Saturday, April 23, 2005

Patient Zero


Odd occurrence at work today. Seven till four (or five or whatever) shift at Florey and I went in, and I'd only been there a few minutes, wandering down to see "32 year old male, lac hand, neurovascularly intact, refuses pain relief" and I walked passed one of the other cubicles... and the patient inside had a seizure. It was a full-blown tonic clonic seizure, of the turn grey and choke type, and we all rushed in there and essentially started resuscitating her, because along with the alternate tensing and relaxing of her muscles she had a prolonged tightening up of her airways, called a laryngospasm, and getting her to breathe was difficult. We ended up putting a mask over her face and using one of those breathing bags.

I should point out that attending two resuscitations in three days is not normal small-town emergency medicine. Normal small town emergency medicine is "I've got this rash" or "I haven't felt quite right since nineteen eighty eight, none of the other thirty doctors I've seen have been able to work it out, so I decided to come in now at three in the morning to get it sorted out once and for all."

Anyway, after a while I left things in the capable hands of Dr Benedict (tight-lippedly ordering adrenaline) and the junior registrar (running through plausible excuses in her head for letting things get this bad), she got somewhat back on her feet. I moved on.

About an hour later I walked passed cubicle twelve, and the reuscitation bell went again. We all swarmed in there like killer bees before someone pointed out that the patient was NFR. NFR is not some new sporting code, in Florey means not for resuscitation, and it meant that the elderly man in cubicle twelve had essentially come here to die. We all swarmed out again.

And then I saw the man with a small (maybe two centimetre long) laceration to his palm and I took the bandage off and he immediately hurled himself on the floor and started crying and vomiting. I stared. "He doesn't like hospitals!" shrieked his wife, glaring at me in an accusing manner. We eventually got him into a bed and I had to give him diazepam before he'd let me look at the palm of his hand, and when he howled and flung himself headlong onto the floor a nurse came over and asked if I wanted my third resus of the day. It was actually the fourth, but we didn't count the elderly woman who earlier that day pressed the emergency alert button because she didn't have a spoon to stir her tea. Two emergency consultants, three registrars and a trainee cardiologist made sure she got one.

Basically an alarming proportion of the people I walked passed fell to shit. I was like some figure of death in a mediaeval religious play. After the third one I became un-nerved and walked across the road for lunch, expecting birds to fall from trees and the girl at the deli checkout to choke on a particularly large air molecule, as if I had become the epicentre of a new plague, Patient Zero of some grave contagion.

Anyway, the day went on, and no-one died, and later on we went up and saw the snow maiden and she was doing fine...ish. Not quite out of the woods. Not out by a long shot.

We shall see.

"Previously on ER..." - I was going to say "Previously on BJ", but that sounds vaguely autoerotic - I foreshadowed a raucuous, knee-slapping series of anecdotes about dead people. I have since been advised that this may be one of those aquired tastes specific to my profession, and that relating that hilarious jape involving the third year medical student, the false teeth, the over-inflated urinary catheter and the woman with advanced rigor mortis may lead some people to believe we are not as deeply caring as we say we are.

None of that's true, by the way. I've never even heard of anyone joking about or with a dead body. I doubt that anyone with that attitude would even get through the first year of medical school. It is my understanding that eighteen years before I started some second year medical student smuggled a cadaver's hand home and produced it at a party. The next day he was called in and expelled from medical school, which basically meant no medical school in Australia would have him, and it was pretty much game over, go off and try to get into accounting. Someone asked the ethics guy about this at uni and the ethics guy said that if the cadaver's relatives had been alive he (the offending student) would have had to appear before them and explain his actions.

But it's a high pressure job, and doctors are often high achievers who have lead sheltered lives, and when high achievers who have lead sheltered lives are hurled for the first time into wards where death, disease and delirium seem to stride freely, when those neophytes have to work long shifts and do things they've never done before, you learn to cope, and one way to cope is to laugh. We don't laugh at the dead or the dying, but we laugh at each other and we laugh about death.

Laughter is meant to be some kind of primitive tension-release thing, a signal to the tribe that everything is fine, a way of looking at something which if it were looked at sanely and sensibly would overwhelm us with with terror, grief, rage, that kind of thing.

My wife was medical intern one year, and eight days out of medical school was called in to certify her first dead body. It was on the eighth floor of the Royal at about five in the morning and she remembered clambering up seven flights of stairs and being shown into the dimly lit "viewing room" with Mr Masters in it. Not that anyone was coming to view Mr Masters at five in the morning, but the hospital needed the bed.

So Sarah's shown into the room and there's Mr Masters lying soft and cold and impeturbable in his crisp linen sheets. His hands looking slightly waxy, his mouth slack, his pupils dark and wide, as if he had died staring at something deeply deeply desired.

She says she approached him quietly, almost awefully, in the old sense of the word.

Felt the underside of his wrist, checked his pulse. Nothing. Wrote it down.

Rested her steothoscope on his still, bowed chest. Nothing. Wrote it down.

Shone her light into his eyes, looking for any response. No movement. Wrote it down.

And just to be sure, reached out and touched his throat, feeling for the carotid pulse, and Mr Masters lurched in the bed and twitched his hand towards hers and said "Gerr".

When she was able to go back in the room again, it was after reciting to herself several times the details of this well known clinical phenomenon. Dead bodies, certifiably dead bodies, often twitch. They may move, they may blink, or close their mouth. They seem to exhale, and formless things like words emerge.

It's quite common, and although it's frightening, it's certainly not a thing to laugh about.

But that didn't explain Sarah and the nurses spending the next fifteen minutes hunched over coffee or hot chocolate giggling until they wept about it.



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