Household Words Chapter 4

Household Words

A weekly periodical examining a rather extraordinary clinical encounter.

Chapter 4

“Telling us to obey instinct is like telling us to obey “people.” People say different things: so do instincts. Our instincts are at war…. Each instinct, if you listen to it, will claim to be gratified at the expense of the rest….” CS Lewis

As we turn the final pages of our narrative, it would be deeply pleasing to arrive at a dramatic denouement, a satisfactory closure equal to the drama of the life and death moments that brought us to this point.  Alas, it is not to be.  Or is it?  Read on, and you may judge for yourself.

But, before all is revealed, there is one final discourse on the Emergency Department management that is worth deconstructing.

How do we behave in situations, heretofore not encountered, and possibly unimagined?

Again referencing some of the titans of #FOAMed, it is worth considering the words of Scott Weingart (1), Cliff Reid (2) and (3) and Reuben Strayer (4). These posts have explored a phenomenon well studied in the athletic world, whereby mentally rehearsing a set of physical actions, in specific order, and in representative time, can significantly improve one’s ability to perform those tasks.  It makes excellent sense in a setting such as critical care, whereby tasks can be complex (eg thoracotomy) and require performance in a stressful, time-poor environment. They examine tactics such as logistics/strategy and cognitive readiness.

This, however, was a situation that one couldn’t have previously envisaged.  One just has to rely on instincts. And they will sometimes be wrong, but one has to make peace with oneself, and hope that the line “ I did the best I could” is true and honest.

For excellent treatises on the decisions we make in the heat of the moment, I also recommend ‘Blink’ by Malcolm Gladwell, and ‘Thinking, Fast and Slow’ by Daniel Kahneman.  With experience and knowledge, our instincts can be very reliable in many situations.  But not all. And I don’t know, again, where the final axe falls in this particular story.

We left our man, up on the coronary care unit, methodically having removed his pacing wire. What transpired after that is the following:

  • His myocardium had recovered sufficiently to conduct pretty normally, and his pacing wire was not replaced
  • He was discharged from hospital within the week.
  • He had a PPM placed non-urgently as an outpatient.
  • He has had several visits back to our ED with unrelated, non life-threatening presentations since, but I have never seen him.

As far as I can see from his medical notes, there has been no documentation of further discussions about the wish to end his life.  He was commenced on an antidepressant by the Psych team, but there is little evidence of the complexities of the issues being further discussed.  I would dearly love to have provided a more dramatic end to the story, and I apologise for the disappointment, however this is a true medical case, not a story of invention.  When I have quizzed the ED staff about his demeanour when they have seen him subsequently, they only report that he shows an irrational fear of blonde female doctors :-/

As to the quote by CS Lewis, author of the Narnia Chronicles, which I devoured in my youth, I shall be forever grateful for that frisson of excitement when I walk into a wardrobe.


(1Mind Resus Doc Logistics – Scott Weingart

(2) It’s up to you... – Cliff Reid

(3Life, limb and sight-saving procedures – Cliff Reid

(4) The usual state of readiness - Reuben Strayer

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  1. Duncan says

    I would see this as a massive fail by the other specialties (or at least, failure of documentation). The time to establish the answer to the hypothetical question “should he be resuscitated in the event of a similar future scenario” is now, when his cerebral perfusion and mental state can be unequivocally defined. Although the risks of that happening are relatively low, lightning does occasionally strike twice.

    However, given the frequency of the out-of-hours presentation from the long-term nursing home resident with no useful transfer documentation and no discussion with patient or family about end-of-life care (although the flowers and music for the funeral have been chosen and thoroughly documented), it would seem that this is not an isolated case of putting something in the ‘too hard’ basket.

  2. james cuthbertson says

    Sally -- Perhaps the elective PPM was sold to him as a means to avoid further repetitive blunt chest trauma?