Wednesday, April 11, 2007

Three deaths

A few minutes before Jacob Rowe - my pleasant, affable sports journalist with the heroin problem - turns up, and I have time to reflect on the last few days.

I don't know about the ICU job. The thing is, there is this distinction between medicine as in the academic subects (psychiatry, emergency, intensive care, etc.) and medicine as in the various jobs. Psychiatry the academic discipline - I love it and was good at it. Psych as a job - not for me. Emergency - love it, not actually that good at doing it, definitely not that good at learning it.

When it comes to ICU, the whole thing's a bit odd. I would love having more to do with the patients, even though we almost never get to sit down and talk to them face to face and explain things at length, it's more a gathering around the charts and murmuring amongst ourselves. I love the complexity of the physiology - how and why your blood sugar falls in the face of overwhelming organ failure, that kind of thing. I love working with the senior consultant, Dr White.

But Dr White is on holiday - finally - and we have a succession of locums (or is it loca? You know, datum, data, stratum, strata?) filling in for him, and things have gone into a bit of a spiral.

This is perhaps best illustrated by the fact that three of my patients died yesterday. Hear me moan, as they say.

The first one was the man we had resuscitated last night, Mr Ivory. We had been about to leave when the MET call pager went off. This means a medical emergency team call, someone crashing who is not actually in the ED, in this case an elderly man who had suddenly become unresponsive with no recordable blood pressure. We got there and found the elderly man, yellowish and trembling, and pumped him full of fluids and almost miraculously he became an irritable, sarcastic and occasionally aggressive man, trying to pull his oxygen mask off and grabbing at our hands - "back to his old self" his daughter said.

I note that in these resuscitations I tend to take a back seat, let others make decisions. I know this is not how it should be, to be honest it is irresponsible and verges on the dangerous, but still it happens. I feel it is to some extent a confidence thing. Three months ago I was detained, I am still new to this, I am still nowhere near my best. The trust in myself will come slowly if it comes at all.

Anyway - our patient. The back-story was that Mr Ivory had been brought in from his nursing home with lack of energy and what turned out to be some rather ugly blood tests - white cell count of twenty eight, high enough to make the treating team consider leukaemia as well as pneumonia. His fever and his rapid breathing and, to be honest, the neglect of the twenty two year old medical intern - had meant that he had become remarkably dehydrated.

So, we gave him fluids and he got better but we moved him upstairs anyway, and handed over and went home.

The next morning when I come in things look worse.

Mr Ivory's blood pressure has dropped and his kidneys are shutting down. The way your body is wired up kidneys both have an important role in controlling blood pressure and are very easily damaged by changes in blood pressure, which makes them less able to control blood pressure - it all seems rather poorly designed, but there you go.

Back to Mr Ivory. His chest sounds raspy and wet and you can look at him and imagine things going wrong - bacteria breeding in his lungs, malignant cells budding in his bone marrow, heart stuttering and failing, the dark blood moving sluggishly through the kidneys and gut, slowly starving them of oxygen. His blood pressure spirals down, his heart-rate speeds then slows.

By ten o'clock in the morning he is almost unrousable. We put him in a room separated by a thin curtain from our eighteen year old girl with the diabetes and his family gather around his bed. His daughter looks up at me and smiled and said "After all your hard work yesterday". We get another blood test back suggesting heart damage, the nurse tells us his kidneys have essentially shut down. He dies silently, while we are all away.

The second patient to die that day is a woman, Mrs Umber, only sixty years old, whose husband has been with her all day and all night for the last few days. She has airways disease - some days it's almost impossible to find someone in here who doesn't smoke or drink or inject. For the last two or three years she has been largely confined to the house - she can't walk ten metres without resting, climbing even the gentlest slope is impossible, cannot dress herself in the morning. Dr Chang rightly uses this as a "quick and dirty" measure of quality of life and surmises that life for someone who cannot walk out to the letterbox may not be much of a life, may perhaps be something that should not be held onto too tightly.

The question as to who makes the decisons about the intensity and duration of resuscitative efforts is complex, and there is no one solution that will satisfy everyone, or be appropriate for all patients in all situations. Doctors, patients and families are involved. Doctors, families and patients have different understandings of the medications, the illness, the life that is being saved or lost or held in that in-between quantum state.

This is a complex area, one that I have written about before and will again. However, the unpalatable truth is we use questions like these ("Before she came into hospital, what could your wife do for herself? Could she walk down to the shop? To the letterbox? Around the house? Dress herself?") to guide decisions about resuscitation. The vigorously healthy get more treatment than the unwell.

Having said that, of course, you wonder about the quality of life of a woman of letters confined to wheelchair versus a woman of action, and you also wonder how Steven Hawking would have fared had he come into our hospital with pneumonia.

Mrs Grey deteriorates over the course of the afternoon. The decline is masked by the chemicals we pour into her that make her heart beat, and the adjustments we make to the machine that makes her breathe, but over the next few hours the numbers climb higher. Some time that afternoon she passes the point where the machine and the chemicals are doing all the work.

