The Superhero Mythos: A Medical Student's Experience of Death

I had never seen anyone die before, but in the second week of my penultimate clinical year as a student, that all changed.

It was my first day on the ICU rotation in a hospital, and I was assigned to the Outreach Team at the hospital, a group of experienced senior ICU nurses who provide first response to emergency calls made anywhere in the hospital, like a mobile resuscitation team. We had just started the afternoon shift when we received our first call: a cardiac arrest on the medical ward. By the time we arrived, someone was already giving chest compressions to the 77-year-old man. Not a moment was wasted—I barely had time to register who else was in the room when the Outreach nurses immediately took charge, each instinctively assuming a niche role: taking turns with the compressions, delivering oxygen, bag-masking, preparing the adrenaline injections. A coordinated team had suddenly materialized out of thin air.

I initially just stood at the end of the bed—the medical student, unsure of his place, even as others in the room took up theirs. My eyes kept wandering to the man's feet, just inches in front of me—two pale pinkish things, rocking gently with each pump on his chest—when a junior doctor slapped her phone into my palm. “Do the timing,” she said. My fingers wrapped around the phone as if the man's life depended singly on how securely I held it. It was two minutes since the CPR had begun.

Just then, a tall, young doctor rushed into the room. “This gentleman, Mr. A, has a son who was visiting him this morning, I believe he's just gone downstairs for a snack. We haven't been able to reach him, but Mr. A's wife is on her way.”

“What's Mr. A's resus status?”

“I think the medical team had discussed it with the family—he is for resus.”

Then he disappeared, perhaps to make another call.

Up till then, my experience with CPR had been limited to mannequins—plenty of second chances, no real urgency. This time, however, someone's life was actually at stake—a real someone, a man who could've been my neighbor, or a stranger I exchanged smiles with on the street on the way to work. The bed recoiled and creaked in protest with the necessary force of each compression, Mr. A's chest bouncing as though pliable.

I realized then how, despite the understated tension in the room, this was one of those forks in life's road where fate is uncompromising and time's quiet strides inevitably pass into either absolute tragedy or utter joy—if not one, then precisely the other, no more, no less.

I found myself unsure if I was prepared for what was about to happen.

I found myself hoping very much that it will be the latter.

I imagined the son and the wife reaching the room in time to see Mr. A, on the bed, unconscious but gently breathing, about to be wheeled out to the ICU. I imagined the pair hugging each other, happy and relieved, and thanking the doctors and nurses, one of whom was wiping the sweat from her forehead. Just doing our job, she will say. Positive emotions would fill the room like premonition, a reflex smile appearing on everyone's face.

But Mr. A was still on the bed—not alive, not (yet?) dead. Someone swapped places to do the compressions. My eyes again hovered to the feet.

At six minutes, the medical registrar announced that he felt a pulse. Mr. A's chest was heaving violently, inflating and deflating like a wet balloon; he was in agonal respiration. I wondered whoever had paired two such words and coined the term? A vulgar divulgence that, yes, even breathing can become an agony.

Still, this was good news.

He was breathing.

The image of someone crouched on the bed over Mr. A, pumping his chest, had ceased. There was less motion in the room, and more quiet—the good quiet. Tension in the air loosened like a slack ribbon, but fortunately the reprieve was only momentary. At eight minutes we lost the pulse again. Chaos recommenced. The room again became full of limbs—moving, grabbing, pushing, aspirating, passing, pumping. Feet scraped incessantly, walking in and out of the door behind me; the bed curtains opened and closed as though by themselves as disembodied heads floated in the vestibule to pass new information, bring new equipment, ask new questions.

“We still haven't been able to reach the son. The wife is on her way,” announced the tall, young doctor, who returned only to disappear again out the door.

Just as he left, a new person appeared in our midst: Mr. A's medical consultant, who had only just reached the scene. “I'm sorry,” she announced urgently, cradling the patient's notes. “I'm sorry, but there has been some confusion. Mr. A is not for resus!”

For a second time, motion suddenly desisted in the room, a bonfire consumed by its own smoke. Elbows returned to their owners' sides. Syringes were discarded, their tips still glistening with a drop or two of amiodarone. Tubes were disconnected, the bag mask put away.

Mr. A was again alone in his bed.

“You can stop the timer,” someone told me, when he saw I was still holding on to the phone. “There's nothing to time anymore.”

And I did.

13 minutes.

People left the room as the nurses cleared up the equipment. We stole a fresh blanket from the unoccupied bed opposite and placed it on Mr. A. “Cover his feet,” they told me. I stretched the blanket down over the toes. Each had already gone pale, almost white, as if soaked in an ice bath for too long.

The bereavement team was paged to manage the ensuing affairs and speak to the family when they arrive; the Outreach Team's work was done. As we left, it kept hitting me that I just saw someone die—not dead, like a cadaver on the dissecting table, nor dying in the way that my other patients had slowly deteriorated over weeks and months, but die, a sudden event, the way a lightbulb flickers then pops into blackness. There, in that room, a moment had passed that's oft-spoken in songs, poetry, stories, films—the moment at which, in some cultures, something ethereal comes to separate the soul from the body, and in others, when the life that once was simply ceases to be.

