In the Shadows of Death
 

(1) I rushed out in the small turnout car and found myself 10 minutes later occupied with the ritual resuscitation of a miller - ritual because the mill was situated too far away from Lörrach to enable any success, in particular while nobody (as usual) had laid hand on the miller after he suffered cardiac arrest until the ambulance came, almost simultaneously with me. It would have been too complicated to discuss such matters with the relatives who, on the contrary, often expect a certain cardiopulmonary resuscitation [CPR] carried out, so it is easier to do so, even if it occasionally appears theatrical. This is the last honour which is carried out, and it can be done more or less energetically. Less, if the procedure is ended within some fifteen minutes, more if it takes much longer and results in the admission of the non-stabilized patient in a hospital, enabling the relatives more time (up to several weeks) to prepare for the coming decay. Please do not think that I am ignoring that some people survive their prehospital cardiac arrest but these patients are found under different circumstances, to be recognized rather fast by the professional, and then it is unfair to speak of any ritual.

But back to the miller. This time it lasted seven minutes, then he had received his endotracheal tube, cardiac massage, electroshock with or without medical reason and I had placed a central venous line, a matter of exercise. During this time I also experienced that the poor man was a mere invalid due to cardiac problems after his second heart attack. The relatives would recognize that it was the best for him if destiny's advice would be followed, where after I with a deep voice announced that now, exactly now, it was all over, that the patient had not suffered under our rough therapy (at least, that was true) and whatever you use to say on such occasions. And then it happened that the widow meant that we deserved something extra for our trouble. The ambulance men and I each received a sack of flour, the natural product of the mill. Driving back towards Lörrach, I was soon forced to stop as I came to think of an old Danish saying (meaning: one person dead, the other person's bread) and my reaction to that was not compatible to traffic safety.

How does one turn our to become so rough? It is probably a necessity in order to carry out this profession that its sad aspects are isolated in order to practice some humanity on other occasions. Partly, it is also a consequence of the exaggeration of CPR, not to be understood as a complaint against the relatives who, until a few minutes ago had made no thoughts that their dear one would soon have a rendez-vous with death, and probably a permanent one. Of course, I have always been deeply moved by dead children, but even in the cases of cot death did I avoid admitting the children to a hospital since the babies, in contrast to most adults, had usually been dead for hours when they were finally found, and that was possible to establish. Among those whom I believed might have a chance and therefore admitted to hospital, about one quarter survived, 1-2 annually (more after a new resuscitation principle, see later). This is in contrast to most emergency physicians who tend, once CPR is started, to admit most patients to a hospital (often under continued cardiac massage during transport), to a prolonged death and hardly more often to their survival.

So even when this behaviour may appear theatrical - as any ritual in fact is, - then there really is a humanistic aspect associated with it, in not pretending that there is something to hope for. Most of the patients had lived their life before and, had it been possible to discuss it with them, would prefer to abruptly rather than go slowly, through a prolonged intensive care therapy, even in cases where there was a faint chance of survival. In other cases, time was up against any attempt, or the passive spectators should have been active before we arrived. And then there were those who just had enough of life, without being able to bring it quite to an end before we arrived. How would you have reacted in my place in the following case?

(2) It was just nearby and I arrived simultaneously with the ambulance. The police was already there - in fact, they had required us, and then there was the wife who had called the police. Her husband had shot himself in the head with a large calibre gun, in the temporal region, just as they do on film. What they do not show on film is, that this is a stupid direction, sometimes "just" causing blindness and rarely death immediately, if at all. But this was a large gun and a part of the cranium and the brain was missing. Unfortunately, the man was still alive and the paramedics prepared for an intubation (a tube leading down to the airways, securing these against aspiration of gastric contents and enabling artificial ventilation). His wife told me that her husband suffered a lung cancer in a progressive stage, causing pain and breathlessness, and this was confirmed by letters from a hospital. Having read this, I declined making any intubation. The paramedics were surprised, knowing that I had a low threshold for performing this measure, but then wanted to prepare evacuation and transport. That, too, I declined, saying we should just await what happened with the comatose and steadily bleeding man. Not being familiar with doing nothing, one of the paramedics fled down to the waiting ambulance while the other stayed. It lasted 18 long minutes before the poor man finally died, and during this time could I ponder about how much more easy it would have been just to deliver "maximal therapy", as most emergency physicians would probably have done. Indeed, I should easily come into trouble if any of the persons present had attempted a forensic process against this passive behaviour - at least, here I found understanding.

I had several encounters with shotguns, though always in connection to suicidal attempts, of which other two shall be reported. This gave me some experience with the various calibres, although you could never quite know what came out of that.

