The Curse of the Chaperone

Medicine is an interesting field that is a mix of science, ethics and art in a way. There is an art in how you apply theoretical knowledge, and a science behind the art of practicing medicine.

For a field that is quite objective and founded on the scientific approach (ie hypothesis based testing and evidence based practice), it seems a bit odd that there are still some superstitions held by practitioners. In emergency departments for instance, one should never mention the “Q” word (which in this case refers to the word quiet), lest there be a sudden increase in patient numbers with complicated issues and emergencies.

Taking that outside of medicine, I tend to believe that there are people that seem to bring trouble all around them ie that they are a “shit” magnet. I’ve heard many colleagues say that about themselves – everything seems to be going well, until the said person starts their shift, and then all hell breaks loose. Or that other person that just seems to bring about rampant chaos around them. A colleague told me that when they started their first shift as a general physician registrar, there were 3 metcalls during her first shift.

Yesterday, I did a shift of house call doctoring. A 6 hour shift. There were quite a few unusual things that happened during this shift, and perhaps it was just coincidence, but to the superstitious, you could attribute it to something other than just pure coincidence.

Perhaps the first sign of something not right, was the fact that I was sent off to see patients in another city, rather than the city I was living in. Then there was the fact that there were bookings from patients who logged jobs over 5 hours ago. I later found out that apparently 2 doctors who were supposed to be seeing patients where I was working had called in sick.

The chaperone (my driver and colleague who helps sort out the medicare details, bookings and phone calls – non medically trained) was a female who looked in her late 30’s to early 40’s. Very talkative and friendly, but appeared to speed quite a lot in the car. A few minutes into the drive, and she informs me that “people seem to say I’m a shit magnet”. At that point, I think it’s probably just coincidental.

In total, there were 18 jobs booked in, although I managed to see 13 patients only, with a few cancellations, and 1 job taken off and assigned to another doctor. I saw my last patient at 11:28pm, and advise that we should get going home.

10 minutes down the freeway, it’s pitched dark, with barely any cars around. On the left shoulder is a truck parked with hazard lights on. Twenty metres on, and I see a man on the side of the road face down.

“Oh my goodness, there’s a guy on the road” I mention to the chaperone.

“Oh, do you want me to stop and go help?”

I hesitate for a moment. We had passed the man for a good 50 metres, and I was concerned about reversing backwards on a busy freeway. I thought to myself that it was probably a drunk person on the side of the road. The car slowed down from 100km/h to 50km/h.

“Yea ok. Let’s go check it out.”

I start to feel some panic as I step out the car. What if it’s not just a simple case of someone passed out drunk? I walk out calmly and approach the scene. Three bystanders are on scene, with one other crouched over the man. At this point, my worst fears are realized. On the road, was perhaps a litre of blood, some of it congealed and caked. Above the man, is a bridge overpass about 10 metres high.

“Hi there, I’m Dr X, a house call doctor. What’s happened?”

“I just got here a moment ago, and found him on the ground. I’ve checked all pulses including pedal pulses but can’t find anything.”

I later established that he was a medic previously. I attempt to check a radial pulse, but don’t feel any. Of note is the icy cold hands. I put my stethoscope on his heart, and hear no heart beat. I open his eyes and check for pupillary reaction, with dilated non responsive pupils greeting me back.

This patient has died already. CPR won’t do anything. Where is the ambulance? What am I doing here?

“He’s not responsive. Should we start CPR?”

I snap out of my daze. The medic was right. We needed to start CPR no matter how bleak it was. CPR on a probable corpse was better than no CPR, because there could still be a very slim chance the man was still alive. We roll him onto his back, and take turns doing CPR. The medic started first. With each chest compression, blood foamed out of his mouth, with the tongue rhythmically moving in and out of his mouth. I attempt to do a jaw thrust, which seems to help prevent the tongue coming out. I ask the chaperone to get the guedel’s airway out, which I use to some effect. Unfortunately, my car has no defibrillator, nor any bag valve mask, so we end up just doing CPR for about 8 minutes before the ambulance arrive on scene. The police arrive later as well.