The family gather around. Her pastor is there, there is a prayer which we are invited to join - our consultant says he will, but sends us out. There is hope that she would be stay for the arrival of her friend from Brisbane, her dearest childhood friend, but we will not have that long. Despite the toxins and the tubes, she is slipping away before our eyes. The consultant tries to explain that the machines are only giving the appearence of life, that there is failure of kidney, lung, heart, liver and brain.

Her sister asks me. So there is no hope at all?

No, there is no hope at all, I say.

A few minutes later her heart stops, despite the maximum doses of the medications.
There is soft sobbing, then the nurse turns off the machine.

I leave to go back to my other patients. As I do, a stout, kind-looking woman, her face stricken, rushes in the door and looks around frantically.

Between five and six there is a brief delay, the eye of the cyclone. It's already a pretty bad day. Downstairs emergency is apparently overflowing, fifty people in the waiting room, doctors called back, working double shifts. Soon it's going to spill upstairs. In the interim, the consultant gastroenterologist comes in to see what can be done for Mrs Slate, our woman in bed four who has advanced cirrhosis of the liver, bone marrow suppression and bleeding from the gut.

As we suspected, nothing that we aren't already doing. She is drinking herself to death, and will die within the year. She is not suitable for the transplant list. She is thirty six.

The last death - and by this time we are exhausted, moving listlessly from patient to patient, is Mr Black, a man who yesterday was out in the garden, in remission, his tumour responding well to the radiotherapy. A few hours ago he collapsed, was found by his wife, was brought in to the ED. We take him on because ED is almost at detonation point, and because a busy Emergency Department is not a good place to die, full of the desperate and the detained.

By the time Mr Black comes to us his breathing has almost stopped. His family are gathered around. We murmur about the diagnosis - pulmonary embolus? myocardial infarction? - but he was down too long, he has cancer, nothing can be done.

Three times I go into the room to discuss things with the family, to try to answer unanswerable questions.

Can he hear us?

Is he in pain?

Does he know we are here?

I say that as far as we know he is in no pain, that we are watching him for signs of pain and giving him the strongest pain killers that exist. I say that some people who have been very unwell and recovered - people who weren't sick in this way, because he will not recover - have said that they could hear people around them, could feel the presence of their loved ones.

I don't know if these things are true or not. I think I say all these things because they seem to be as true as but more comforting than the alternatives.

Mr Black takes only a few hours. The room fills - each time I go in there there are more children and nephews and nieces and grandchildren. Several times they watch the halting movements of his chest, the unbearably slow, struggling agonal breathing, and for a few short minutes after his breathing stops his heart can be heard through the stethoscope, beating softly and slowly. His children hold his hand and cry out that they love him.

Finally I listen for a full minute, and look up and tell his wife that I cannot hear a heartbeat.

As soon as I say that I am called out of the room, which is perhaps for the best, because I have tears in my eyes. There is another resuscitation call on the fourth floor, but at that moment Dr Ferentes (smart, hardworking, easy to get on with and at this moment, due to our almost palpable gratitude at seeing him, certifiably hot) arrives and volunteers to go down and do the MET call while I sit down and start the day's death certificates.

Anyway. Don't really know why I wrote all of this down. There's a horrible tendency when I write this kind of stuff for it to end up being about me, about how difficult my job is, about the psychic pressures I put up with all day and, by extension, how noble I must be. I'm not trying to say that at all - or at least I don't think I am, I hope I'm not. I am among the least noble people I know, I crumple under pressure. Having said that, I don't really have any other explanation as to why I write this stuff down.

I don't know. Normally in my life, even my career, months go by without a death. This last ten days there have been five, three in the ICU and two in the addictive substances side of things. It's not that I am the victim here, I am not the one left holding my father's hand telling him I love him, or being too late to see my best friend die, but at some level I am knocked about by this, and in some way talking about it - or writing about it - works some stuff out.

Anyhow. Thanks for listening. I will try to be more cheerful next time.


Blogger The Girl said...

An excellent and moving post. Thank-you for sharing. It sounded like the day from hell - here is hoping that tomorrow is better!

10:10 PM  
Blogger Foilwoman said...

BJ: No obligation to be cheerful, please. Just write.

12:38 PM  
Blogger Camilla said...

Ah damn, maybe I shouldn't have read this just before work :(

*sends hogs*

I can understand why you write about this stuff - I think I would too, if it were me. To use a cringeogenic new-ageism, writing about stuff helps to process it somehow.

Like Foil said, no pressure to be cheerful - just write whatever it is you need/want to write about.

4:09 PM  
Blogger Juanita J. Sanchez said...

John, I don't know how you do it. I can so relate to that feeling of crumbling under pressure. If only you could see me! You'd realize you're probably pretty good. In any case, take it easy on yourself. You said the right things, you did the right things. You were merciful and kind. You allowed yourself to feel. The families of those patients won't forget you. Good job.

11:16 AM  
Anonymous Anonymous said...

locus, plural loci

Very nice post.

11:30 PM  

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