This won't hurt for long

Hail,

A wee bit morbid, the following post. As they say in the football, if you don't want to know the score, look away now.

It was quiet in the ED this morning (which is just as well, since I didn't know I was on until they woke me at eight AM, and I am doing this on literally three hours sleep and last night's bottle of Merlot). Sarah and I stayed up until five this morning watching House. Good drama, good person, bad doctor.

Anyway, the overnight staff had seen a man with a paracetamol overdose, and sent him off to the Royal just as I arrived, in what I once heard referred to as a "transfer TDT".

People can be transferred to the Royal for various kinds of surgery, for an MRI, for assessment by a neurosurgeon or an endocrinologist or one of the several kinds of ologists that they have and we don't.

Or patients can be transferred 'TDT', which means "to die there". He was one of them. Rather distressing.

Anyway, the paracetamol overdose (I believe you call it acetominophen over there) reminded me of one night a few years ago in Shipton, when I lied to a grieving family in the presence of a dying man.

It was two years ago, in the early spring after a wet winter, and during those last few months at Shipton, when it was as bad as anyone thought it was possible to get.

It was a busy night, and it was made more difficult by the preponderance of junior doctors we had. We had Dr* Sutekh (hardworking, but neither smart nor easy to get on with), Dr Zygon (easy to get on with, but daft as a brush and treacle-slow), and Dr Miaow, (smart, hardworking, easy to get on with, hot... in fact so smart she transferred to a large private hospital as soon as she worked out what was going on. She left Shipton for Saint Dymphna's after two weeks - a private hospital in the centre of town, catering exclusively for the wealthy healthy).

So I was trying to keep the body count down in my side of the ED, when Mr Grieve was brought in by ambulance.

His family told an unusual story. He had been unwell, they said, for a few days, more unwell than usual (what with his rheurmatism, and his drinking, and his depression and so on), and he'd seemed to be off his food. Then he'd come down the stairs from his bedroom and in front of their eyes, collapsed on the kitchen floor. So they'd called the ambulance.

I looked at his bruised and discoloured side, and the shadow on the chest Xray of early pneumonia.

"And when was it that he collapsed?" I asked.

"Tuesday" they chorused.

"So he's been lying on the kitchen floor for... three days?"

"I put a blanket over him" said his wife.

I stared. There was a pause, which the wife ( quite uncrazy to look at), stared back at me. After a minute she spoke.

"He does this kind of stuff all the time. Never happy unless he's the centre of attention."

"Well, he doesn't look that happy now" I said. "He's been lying on one side for three days - his skin is starting to break down. Plus, I think he's got pneumonia. Anyway..." and I described the various tests we'd do, the xrays and blood cultures and recordings of his heart, and we moved on.

Half an hour later I got a chance to speak to Mr Grieve alone. He was not well, and we spoke only briefly. He had little to add to the story - he remembered having a fair amount to drink that night, he'd been very depressed. He hadn't felt any chest pain or shortness of breath, he hadn't taken the wrong doses of his medications - was all this fuss really necessary? Couldn't he just go home?

I smiled and shook my head in that way people do when they know better than you do, and said we'd wait to see what they had to say. And then I went off and tried to sort out 28 Year old Woman With Cramping Pain In Abdomen.

An hour later - things had been busy - I logged onto the computer to find the blood test results.

"Oh my God."

"What's wrong?"

"The man in cubicle seven," I said. "He's dying."

I'd tested for levels of paracetamol in the blood, just in case. His levels were monstrous, over a thousand micromolar three days after dosing. Much too late for NAC, the only antidote, to have anything more than a theoretical effect. I'd done liver function tests, they were bad. His liver was already starting to necrose, to break down.

Jesus. He needed a transplant. We could send him to the Royal, put him on the transplant list... but his liver had only a few more days of function left, he needed a transplant in the next week. The Royal didn't have spare donor livers lying around, a few ice-cream containers in the fridge. There wasn't going to be one.

He was going to die.

Christ.

I sat for a few minutes, trying to rearrange the words in my mouth to make them seem less horrible. In the end I walked into his cubicle. It was silent, the light down low, the garrulous, chattering family outside having a collective cigarette.

"Mr Grieve," I said. "Can you hear me?"

His conscious state, as I remember it, was fluctuating - awake one moment, asleep or confused the next.

He opened his eyes, looked at me.

"I've got your blood tests back." I said. "They are bad."

For a moment he looked away, then looked back. Eyes wide.

"Sir, a few nights ago. Wednesday. The night you collapsed. Did you take your medication?"

He nodded. Like a lot of chronic pain patients (looking back now, the risk factors were there in abundance - male, forties or fifties, chronic pain, dysfunctional family, previous alcohol abuse, depression - he was on an unusual amount of medications. Antidepressants. Anti-inflammatories. Anticonvulsants for nerve pain, morphine and codeine and panadeine forte.

