Evening here in the ICU, and I am deep bone tired. I’m too tired to go home right now – that time when you know your reflexes are just that tiny bit off, your decision making that teensy bit impaired, that yearning for warm soft bed and warm soft Sarah just a little bit too urgent – so I am sitting in the registrar’s room on the last day of my ICU rotation, drinking a weapons-grade slurry of coffee and writing about today.
Before I do, by the way, have a look at this. It's a documentary called "Guys and Dolls", about some truly unusual people. I haven't seen all of it, but it's startling, distressing, heartrending and frightening all in the same ten minutes. You might need broadband - I don't know how broad, the documentary's pretty long so you might need pretty broad.
It’s hard to put the last few days into words. I sit here and write and ten metres from me there are four people – four of my patients - between life and death, three people who are in the twilight in one way or another. In each case I have been involved in their care from early on, and in each case I feel, or know, things will end, or have ended, badly. In each case I will try and explain what happened. I don’t know if there is a less bad, a least terrible, but I suspect I will end up leaving the worst ‘til last. And tonight I am almost incoherently tired, and when I get that tired my glucostat goes awry, I can't detect overabundance of sugar, so this will probably dissolve into something cloying towards the end.
Anyhow. I started at eight and got the handover from Dr Fang. He was walking with considerable difficulty – he’s come down with something contagious and as such is unlikely to be returning to work. I took over the patient, waved him on when he tried to finish off “ a few last things” and the CNC rang the consultant to get him to ring around for night-shifters. At eight thirty the pager went off – code blue in resus.
Code blue means someone in cardiopulmonary arrest, and ICU are required to attend. I walked down the stairs – code blues in resus are not the same as code blues at other places in the hospital. At resus code blues you walk in and the patient is surrounded by extremely competent doctors, they have high flow oxygen on, there are lines going in and fluid being squeezed in, you look up to the monitor and see heart rate, blood pressure and oxygenation. In non-resus code blues you run in and there’s one terrified looking agency nurse, no-one knows where anything is and a patient in the early stages of rigor mortis.
On the resus Mr Fell was a large man, well over six foot, easy two hundred pounds, with blue eyes and gingery-blonde hair and pale, soft skin. He had been attending a garage sale, started coughing, complained to his wife that he “didn’t feel too good”, was driven to the hospital, clutched his chest and stopped breathing en route. His frantic wife – and I can’t imagine what this must have been like – drove at un-natural speeds to get him to the hospital, and leant on the horn in the carpark. Ambulance men and a group of medical students dragged him from the car and ran him into resus.
By the time I got there Dr Hu was clearly exhausted, thin arms flexing, tiny hands placed precisely over Mr Fell's large and silent heart. I took over and started shoving. This is one area where physical mass, basic substance, is important. I looked up at the monitor. Blood pressure unrecordable. Heart rate unreadable – the line jittered each time I lurched forward, leant all my weight on that massive sternum. Oxygenation – none.
“Adrenaline,” said Dr Kaspar, a woman who gave up neurosurgery to be an emergency doctor, and one of the two or three most respected doctors in the ED. She spoke in that calm, enunciated way that cut through the alarms and the murmur of instructions and the jostling of the resus table, and she always said the right thing. Someone gave adrenaline.
“Pause,” said Kaspar. I stopped, breathed deep. We all looked up at the monitor, which functions something like an oracle and something like a judge.
Twenty one. Five.
“Commencing,” I said and he started lurching again. I looked down and slightly to my left you could see Mr Fell’s eyes, ever-so-slightly open, like some people when they are asleep, watching me as I fought to batter some life into the unyielding, inert mass of him. We shocked him - Dr Kaspar calling "everyone clear", everyone standing back - in real life there is a pause between being able to shock and shocking, everyone looks around to check that no-one is standing close enough, the people closest to the patient edge back - and her pressing the paddles onto his chest and jolting. For that few tenths of a second life - movement, response, energy - enters into him, arms swing, maybe a grimace - and you can see why when electricity was discovered it was called "galvanizing". But as soon as the current stops, he falls back. I climb on top of him again and begin lurching.
After a while Dr Sanjeev takes over and I stand back. Every few minutes we stopped to check, every few minutes, nothing. Underneath the seeming chaos, the insistent ringing of the alarms, the calls back and forth of drug doses and blood pressures and milliamperes there is order, and underneath that a growing quiet, a sense of rising despair. People not directly involved turn to each other and murmur. At least ten minutes down-time in the car. Forty five minutes in resus without oxygen. Asystolic almost all that time. Survival after this is at best a matter of increments - we may save a bit of mobility, he may be able to open his eyes. The undamaged man is long gone.
The door bleeped behind me and Dr Kaspar emerged. She had been talking to the family.
"Pause" she says. Dr Sanjeev steps down, I step up, put my hands on Mr Fell's chest, right hand gripping left, elbows locked. Dr Kaspar gazes at the monitor. Nothing. Everyone gazes at Dr Kaspar.
"How long?" she says.
"Forty eight minutes."
"That's it" she says. "I'm calling it." She peels her gloves off. "Time of death, ."
And like that, he is dead. It is as if she speaks death, as if her words slay. There will be no feeding tube for Mr Fell, no blank stare, no aphasia, no nurses turning him every few hours, tubes in and out of orifices.
Dr Kaspar turns and goes out to speak to the widow. I know she hates this bit. But I also know the last time Mrs Fell saw her husband alive he was walking and talking and laughing, the man she married. I hesitate to draw a moral from this kind of event, as if it were something performed with us in mind, played out for some didactic purpose, but if I did it would be that I believe, almost as much as I believe anything, that Dr Kaspar has said the right thing.