A call for the issuing of a guidebook to the undiscovered country

As I've said before, I'm not quite sure how I should (or why I do) write this blog. Sometimes it's pretty much straight "what happened today", brain-to-screen stuff that maybe other people will find interesting, or that maybe I can use later - chunks of data for the novel, the television series, the pop-up 3D erotic cookbook... (perhaps not). That kind of thing.

Other times it's thoughts that I carry around in my head for a few hours or a few days, things I try to write in a way that means something, to get some idea out, explain something that at some level has been bothering me and will not let me rest.

This, unfortunately, is about something that's been bothering me, but due to the aforementioned unholy sleep/motivation/concentration trinity, it's not going to be polished prose. It's just going to be data.

Okay. In the last few days, I have seen two particularly upsetting cases, which I will now share with you so that you, too, can be miserable and perhaps make your friends and family, those close to you, miserable too.

(You know, I've never understood all that "a trouble shared is a trouble halved thing". Scarlet fever shared isn't scarlet fever halved, is it? It just means two people with scarlet fever).

Anyhow, case one, Sunday morning, inpatients. Theoretically, our ED is divided into "inpatients" (people who come into the ED and will probably be admitted to the hospital - heart attacks, pneumonia, that kind of thing), and "outpatients" (people who will probably be sent home - dislocated shoulders, the majority of psychiatric cases, etc.).

In reality, half of the inpatients beds are taken up with people who have been admitted to the hospital but are stuck in the ED because there are no beds, so outpatients is full of inpatients plus people who have been sent in by nursing homes, are waiting for pickup, and the waiting room is full of extremely pissed off people - many of whom have problems that would take minutes to fix were we able to have somewhere to treat them.

So Sunday morning ten AM, the box goes off (that's the box we have in the corner that fires up whenever the ambulance are coming on a category one - a big green light flashes, the speaker crackles and pretty much every doctor and nurse in the inpatients end stops what they are doing and listens):

"Florey, we are four or five minutes away with a sixteen - that's one six - year old girl who was in VF arrest. Found by mother who performed CPR, VF when we found her, defibrillated, reverted for about a minute, then another episode lasting over a minute, shocked her, currently sinus tachy, GCS 3, BP holding at 120. No further information at present. With you in four minutes."

VF is ventricular fibrillation. It means the most important part of your heart, the part that does the pumping has gone into spasm. Instead of squeezing rhythymically it quivers uselessly - I have been told that when a heart does this when held in the human hand, it feels like a small bag of worms.

Anyway, when the heart is in VF there is no heartbeat, no bloodflow, and soon, no life. It is "cured" by electrical shock, which is what the men in the back of the ambulance had had to do twice in the ten minutes between this girl's home (where she had been found unresponsive by her mother) and the ED. But by that time, of course, the brain has been without blood for an indeterminate amount of time.

So she came in and there was relatively little for us to do, a quick intubation and some lines in her veins and arteries ... and then she went up to ICU and we started to try to work out what had happened.

Perfectly normal girl. No drugs, no alcohol, no family illnesses. No boyfriend. Not happy, but not unhappy, certainly not the kind of girl anyone ever thought would overdose or anything (and she hadn't, as far as we could tell). A silent father, a staring brother, a mother who wept in the corner of the room. A difficult conversation with the parents, a conversation in which we had no answers, no reassurances, no real ideas - nothing beyond the facts that they had done the right thing, we were doing what could be done, she was stable.

And her in the next room, obese, unmoving, fingernails painted black and a little bit of purple in her hair. "A bit wild", her father had said, "but a good child."

I've said the same about my niece.

I don't know. Out on the floor people were talking - the CT was normal, someone reckoned Wolf-Parkinson-White syndrome, I said maybe long QT, Dr Bedlam suggested some overdose. Sometimes in cases like this all we do is keep people alive and hope they get better. Sometimes they do and sometimes they don't. Sometimes we never know.

I don't know. She isn't dead, but as I speak neither is she alive. She is intubated, paralysed, sedated - it's impossible to know at the moment which of any of her vital functions would return - would she breathe? Would she move? Could she speak? Vital functions, as the name suggests, are those things without which there is no life. Functions essential to the maintenance of the body.

And we don't know about the degree, if any, of what we call hypoxic brain damage. This is the damage sustained by your brain - often the parts of your brain that make up memory, personality, character - as a result of the "downtime", the time your heart is quivering uselessly inside your chest.

There is a second set of vital functions, functions essential to the maintenance of the person. Will she still laugh, and at the same jokes? Will she recognise us? Will she lose memories, abilities, capacities for feeling?

Part of the problem, obviously, is our bicameral understanding of death.

In the old days Death came for you. One moment you were there, one of God's creatures, walking to and from upon the earth, and then you were gone, taken, irrevocably lost to the world of men. Once you're gone, bar miracles, you can't come back.

But that view is inadequate now. There are not just two states, death and life, there are degrees. People are more or less alive, there are degrees of being dead.

Life and death are no longer simply obeservable, they must be deduced, inferred, derived.

Whether someone lying on a bed in front of you is alive or dead may depend upon individual philosophical or theological niceties, or the machinations of the law - which is to say the decisions of lawyers and politicians.

Death has become fragmented - parts of you may be alive, other organs may not. If the situation calls for a corneal transplant, someone can remove the eyes from a person who is legally dead. You can't do that to someone who is alive, although exceptions can be presumably be made for ocular surgeons and military torturers. But you can't remove the eyes from one of those really dead people - or rather, you can, but it's not much good to you. You need one of these heart-beating dead types.

And death is no longer an absolute, it is contingent on simple things - "She is alive as long as we keep the machine going".

So that's death in the twenty first century. Fragmented, contingent, partial, sometimes temporary - but still occuring in 100% of those who survive being born.

Rather than a switch, with only two states, on and off, I sometimes think of two walled cities, separated by a disputed territory. In my mind, one city is always in sunlight, the other in darkness.

A traveller - a man, a woman, a child, a car of teenagers, an aeroplane - leaves the city of light and wends its way towards the city of darkness - (maybe we're dead before we are born, and this is a returning - I don't know). The travellers may cross from one city to the next in the blinking of an eye - instantaneous, irrevocable, uncomplcated. But alternatively, and I suspect increasingly, a lot of people spend time in the hinterlands, the dark forest between the two cities, the undiscovered country from whose bourn no traveller returns. Solitary, unable to communicate with those they have left behind, with no road or track to guide them.

Anyhow. These are, as to be expected, morbid thoughts. And that was Sunday. And then the next day they brought us a twelve year old girl, twelve years old, I tell you, who had had a massive stroke, and we bundled her up and sent her to the Royal.

And to be honest, I'm not sure anyone wants to hear what I have to say about that at the moment.

You know, there is really no unarguable impediment to my getting very drunk at the moment. Sorry about these posts, normal serotonin levels will resume shortly.

More later,

John