When the ambulance arrive, I let them takeover. They continue for a further 15 minutes. The medic approaches me, advising that him and the paramedics have noticed clear fluid leaking out of his ears. An extremely bad sign of cerebrospinal fluid leaking out. An ECG tracing is taken. From the distance, I look at the printout and note a flat tracing. A white towel is draped over the man shortly. My chaperone and I leave the scene later on.

“This would be the 5th incident that I’ve witnessed or participated in CPR of someone,” says the chaperone in a matter of fact manner on the drive back home.

It gets worse.

“I’ve also been involved in 13 car accidents in which I was a passenger. 4 of them resulted in fatalities. I have witnessed 4 other accidents as well in which CPR had to be performed. And I was also a passenger in an aircraft accident on the runway”.

I can understand if someone is involved in a car accident with a fatality occurring once in their lifetime, but this chaperone has witnessed it 4 times! I am in shock of this chaperone, and I can understand now why she was a “shit” magnet. Maybe this person really was cursed in a way. I certainly thought nothing eventful would come from my shift, but even on the way home, something like this happens where I witnessed a horrific fatality.

The curse of the chaperone? Or merely a coincidence?

The Issue of Brain Dead

I think perhaps one of the most horrible things that could happen to someone would be to be ‘brain dead’. Now I’m sorry to anyone if my use of the term ‘brain dead’ is offensive, but I simply don’t know any other way to convey a more concise meaning, without being too wordy. The alternative is something like “loss of higher cerebral functioning secondary to brain hypoperfusion”, which is a handful. I do feel it is less offensive than the term ‘vegetable’ however. So I’m going to use the term ‘brain dead’ throughout. I’ve seen the term used in my medical lectures too, so I’m assuming it’s not necessarily as offensive as it sounds.

The state of being brain dead; it’s a mysterious state – the state of existing, but having no existence mentally.

The person essentially, just exists, sort of like how a desk just exists. The person still has relevant physiological processes occurring, like the body can maintain itself plus a little bit of support from external sources like ventilators, but there is no deeper cerebral function to actually define a brain dead person. The person loses all personality, loses all abilities to make judgements, loses all their emotions, for none of that they can possibly do.

And that is just the tragedy of facing such a situation. A person who once had a uniqueness about them, who had a character and personality that defined them, are no longer there anymore. And it happens so suddenly.

Speaking back from one of the first such patients I had encountered, it was very sad. The patient was in her mid 30’s. Three weeks prior to presentation to hospital, the patient had some cosmetic procedure of varicose vein removal. Two weeks after her surgery, she started getting some leg swelling, and some shortness of breath, but ignored such signs. It wasn’t only until another week afterwards, that when she saw the GP, she collapsed in front of the GP, having cardiorespiratory arrest, with the GP having to provide full CPR. The estimated downtime of lack of perfusion to brain was around an hour. The patient had had a massive PE secondary to DVT developing in her legs.

Investigations I believe, showed her to have a massive saddle embolus, which caused her sudden collapse.

The prognosis from the outset of hearing her presentation wasn’t good. A full hour of no brain perfusion, would certainly lead to irreversible brain damage. Seeing the family was heart breaking, as the husband held his wife’s hand, and ran his fingers lovingly through her hair.

There were hopes of the patient surviving, as there were talks that the patient was spontaneously breathing. But I’m not sure if it was a reliable finding or not.

CT brain scans however, confirmed the worst possible news; there were irreversible brain changes, with loss of white matter differentiation, and changes consistent with someone who was ‘brain dead’.

The thing that makes it so sad is the young age of the patient, and the fact that something so devastating happened from a procedure that had cosmetic value only.

A few days afterwards, I heard that the surgeons were busy retrieving her organs for organ donation. To me, it is very noble of the family to allow organ donation to proceed ahead, and I’m sure no doubt that the doctors bringing up such a topic would have had a hard time in doing so. The fact that someone beloved does not mentally exist anymore, and then to have them get asked whether they would like for doctors to extract all healthy organs would be even more traumatizing.

Seeing the patient during my ward rounds was something that still kept me thinking. She exists in terms of being alive, but she doesn’t exist, because she is no longer who she used to be.

I remember my registrar saying that she hoped this patient dies. Taken out of context, it sounds like something really horrible to say. She added on later “because if she didn’t she’d be continually suffering, and putting her family through suffering.” In that regards, I too had the same wishes as my registrar. The suffering would be too great for her and her family.