Are We All Agreed?

I’ve been watching the new series of Junior Doctors, which has been on BBC 3 for the last month and this year is set in the Royal Liverpool. It’s a very surreal thing to watch – not like during Series 1, when I was a fourth year medical student and being a proper doctor was just far enough away that this was all a bit exciting, and, besides, that was in the hospitals that I had grown up around; and not at all like Series 2, which aired right through written finals and less than five months away from graduation and, well, I never worked up the nerve to actually watch it. Series 3 shows five doctors who started working on the same day that I did, and now I have these memories that run almost in parallel to the things I’m watching on TV. I find myself having flashbacks to things like wanting to vomit the whole way to work on my first day and trying not to giggle the first time I had to tell someone I was a doctor.

And so when Emily talked a few weeks ago about the death of one of her patients, I remembered being that doctor and that the first time I agreed it was time to stop was the single most heartbreaking thing I’ve done in the last six months.

It was a weekend, I think. Perhaps. The days all merge together in the end until one day you look up and it’s February. I had never attended an arrest before. Not really. I had been to never-mind-patient-just-fainted arrests and patient-drank-coffee-while-having-five-second-runs-of-asystole arrests and oops-thought-that-was-the-light-switch emergency buzzers. I had one day when the arrest pager went off five times and none of them were an arrest. I had done all of the  adrenaline-racing pager-going-off-on-the-loo pounding-up-three-flights-of-stairs-in-dress-shoes… and then I had turned around and walked back down the stairs and back to my day job. It was a joyous state of affairs, but one that could hardly last forever.

On that day, I was drinking coffee and writing a discharge letter when my pager started in with rapid sequence of bleeps that mean “on your marks” and the fuzzy hiss of static that means “get set”. And, on that day, when I arrived on the ward with the rest of the team, I didn’t arrive to never-mind-patient-just-fainted or to oops-thought-that-was-the-light-switch. I arrived in Beirut.

I remember wondering what the other patients in the bay must have been thinking.

The noise hit me like a brick wall, muted through the pounding of my own blood in my ears.

For a split second, the only thought I had was, “Shit, this is for real.”

And then I waded in.

In the chaos around about, there were people putting up fluids and trying to get a better venflon in and looking for somewhere to take a blood gas and getting out the emergency drug box and leafing through medical notes. I think I ended up taking control of the airway.

He was a patient who I hadn’t known before. I don’t know why he was in hospital or what had happened to take him to that point. I think he was pre-op, or post-op, maybe, but I don’t know for what and I might even have just assumed that because of the ward he was on. I don’t know his name. I could describe him, perfectly, what his face was like in that moment, but he didn’t look like that before I met him and I don’t think he would have wanted people to remember him the way I do.

They asked if I could take over CPR. I nodded. It isn’t like the training. It’s a million miles away from the air conditioned room and the mannekin and Nellie The Elephant. My stethoscope and ID lanyard were on the floor, thrown there when they had started to get in the way. I thought, with my lungs burning (“watch it, Beth, there’s a sharp coming out near your leg”) and heart racing (“third round of adrenaline in”) and muscles screaming (“has the gas come back yet?”) and sweat starting to roll down my neck (“still in asystole, continue CPR”), that if this was it for him, this would be a horrible way to die, so please, I thought, please don’t, wake up and just stop being dead, stop it now. It doesn’t get more personal than this. “We aren’t letting you die,” I heard someone mutter. “You aren’t dying, not today. Don’t you dare.”

It felt as if we were there for hours and at the same time for no time at all.

And then the noise stops. At the beginning of an arrest, there are bloods to be taken and access to be got and drugs to be given and things to be found out and problems to be fixed. Later, all of the things that can be done have been and all of the things that can be fixed are being and the only noises left are the quiet occasional hiss of the ventilator bag deflating and the odd grunt from the person doing CPR.

The consultant took a breath in. “I think going on now won’t make any difference,” he said. “I think we’ve done everything that we can. Does everyone agree that we should stop? Does anyone object?”

We had done everything that we could. We had.

“Thank you,” he said.

Afterwards, I had picked up my stethoscope and ID from where they had landed and I had walked back down the stairs and was going back to my department to somehow get on with the rest of the day. The living don’t go away just because the dead are dead. On the way, the colleague I was walking with offered me a hug that I fell into, crying like I had managed not to upstairs, and I have seen some awful things in the six months that I’ve been doing this job and in the two years before that, but being in that room, with that man and on that day and at that time, that is the thing that I will never ever forget.