"Sir, is it possible that, for some reason, you may have taken a larger amount of panadeine forte than usual?"

A pause, then a nod.

There was a long pause. Somewhere in the fishbowl the box crackled, an ambulance on its way. I didn't have long. Neither did he.

"Sir, I have to ask this. People, people who are unwell, people who've suffered with depression...when you did this, when you took the panadeine forte, was it possible you were you trying to end your life?"

Nod.

I continued. "The blood tests, Mr Grieve. They're very bad. The panadeine forte you took - it seems it has damaged your liver. Badly. It seems your liver is failing, shutting down. Basically, you need a transplant... very very soon... or you will die."

There was a silence. His eyes were bright with tears.

He managed one word. "How -?" and fell back on the pillow.

I remembered the rest of the blood tests. Deranged liver function, white cell count up, probable pneumonia... he was lucky to be speaking at all.

"How long?"

He nodded.

"A few days, maybe. Maybe as much as a week. Not two weeks."

There was another silence. He seemed to sink into the mattress, head settle back down into the pillow, as if his body were already breaking down, returning to the earth.

Outside I could hear voices raised in conversation, someone on a mobile phone. The family returning. I thought of his wife leaving him lying on the floor for three days. The centre of attention. I looked at Mr Grieve. He face was turned against the wall.

"Sir - when your family comes in, do you want me to tell them about the blood tests? About the liver?"

He stared straight ahead, shrugged. I waited. After a while he nodded. A woman's voice asked a question outside, a nurse answered - said doctor wouldn't be long.

"Sir. People who take too much of their medication. They do it for a number of reasons. Sometimes they make mistakes - take some tablets, forget they took them, take them again, and so on. It happens all the time."

He nodded.

"If you want, that is what I can say. Is that what you want me to tell your family?"

He looked at me, and I noticed the colour of his eyes for the first time, a remarkable deep blue, the colour of the sky at the very zenith where the atmosphere is thinnest, that soft, dark blue that barely masks the emptiness and blackness of space behind it. He nodded.

And the door opened and in they came.

There was a lot more after that. I left them together, went out and checked the amubulance - some man thrown from a horse, and something Dr Miaow could do in her sleep - and went back inside.

Mr Grieve was lying, eyes closed, face against the wall. Apparently asleep.

I explained, in low tones. Chronic pain, depression, multiple medications, understandable confusion, very common. Confusion leading to re-dosing with his medications, more confusion - a rapid cycle. And the Royal, they were the best at this kind of thing, they had all the transplant doctors, the best facilities in the state. Althought I did have to emphasise that the likelihood was very very small, and that the most likely outcome was that Mr Grieve was going to become weaker, more confused, and die. Within a few days, maybe a week. Not as long as two weeks.

The family nodded, asked questions in hushed tones. His wife sat beside him, wiped her eyes, clasped his hand. I asked if anyone had any questions.

"I should have seen this," she said. "I should have told somebody."

"Told them what?"

"A few days ago. Monday night. When he took the overdose."

Her son said "Mum, it's not your fault," but she shook her head. "Monday night. I was down watching tv and I kept hearing the tap running. Upstairs, in the ensuite. Just running for a few seconds, then off. Then a minute later, on, then off. Same thing, over and over."

For the first time that night I felt cold.

"Like he always did, when he took his tablets. But it just went on and on and on..." she said nothing.

"You weren't to know," I said. "Nobody's to blame. This is just one of those terrible things. Look, I'll go arrange an ambulance. Back in a minute."

And I went out, and got on with stuff, and popped my head in occasionally, and the ambulance came and took him to the Royal, "transferred TDT." And his family, silent, weeping, attentive, followed in their wake.

Anyway. Every since then, every so often, when I hear a tap run, I think of him. The man standing alone in his room, handful after handful of panadeine forte, and his wife downstairs listening, hearing but not understanding. He got to the Royal, and I rang the transplant registrar at the Royal a few weeks later, and it wasn't a name he'd heard, and his file at the Royal is now marked closed.

Anyway. There are a few more transplant stories, the accidental suicides, the feast days of the transplant unit... but I feel the need for a bit of quiet now, myself.

And thanks to everyone for their support over the last few weeks. Means a lot.

Thanks for listening,
John

*Note: for reasons which will be clear to no-one but myself, I have decided that as most of the Florey doctors generally have archaic medical terms for names, most of the Shipton ones are going to have names of Doctor Who monsters. The parallels between my two or so years in the Shipton Emergency Department and a low budget, rubber-suited-monster TV show should be pretty obvious.