Portal de Periódicos da CAPES

Restored to the Consciousness of this Existence

2001; Lippincott Williams & Wilkins; Volume: 23; Issue: 10 Linguagem: Inglês

10.1097/01.eem.0000288603.21297.9c

1552-3624

Arno Vosk,

Cardiopulmonary resuscitation is not only a medical procedure, but also something that has profound psychosocial, moral, emotional, and spiritual aspects. The first recorded resuscitation in Western literature is in the Old Testament, in Kings I, when the Prophet Elijah brings life back to a child who had apparently died. “And Elijah carried him up into a loft, where he abode, and laid him upon his own bed…. And he stretched himself upon the child three times, and cried unto the Lord, and said, O Lord my God, I pray thee, let this child's soul come into him again. And the Lord heard the voice of Elijah; and the soul of the child came into him again, and he revived. And Elijah took the child, and brought him down out of the chamber into the house, and delivered him unto his mother: and Elijah said, See, thy son liveth.”1 Although some might wonder if Elijah stretching himself upon the child three times is an allusion to some form of artificial respiration, most would consider this less a medical event than a manifestation of the prophet's ability to summon the power of God. Still, anyone who has ever succeeded in resuscitating a child will recognize the feeling of the moment when Elijah “delivered him unto his mother: and Elijah said, See, thy son liveth.” In the small town ED where I work, it is rare to have two codes in one day. One day, a shift started with a paramedic call to a “child unresponsive.” It turned out that a young mother had put her 3-month-old daughter down after feeding her at midnight. Around 8 a.m., she awoke. She had a moment of pleasant surprise that she had been allowed to sleep through the night, but suddenly became apprehensive. She went to the baby's crib and found her pale and apniec. Attempts by the parents at CPR were followed by those of the EMS team, and after the baby arrived in the ED we worked on her for nearly an hour, though it seemed clear to me from the beginning that it would be futile. When we stopped, the room was crowded with physicians, nurses, paramedics, EMTs, respiratory therapists, and various others, but it fell to me to tell the parents and family members who crowded the waiting room and spilled out into the adjacent corridor that there was no more hope for their child. Late that afternoon the paramedics received another call to a “person unresponsive,” this time an adult. This patient was breathing on his own and even muttering in a vaguely annoyed fashion when the medics picked him up at home, and we recognized him as he rolled through the door, although we recalled that most of his previous, and numerous, ED visits had been as a less than willing companion of one or another local authority figure. It appeared that his mixture of drugs and alcohol the previous night had gotten out of control. His girlfriend had last spoken to him before he went to sleep on the couch around 3 a.m. Twelve hours later, she noticed that he was “breathing funny,” had difficulty arousing him, and called 911. This man turned out to have a large aspiration pneumonia. His PAO2 suddenly dropped from 85 to 60 to 50, and before we could get him intubated, he went into a bradycardia that turned into ventricular fibrillation. Fortunately, we got things back in motion after less than 10 minutes. It was again my job to go out to the waiting room to tell his girlfriend, sitting there alone, what had happened. At the end of the shift, I was drinking coffee in the break room with a nurse who had worked with me on both these patients. She said, “I know I shouldn't say this, but it just doesn't seem right. Here is this little child who has all her life ahead of her, who is completely innocent, who is loved by so many people, and we can't save her. Then here is a man who has wasted his life, who causes trouble whenever he is out of jail, someone hardly anybody cares about and most people actually can't stand, and we save him! Where is the justice in this?” Years ago when I began practicing emergency medicine, I felt the drama of every resuscitation, as if it were a struggle with the Angel of Death. Today I am more impressed by the difficulty of other parts of the task, like dealing with the survivors. All I answered was, “Who said there was supposed to be justice? And don't you think, actually, that it is a blessing we don't get to chose who lives and who dies?” Not long after this, reading Our Mutual Friend by Charles Dickens, I found an extraordinary passage dealing with nothing more nor less than the ethics of resuscitation and the emotions of people participating in it. Modern CPR was invented in the 1960s and 1970s, and we who practice it sometimes assume that discussions of the moral issues surrounding it date from around