I wasn't sure what to make of it. This was not like the names crossed out on the handover list because their owners had passed away in the night—a death that I saw in a newly empty bed on the morning ward rounds.

No, this was a man who had initially almost survived—whose heart woke up, for two whole minutes—but later died because we stopped trying to resuscitate him. This was a man whom I knew nothing about except that he had had a cardiac arrest, yet in some ways had learned more of in the ten minutes I was by his bed than I had of any other patient before: how he had a son—still right there, somewhere in the hospital, unknowing, who might've wanted to be there in the room but whom we had failed to contact, and a wife—a rushing wife, a running wife, a wife climbing up the stairs or puffing down a corridor, trying to reach her dying husband in time.

A wife who was perhaps still running, not knowing what had just happened.

It was an awkward experience. I didn't know how to talk about it with the team afterwards and sound casual. In the end, to make conversation, I simply asked, “What happens in the wards after someone expires?”

For the rest of the day Mr. A's death hovered over me like a cloud. Although I understood the DNR was his own choice, what I couldn't help feeling was regret at something like a lost opportunity—or worse, like a betrayal of trust, as if we had deserted a friend in battle.

I kept thinking: What if Mr. A had not had a second cardiac arrest?

Over the next few weeks that nebulous entity called death came up in the topics of my conversations again and again—with seniors, colleagues, friends. I reflected on the inevitability of death in medicine and my future encounters with it. I understood the importance of both respecting a patient's wishes and primum non nocere, but I understood less on how to reconcile the two when they seem to be so much at odds.

There had been nothing physically stopping us from continuing Mr. A's CPR, but we had nonetheless—how was permitting death doing “no harm”?

The answer may lie in the most primordial question in this profession: What is medicine, and what is its purpose? In my selection interview I'm sure I must've said something to the effect of wanting to “save lives”—if not out loud, then in implication. After all, that is how the average person, even the medical student, sees the doctor—it was how I understood medicine when I first played with a plastic stethoscope as a six-year-old, how I envisioned it in my schooling days when I dreamed of it as a career. This exaggerated reality feeds and is fed by society—the heroic doctor on an endless crusade of acute situations in which he regularly triumphs over death, and when unable to, is despondent and chivalrously self-blaming. Despite knowing better, it is easy to get caught up in society's veneration of the profession. Enthusiastic medical students, full of hope and ideals, further reinforce its raison d'être as that of “saving lives.”

Yet, is this an accurate depiction? Sometimes, as in Mr. A's case, a doctor has to decide to not do anything at all, either out of respect for the patient's own wishes, or because nothing good can come out of an all-out aggressive intervention but pilfered dignity. Perhaps doctors no more “save lives” than a clockmaker “rescues” a broken watch, or an engineer perform heroics when he “saves” a bridge. In fact, unlike a clockmaker or an engineer who can prolong the “lives” of their “patients” indefinitely with new parts and replacements, in medicine the patients may be “cured” or “fixed” temporarily, but death is predestined. The age-old battle between life and death is a myth first perpetuated by our medical forebears in the age of poultice and incense, a myth that has become a reality that motivates many, when the truth is that there is no such battle—medicine cannot ward off the inevitable. Yet our culture can sometimes give the impression that death is unnatural, and medical education's intense focus on “fixing,” although rightly so, rarely reminds students of the obligatory yang of the profession. It's the hard reality that we're taught on the wards: how medicine is not only about curing or “saving lives,” but also in having the wisdom to understand that helping is not always in the doing—it is equally in knowing when to stop.

To become a doctor and “save lives,” the quid pro quo is to be comfortable that death is as much a companion along this journey.

Perhaps a better descriptor for medicine, then, is that of a mediator: the doctor who merely plays the patient's advocate in a conversation with Death and Deterioration to reach a consensus agreeable to all, especially the patient, who may sometimes be more comfortable looking Death in the eye than the doctor is.

More so than tablets or crutches, the first thing a doctor prescribes to her patients, on first contact, is hope—the hope that she will respect them and will do her best to help them, not own them; the hope that she will attempt to “cure” or “fix” when she can, yet remain at hand and alleviate when she can't; ultimately, that she will respect their dignity, whatever the nebulous concept may mean.

If we had continued on with Mr. A's resuscitation despite being aware of the DNR, it would've been an act of betrayal—to deprive him of his rights and usurp his body, his choices, and his life as our own.

I have by no means decided that the mediator role (and not “saving lives”) is what medicine truly is about. I expect that my understanding and conception of the profession will continually evolve over the years, especially once I begin to practice, and that I will look back to revise and re-revise these ideas. That said, what my encounter with Mr. A has taught me is that a close acquaintance with Death, however uncomfortable the notion, is inherent in medicine, and that he is such an acquaintance who commands respect, someone to acknowledge the presence of, and not to detest nor reject. When the time comes and Death “imposes” his company on my patient and I. I hope that I will be able to be the better person and play the gracious host, who will remember the distinction between saving lives and respecting the ones he wants to save.