Cracking the Code
I am a medical student in Pavia, Italy, doing my fifth year out of six. It is summertime, and, as I've done every summer for years, I've returned to my small hometown in the south of Israel. There, among other things, I volunteer as an emergency medical technician (EMT) with Magen David Adom, the Israeli Red Cross.
It's 7:30 on a Friday morning. I'm at the Red Cross office, talking with the paramedic and a doctor, when a young volunteer runs in.
"There's a car pulling up outside--they're bringing an unconscious patient!" he says.
The paramedic goes to get the advanced life support equipment, and the doctor and I quickly go out to the car.
The patient, a pale, eighty-year-old women, sits in the front seat. Her family says that she complained of chest pain, so they drove her here. She lost consciousness on the way.
We whisk her out of the car and begin chest compressions right there on the pavement. The equipment arrives almost instantly, and we have plenty of staff and volunteers around to help perform CPR. Even though this is the paramedic's first case as a licensed practitioner, he stays calm and runs the code very well. Soon we're also joined by a senior paramedic.
As we work, the patient's family members stand a few feet off--some crying, others trying to calm them down, and more showing up all the time (it's a very small town).
In the past, when helping with CPR, I used to focus solely on saving the patient. Whenever I couldn't--which was most of the time--I felt sad, frustrated and filled with self-doubt. Maybe we should have tried bicarbonate, maybe I was too slow, maybe I didn't run the code well....
Now, though, my focus has changed. As part of my MD thesis, I've been studying the issue of family presence during CPR, and it's really shifted my perspective.
The existing research, I've found, supports the value of allowing family members to be present during a loved one's final moments. Many CPR survivors report that they could feel their family's presence in the room, and that it helped them get through the procedure. Virtually all the family members who had been present during unsuccessful CPR felt that being there had eased their grieving process and would elect to be present again. And most healthcare professionals who've experienced family presence during CPR have reported positive effects for both the family members and themselves.
This is the first code I'm participating in since learning all this. Now, as in the past, the patient's prognosis is poor; the difference for me is that I now feel that we should focus on treating the patient's family as much as we're focusing on treating her.
The woman's daughter, a middle-aged woman of Moroccan descent, stands nearby, crying. I walk over to her.
"Mrs. Cohen, would you like to come and sit at your mom's side and talk to her, perhaps touch her, while we are performing CPR?"
"Yes," she answers. "Thank you."
For me, from this moment on, the patient becomes more than a patient: she is Mrs. Levi, Mrs. Cohen's mom.
Mrs. Cohen sits there with tears in her eyes, talking softly to her mom and caressing her right arm with both hands. Somehow her hands end up on either side of the EMT's leg as he performs chest compressions. This is a bit awkward for him, but other than that, she doesn't interfere--that is, she doesn't faint, hit us, scream or tear out her hair.
To me, it's a whole new experience. The CPR has become secondary. Our presence as a crew--my presence--has become somewhat less important. Instead, it's just a mother and a daughter, alone among many, saying their last goodbye. I feel glad; it feels like I'm actually helping someone.
Ten minutes pass. Then the senior paramedic turns to Mrs. Cohen.
"Madam, you're interfering with our work!" he says. "Please step aside and let us treat your mother."
She obliges. I decide not to confront him about it right at this moment.
We continue CPR, but for me, it doesn't feel the same.
After another thirty minutes, the doctor says, "That's it. We can't do any more for her."
He and the paramedic go to speak with the Mrs. Levi's family. Because we are Jewish, and because it's a Friday, they will bury her within a few hours in a nearby cemetery.
In the aftermath, with the body lying inside the ambulance by the building, and family members, friends and police still jostling about, I approach the various medical personnel individually--the doctor, the two paramedics, the volunteers.
"How exactly was Mrs. Cohen in your way?" I ask the senior paramedic. "Why did you tell her to step aside after the paramedic had allowed me to invite her to come closer?"
"I also invite the family sometimes," he answers. "But this wasn't the right time or place."
The junior paramedic says, "Look, it was reasonable in this case, but would I do it again? Who knows?"
The EMT volunteers--ages sixteen to eighteen--echo the more experienced healthcare providers: "It interferes with our work...It might be traumatic for the family."
Worst of all, the physician says, "As a medical student, you're supposed to listen while we talk to you about cases. You shouldn't try to educate us."
I try to understand their viewpoints--and to get them to consider mine. But I fail in both regards. Now I have a new frustration to think about when I'm helping with a CPR attempt: How do I, as a medical student, convince senior clinicians to change the way they do things?
Simply put, I believe that patient's family members have a right to be present when a patient is dying. Although I've seen some successful resuscitations, in most cases the patient is beyond rescue. And so I want to ask: Considering that the chances of successful CPR are so slim, shouldn't we look beyond the patient to his or her family? Shouldn't we focus on their welfare, too?
A loved one's last moments of life are also the family's last moments with the loved one. We need to remember that. The patient isn't just a patient; it's Mom.
About the author:
Zohar Lederman is in his last year of medical school in Pavia, Italy, and also studies humanities in the Open University of Israel. He hopes to do a residency in primary care in the United States, as well as a PhD in bioethics or medical humanities. "I have been writing ever since childhood, and it has helped me through many difficult periods. Luckily, medicine is a never-ending fountain of wonderful stories, both happy and sad."