intra-aortic balloon pump placed for cardiogenic shock. He then spent the next 5 days in a coma in the ICU. Miraculously, the day after we talked to his family about withdrawing care, he woke up. And during the next week or so, he went from delirious to angry to appreciative.

On his day of discharge, I was post-call and tired. I had maybe caught an hour or two of very uncomfortable sleep on a couch and was mentally exhausted from the night’s events. I was without coffee and once again questioning, “Why do I do this?” Nonetheless, I shuffled my emotionally drained and vacant carcass into his room to make sure any questions had been answered and to wish him well.

“Do you have any questions, Mr. 533?”

“No, doc. But I wanted to let you know that you have impressed me and have given me hope like no one else ever has in my life. And I don’t say things like that to many people. So thank you.”

Like a wilted flower that receives water, I instantly felt my emotional tank fill up and my battery get re-energized. And I was immediately reminded why I do what I do. In that moment, just as I had brought life back to him during his arrest, Mr. 533 brought life back to me during mine. This is a true example of breathless CPR.

18 Responses to “The Real Breathless CPR”

  1. Andrea Parent says:

    Excellent story Dr. Bratton.

    • Krish says:

      Medicine is a calling not profession per se. Those called pickup the yoke do it without any reservation and possess the mental make up for it. Though the financial rewards are good or better in the long run, these come when not desired.
      I was almost commanded by our old country physician to avoid it as I was too compassionate, involved and eager to help where I could not. His advice was correct.

      I went in pure science and have no regrets.

  2. Dr Amit says:

    The story of all hungry,tired,lifeless zombie residents having no fun just working for satisfaction(ours or patients), I still dont know. Thanks for sharing Dr Brtton

  3. David Lee says:

    Not bad – though the self-abusive introduction is very disturbing. Excellence in medicine is not only technical: it can also be spiritual and emotional. And emotional exhaustion is so depleting, as you described.

    The little bit of appreciation your patient provided was like springtime water in a desert, and the blooming afterwards was beautiful. But why deplete yourself so much??

    Now don’t forget to pass on the appreciation – to your medical students, your nurses, everyone. In these times of lean and mean, be the one who can nourish others.

    But first you must take care of yourself.

  4. christopher schemm,md says:

    As residents and interns, we had to take praise where we could get it. Even a silent handshake lets you take a deep breath again. Great experience !

  5. cc keller says:

    I have said for years medical schools and doctor’s training is concentrated too heavily in math and science. Better doctors are those that did have a little more of the baccalaureate studies in their degrees. Broader schooling makes for more creative physicians who can diagnosis accurately. Oh by the way I’m sure you’re nurse ran that code. Doctors are only as good as their nurses who by the way suffer a greater burn out rate because of lack of recognition. Stop waiting for parade and applause.

  6. PGY-4 says:

    Great story….. Hit way too close to home.

  7. f.fallahian says:

    congratulation for your successful CPR.We should learn at work that Sometimes the patients are who learn us and let us to learn more and has the geater impact of work than medical personnels. Always it is a dilemma when to start chemotherapy in a debilitated patient with shortage of nutrition and cardiac reserve and insufficient readiness to accept the cancer disease and is current therapy tolerable and good for him. In this case despite final hopelessness to treatment the patient showed still wanted to live and hope the light candle of life persist more for him!

  8. Sandi says:

    AWESOME STORY! ONCE UPON A TIME I WANTED TO BE AN MD. HAVE THE COMPASSION AND CARING DOWN-PAT, BUT KNEW I DID NOT HAVE THE STAMINA, SO I BECAME A PHARMACIST. MY PROFESSION IS ALSO STRESSFUL AND SOMETIMES GRUELING, BUT IT IS NOT ANYWHERE NEAR THE STRESS LEVEL DR BRATTON DESCRIBES. KEEP UP THE GOOD WORK DOC, WE NEED YOU AND YOUR COLLEAGUES DESPERATELY!!

  9. Peter Shi says:

    I was moved deeply by your story. Doctors working in China also face the same stress from clinic as well as social presure. However, a good result of treatment and the smile of patients are best rewards for doctors. Medicine is a calling profession.

  10. alan says:

    I wanted to concur with you dr. Bratton indeed patients transfer this energy so efficiently it’s almost like the elixir that drives many of us physicians wouldn’t you say so? on the other hand isn’t this so selfish on our part? when i let people know i want to become a psychiatrist the mayority jumps to the economic advantages i will have, and deep within me i crave nothing but recognition, understanding but above all the pleasure/energy/”that something” derived from helping.

  11. alan says:

    #5 it’s sad to refer to these circumstances as a parade and applause when they are so intimate between caregiver and the receiver but who knows everyone’s got an opinion

  12. AVA MD says:

    You hit it right on the mark.

    Thanks for writing this– you acknowledged the plight of all of us in residency– what we face everyday. I’ve wanted to be able and explain what we go through as residents- to family and friends but haven’t had the words. It’s funny because I have used the exact words of recharging my battery— because that is what it’s like.

    Appreciated much… and may you always have that patient that recharges your batteries ;) it’s easy to forget why we’re here- half comatose; yet trudging forward– and then we are given the gift of that awakening to truly remember our purpose… and what brought us to this life in the beginning :)

    well said.

  13. Beverly Crusher says:

    I’m on the precipice of entering medicine and your article is quite a wake-up call in reflections of my possible future self: “Moreover, you see yourself: tired, unshaven and in need of a haircut, pale from not seeing daylight, 20 lbs heavier – thanks to late-night McDonald’s runs – and $200,000 in debt.” Although these initial descriptions resonate quite an emotionally drained state-of-mind, your epiphany of the ineffable service you provided the patient radiates a lot of hope for your own self-reflections on your future as a physician. How about thinking 10 years ahead when you have these visions: “you see your friend who graduated from college with a 2.0 GPA is running his own business; the guy who cheated off you in biology …. and the girl who was clearly in college for her “Mrs.” degree…” Who will you be in 10 years (a successful physician – don’t doubt it) and who will they be? Why does it really matter? Great article!

  14. Lorraine McDonald M.D. says:

    I loved reading this. Reminds me of a patient I accidentally resuscitated in the ICU in my residency (had a DNR). “Mr. X. we just shocked you because you were in cardiac arrest. Did you feel that?”
    “HELL YES!”
    “I was not supposed to do, that according to your chart, but if this happens again, should I shock you again?”
    “HELL, YES!”

  15. DocTracy says:

    Dear Dr. Bratton,

    You are such a wonderful writer. Very much looking forward to your future contributions.

  16. Vineeta Gupta says:

    Excellent story. Thanks for sharing. There are moments like this in every clinicians life and they give you courage and hope to go on.

  17. Fernando Ramos M.D. says:

    An appealing text! I agree with the general description of your professional feelings that are a common rule among us, but burnout is not far away. After 25 years working as a hospitalist,I am convinced that patient’s gratitute is the main fuel of our professional life, but please take care of yourself if you intend to continue helping the people for years. A good salad and fresh fruit, good music, a glass of good wine with your friends (why not?), and a refresing spring walk after leaving the hospital would be a good alternative to MacDonald’s way of life and the best way to love medicine forever.

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