that time. Actually, techniques for artificial respiration and cardiac resuscitation, especially for victims of near-drowning, have existed at least since the 18th century, and for centuries before then efforts were made to revive people who had suffered respiratory or cardiac arrest.2 Readers of Dickens will know that his writings contain numerous passages dealing with medical subjects. If we count the death scenes, there are few of his books in which doctors and medicine do not make an appearance. Dickens had no medical training, but appears to have had friends who were practicing physicians.3,4 In 1863 he was involved in what today would be called a mass-casualty incident. A train on which he was a passenger derailed, and several cars plunged off a bridge into a river. Dickens assisted in rescuing people trapped in the car in which he was riding, and wrote a dramatic description of attempts to rescue other victims.5 This event is mentioned in the epilogue to Our Mutual Friend as a source for some of the material in the book, and it may have been then that Dickens witnessed the resuscitation of near-drowning victims, although it may have been just as likely on some other occasion because he traveled extensively in search of material for his writings. The Royal Humane Society, founded by two London physicians in 1774 as an organization for promoting proven reanimation techniques, was well known in 19th century England. It established rescue stations along the Thames River, and even issued pocket-sized cards for the public containing directions for resuscitating victims of drowning.6 Our Mutual Friend,7 Dickens' last completed novel, published in 1864–65, contains a remarkable scene taking up the better part of two chapters, in which the resuscitation of a man who fell into the Thames River is described. Little is said concerning technique, but there are vivid descriptions of the emotions of the people participating in the resuscitation. Throughout his career Dickens was deeply concerned with questions of good and bad character, and a point he makes repeatedly is that virtue, or lack thereof, is unrelated to an individual's social class. Written nearly 150 years ago, the issues raised in this case are remarkably similar to those heard in contemporary break room discussions after a code. The victim is Mr. Rogue Riderhood, an unsavory character who makes his living dragging corpses and other items from the river, and he is universally disliked in the riverfront community for his devious ways and bad temper. The drowning takes place near the Six Jolly Fellowship Porters, a tavern built on pilings over the water, whose proprietress is the formidable Miss Abbey Potterson. The following is an abridged version of the original text.7 “…(I)t became a noise of clamouring voices and of the stir of feet; then all the windows were heard to be hastily thrown up, and shouts and cries came floating into the house from the river. ‘What is it?’ asked Miss Abbey. ‘It's summut run down in the fog, ma'am,’ answered Bob. ‘Does anybody down there know what has happened?’ demanded Miss Abbey, in her voice of authority. ‘It's a steamer, Miss Abbey,’ cried one blurred figure in the fog. Boats were putting off, torches were lighting up, people were rushing tumultuously to the water's edge. Some man fell in with a splash, and was pulled out again with a roar of laughter. The drags were called for. A cry for the lifebuoy passed from mouth to mouth. It was impossible to make out what was going on upon the river, for every boat that put off sculled into the fog and was lost to view at a boat's length. The cries changing their note, and becoming more fitful and more excited—shadows of men and boats could be seen moving, while voices shouted: ‘There!’ ‘There again!’ ‘A couple more strokes ahead!’ ‘Hurrah!’ ‘Look out!’ ‘Hold on!’ ‘Haul in!’ and the like. ‘How many in the wherry?’ ‘One man, Miss Abbey.’ ‘Found?’ ‘Yes. He's been under water a long time, Miss; but they've grappled up the body.’ ‘Let 'em bring it here.’ Door opened. Heavy tread of laden men. A halt. A rush. Stoppage of rush. Door shut. Baffled boots from the vexed souls of disappointed outsiders. ‘Come on, men!’ said Miss Abbey; for so potent was she with her subjects that even then the bearers awaited her permission. ‘First floor.’ The entry being low, and the staircase being low, they so took up the burden they had set down, as to carry that low. The recumbent figure, in passing, lay hardly as high as the half door. Miss Abbey started back at sight of it. ‘Why, good God!’ said she…. ‘That's Riderhood!’ In sooth, it is Riderhood and no other, or it is the outer husk and shell of Riderhood and no other, that is borne into Miss Abbey's first-floor bedroom…. ‘Fetch a doctor,’ quoth Miss Abbey. And then, ‘Fetch his daughter.’ On both of which errands, quick messengers depart. The doctor-seeking messenger meets the doctor halfway, coming under convoy of police. Doctor examines the dank carcase, and pronounces, not hopefully, that it is worth while trying to reanimate the same. All the best means are at once in action, and everybody present lends a hand, and a heart and soul. No one has the least regard for the man: with them all, he has been an object of avoidance, suspicion, and aversion; but the spark of life within him is curiously separable from himself now, and they have a deep interest in it, probably because it is life, and they are living and must die. In answer to the doctor's inquiry how did it happen, and was any one to blame, Tom Tootle gives in his verdict, unavoidable accident and no one to blame but the sufferer. ‘He was slinking about in his boat,’ says Tom, ‘which slinking were, not to speak ill of the dead, the manner of the man, when he come right athwart the steamer's bows and she cut him in two.’ Mr. Tootle is so far figurative, touching the dismemberment, as that he means the boat, and not the man. For, the man lies whole before them…. There then remain, to assist the doctor and Tom, three other regular customers, Bob Glamour, William Williams, and Jonathan (family name of the latter, if any, unknown to mankind), who are quite enough. Miss Abbey having looked in to make sure that nothing is wanted, descends to the bar, and there awaits the result. If you are not gone for good, Mr. Riderhood, it would be something to know where you are hiding at present. This flabby lump of mortality that we work so hard at with such patient perseverance, yields no sign of you. If you are gone for good, Rogue, it is very solemn, and if you are coming back, it is hardly less so. Nay, in the suspense and mystery of the latter question, involving that of where you may be now, there is a solemnity even added to that of death, making us who are in attendance alike afraid to look on you and to look off you, and making those below start at the least sound of a creaking plank in the floor. Stay! Did that eyelid tremble? So the doctor, breathing low, and closely watching, asks himself. No. Did that nostril twitch? No. This artificial respiration ceasing, do I feel any faint flutter under my hand upon the chest? No. Over and over again. No. No. But try over and over again, nevertheless. See! A token of life! An indubitable token of life! The spark may smoulder and go out, or it may glow and expand, but see! The four rough fellows, seeing, shed tears. Neither Riderhood in this world, nor Riderhood in the other, could draw tears from them; but a striving human soul between the two can do it easily. He is struggling to come back. Now, he is almost here, now he is far away again. Now he is struggling harder to get back. And yet—like us all, when we swoon—like us all, every day of our lives when we wake—he is instinctively unwilling to be restored to the consciousness of this existence, and would be left dormant, if he could. Bob Gliddery returns with Pleasant Riderhood, who was out when sought for, and hard to find. She has a shawl over her head, and her first action, when she takes it off weeping, and curtseys to Miss Abbey, is to wind up her hair. ‘Thank you, Miss Abbey, for having father here.’ Poor Pleasant, fortified with a sip of brandy, is ushered into the first-floor chamber. Crying bitterly when she sees him stretched unconscious, asks the doctor, with clasped hands: ‘Is there no hope, sir? O poor father! Is poor father dead?’ To which the doctor, on one knee beside the body, busy and watchful, only rejoins without looking round: ‘Now, my girl, unless you have the self-command to be perfectly quiet, I cannot allow you to remain in the room.’ Pleasant, consequently, wipes her eyes with her back hair, which is in fresh need of being wound up, and having got it out of the way, watches with terrified interest all that goes on…. It is something so new to Pleasant to see her father an object of sympathy and interest, to find any one very willing to tolerate his society in this world, not to say pressingly and soothingly entreating him to belong to it, that it gives her a sensation she never experienced before. Some hazy idea that if affairs could remain thus for a long time it would be a respectable change, floats in her mind. Also some vague idea that the old evil is drowned out of him, and that if he should happily come back to resume his occupation of the empty form that lies upon the bed, his spirit will be altered. In which state of mind she kisses the stony lips, and quite believes that the impassive hand she chafes will revive a tender hand, if it revive ever. Sweet delusion for Pleasant Riderhood. But they minister to him with such extraordinary interest, their anxiety is so keen, their vigilance is so great, their excited joy grows so intense as the signs of life strengthen, that how can she resist it, poor thing! And now he begins to breathe naturally, and he stirs, and