(3) I was on my way home with the turnout car as they told me that the police had seized a house where a man had threatened to shoot himself. They negotiated with him, mediated by another doctor, but in case of a shooting they would appreciate the presence of an emergency physician. I stopped the car nearby and waited for a quarter of an hour but then decided that "the dog which bells does not bite" and still, if anything happened, they could call me from my home which was not so far away. The following three hours seemed to confirm my prophecy but then the man suddenly ignored the ancient proverb and shot himself in the head, the same route as describe for the previous mission but with a small calibre gun. The patron had not enough force to penetrate the second wall of the cranium and was instead reflected. I came, saw and intubated, then transferred the patient to the University Hospital of Basle (Kantonspital Basel) where the nearest neurosurgical department was situated. Although Basle is situated in Switzerland and thus "abroad," it is the biggest suburb to Lörrach (or reverse) and we have an unproblematic co-operation with their hospitals and, in particular, with the trauma centre when seriously injured persons are dealt with. In this case, a computed tomography [CT] was performed. The neurosurgeon showed me the CT-recordings and told that the patient would probably not survive this massive brain injury - besides, they did not intend to perform a big operation upon a patient who just tried to commit suicide (something the Swiss doctors have always expressed clearer than the Germans who do not appear to know any limits what big dubious projects are concerned), so would we be so kind to transport the patient back again, then we could clarify the formalities in Lörrach. It sounded plausible and was carried out as suggested, with the important exception that the patient did not suffer any brain death. In the end, the patient was discharged to a nursery home with serious brain damage after having contradicted the prognosis for the second time. We may be as good as mediocre medical doctors but quite miserable as prophets.

(4) And then I have also met a real murderer. It was a rather prejudiced encounter, he was dead as I met him. He had just shot himself with a large-calibre gun while his car was still moving and only later stopped by some bushes. This time, the direction of the shot was beyond any criticism and it caused the desired effect almost instantly. I arrived ahead of the ambulance ("the furniture van," as we call it, referring to its luxurious equipment and speed when climbing a mountain of which there are so many here). Beside the car were some unshaven men with a primitive outlook. After having determined the death of the culprit in a few seconds, I told them: "Please step aside, gentlemen, the police will soon be here!" They all laughed and one of them kindly told me: "We are the police." Later I was told that the suicidal victim had murdered two women in advance, now was persecuted by the police and driven towards a road block. Recognizing that further escape was impossible, he left the road and used his weapon against himself.

(5) Upon another occasion, it was not the murderer but his victim I met, who had been stabbed and lied in a pool of blood. He was already dead as I arrived and a brief, colourful resuscitation attempt ended with the recognition that aorta had been hit by the knife. Since it was at first not obvious, who had delivered this fatal strike, I tried to help the police by limiting the scope of possible culprits: "It is certainly none of our surgeons, I have never seen any of them working so fast with a knife!" Proudly I can announce that I proved to be right, when the murderer was arrested 2 days later.

(6) Again, I must pray for excuse for a tough behaviour, developing with an increasing occupation as emergency physician, but it was difficult not to smile a bit after having informed the vainful end of a resuscitation attempt in the middle of the night to the young, lightly dressed lady who then, shocked by the information, answered, "Oh God, then I shall have to call his wife."

But enough talk about the dead ones. Fortunately, we were predominantly dealing with living subjects and rather often in a successful manner; that is, if you do not understand "success" as necessarily "life preserving", which is a quality that is impossible to measure. The dead ones (e.g., after accidents) would probably have been dead all the same and we were by far not responsible for all survivors, although I am sure that there were cases in whom exactly our therapy was responsible for the difference. Most importantly- and that one can demonstrated, - is that it was almost always possible to remove any feeling of pain and respiratory distress, also among those who could not be saved. Unfortunately, my attempt to let the emergency physicians classify what they are doing (and thus moving therapy into focus) instead of the degree of severity of injury or disease (diagnosis) has largely failed.

(7) Another experience from the stabber’s world deserves mention: I had once been able to talk one out of an attempted suicide by a long knife, accepting certain compromises not to be revealed here. This tactic failed the next time I tried it. Whether I had said something wrong or not, I do not know, but all of a sudden the man violently stabbed himself in the stomach. The police officers present immediately overpowered him, while I left it for them to fight alone. Afterwards, I was performing an anaesthesia upon the severely bleeding man, a strange feeling to treat a patient fixated in handcuffs. We were in a hurry and the hospital not far away, so I did not inspect the wound further, which we had simply closed with a dressing. As we arrived, I explained the observed "hara-kiri" to the admittance physicians. However, after having found that the wound was rather superficial, one of them answered: "This can only be carried properly out by the japanese!"

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New methods incidental appearance.