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13 comments

  1. It is a bit late for a virtual hug on this one. Have one anyhow. It is hard for a non-medic to say anything useful – except, I suppose, that I don’t think I much care what last images I leave in the minds of my medical team when the day of death comes as come it must. And it is always a pity when that day comes too soon, and I would probably care more about whether my day came a bit early (left it too late for VERY early!) or happily late, if I thought it could be avoided altogether. As it cannot, well, lets be philosophical about it, and let us hope this man, in that place, was also able to be philosophical too.

  2. Beth – It won’t make you feel better, and it won’t bring him back, and I’m sure wise people have already told you, but I’ll say it anyway: that’s how we all feel, the first time. And the second time. And the third. That’s as far as I know, thankfully. But that very personal feeling of defeat, and shock, and grief, it gets us all, because we’re human. I find going straight back to the day job the hardest part, too. I want to stay and help tidy up, for the closure, but of course there are always more pressing things than that for a foundation doctor to be doing. It’s worth remembering that part of it is the adrenaline crash, and part of it is the nature of who you are, that thing that makes you fight to save lives and that made you want to be a doctor in the first place. And that combination is what makes you good at what you do.

    I think it will get easier. As long as it never gets easy, because that’s when we need to get out.

    I hope FY1 is treating you well. The only other thing I have to offer from the other side of full registration is that F2 actually is easier, just like everyone says it is. You suddenly realise that you know approximately what you’re doing most of the time, and you compare yourself to the new F1s in wonder that you’ve come so far, and starting a new job stops being terrifying. It’s not so bad!

    Lesley

    • Thank you, Lesley. F1 is treating me very well — terribly busy and perpetually exhausted (except not now because I’ve just finished annual leave) and as you are all too well aware, there are shit days, of course, but everyone sounds surprised when I tell them that I actually like my job!

      As long as it never gets easy, because that’s when we need to get out.

      This. This, more than anything.

  3. I meant to write this morning but the time wasn’t there. As a nurse, I’ve seen some deaths that were deeply unpleasant but, one memorable ‘very good’ death seemed to put everything else in perspective. The man was elderly, and a retired priest who had worked most of his life in Idi Amin’s Uganda. When he grew very weak his entire family (some of them missionaries) took over his spacious side room. They carried out every nursing duty for him including preparing him after death. They prayed with him at set times each day until finally he died very peacefully. It was a great privilege to have witnessed it. Would that every death could be like his but that is something we can’t make happen. Doing your best on each occasion when someone is dying is all one can do, and it’s enough.

    • Thanks, Jackie. I’ve seen many more very peaceful deaths since starting work than I have deaths like this one. The ones like this make me all the more grateful for the times I have the privilege of writing, “I was asked to see the patient to verify expected death; informed by nursing staff that Mr Smith died at 0600 with his family in attendance.”

  4. The noise is always amazing to me, in an ER – just when people come running with a crash cart, and we civilians realize we are well in the wrong place, and egads, I always think, how do they stand it? And while I’ve been glad and blessed so far that the loved ones of mine who have faded have come back, it is with bruises and aches. Survival is brutal. But, thank you for always trying for that.

    • I think everyone is different in how they stand it. I do, mostly, because I’ve got good colleagues and because when I leave work I’ve got music and books and cats and God and friends who are there for both hugs and for good soul-cleansing laughter. And because I figured out early on, on a different day and because of one of those good colleagues, that sometimes the only way to stand it is to have a good cry, after, and that that’s okay.

  5. I can only remember one death that horrified me beyond bearing – I had a member of my church in hospital and as she had few relatives, a team of us were visiting daily. The father of an acquaintance was in the same hospital (a cottage one, not much more than nursing care, really) dying. He had lung cancer. Every day he would scream: ‘Don’t let me die, I must not fall asleep,. I don’t want to die.’ The hospital was full of the elderly – they were either dying or fairly near the age when death becomes a near acquaintance. They listened and the looks passed. In then end the dying father was sedated. That was, in my view, a really horrible death – far worse than pain or indignity, or anything else I can actually imagine. That naked terror, not even dulled by stoicism. God save me from such a thing. Beth, if I am dying, you are to pop by and sing me a few hymns to steady me.

    • Oh, gosh, Rosemary, that’s terrible and I’m so sorry for him that he had to go through that and for you that you had to witness it.

      I will be there with hymns and hand-holding, but I hope not for some great number of years yet.


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