the doctor declares him to have come back from that inexplicable journey where he stopped on the dark road, and to be here. Tom Tootle, who is nearest to the doctor when he says this, grasps the doctor fervently by the hand. Bob Glamour, William Williams, and Jonathan of the no surname, all shake hands with one another round, and with the doctor too. Bob Glamour blows his nose, and Jonathan of the no surname is moved to do likewise, but lacking a pocket handkerchief abandons that outlet for his emotion. Pleasant sheds tears deserving her own name, and her sweet delusion is at its height. There is intelligence in his eyes. He wants to ask a question. He wonders where he is. Tell him. ‘Father, you were run down on the river, and are at Miss Abbey Potterson's.’ He stares at his daughter, stares all around him, closes his eyes, and lies slumbering on her arm. The short-lived delusion begins to fade. The low, bad, unimpressible face is coming up from the depths of the river, or what other depths, to the surface again. As he grows warm, the doctor and the four men cool. As his lineaments soften with life, their faces and their hearts harden to him. ‘He will do now,’ says the doctor, washing his hands, and looking at the patient with growing disfavour. ‘Many a better man,’ moralizes Tom Tootle with a gloomy shake of the head, ‘ain't had his luck.’ ‘It's to be hoped he'll make a better use of his life,’ says Bob Glamour, ‘than I expect he will.’ ‘Or than he done afore!’ adds William Williams. ‘But no, not he!’ says Jonathan of the no surname, clinching the quartette. They speak in a low tone because of his daughter, but she sees that they have all drawn off, and that they stand in a group at the other end of the room, shunning him. It would be too much to suspect them of being sorry that he didn't die when he had done so much towards it, but they clearly wish that they had had a better subject to bestow their pains on. Intelligence is conveyed to Miss Abbey in the bar, who reappears on the scene, and contemplates from a distance, holding whispered discourse with the doctor. The spark of life was deeply interesting while it was in abeyance, but now that it has got established in Mr. Riderhood, there appears to be a general desire that circumstances had admitted of its being developed in anybody else, rather than that gentleman. ‘However,’ says Miss Abbey, cheering them up, ‘you have done your duty like good and true men, and you had better come down and take something….’ This they all do, leaving the daughter watching the father…. The short delusion is quite dispelled now. As plainly as she sees on her arm the old father, unimproved, Pleasant sees that everybody there will cut him when he recovers consciousness. ‘I'll take him away ever so soon as I can,’ thinks Pleasant with a sigh; ‘he's best at home.’ Presently they all return, and wait for him to become conscious that they will all be glad to get rid of him. Some clothes are got together for him to wear, his own being saturated with water, and his present dress being composed of blankets. Becoming more and more uncomfortable, as though the prevalent dislike were finding him out somewhere in his sleep and expressing itself to him, the patient at last opens his eyes wide, and is assisted by his daughter to sit up in bed. ‘Well, Riderhood,’ says the doctor, ‘how do you feel?’ He replies gruffly, ‘Nothing to boast on.’ Having, in fact, returned to life in an uncommonly sulky state. ‘I don't mean to preach; but I hope,’ says the doctor, gravely shaking his head, ‘that this escape may have a good effect upon you, Riderhood.’ The patient's discontented growl of a reply is not intelligible; his daughter, however, could interpret, if she would, that what he says is, he ‘don't want no Poll-Parroting’. Mr. Riderhood next demands his shirt; and draws it on over his head (with his daughter's help)…. ‘Warn't it a steamer?’ he pauses to ask her. ‘Yes, father.’ ‘I'll have the law on her, bust her! And make her pay for it….’ He then doggedly demands his other garments, and slowly gets them on, with an appearance of great malevolence towards all the spectators. He has an impression that his nose is bleeding, and several times draws the back of his hand across it, and looks for the result…. ‘Where's my fur cap?’ he asks in a surly voice, when he has shuffled his clothes on. ‘In the river,’ somebody rejoins. ‘And warn't there no honest man to pick it up? O' course there was though, and to cut off with it arterwards. You are a rare lot, all on you!’ Thus, Mr. Riderhood: taking from the hands of his daughter, with special ill-will, a lent cap, and grumbling as he pulls it down over his ears. Then, getting on his unsteady legs, leaning heavily upon her, and growling, ‘Hold still, can't you? What! You must be a staggering next, must you?’ he takes his departure out of the ring in which he has had that little turn-up with Death.”