Thursday, 23 July 2009

For whom the bell tolls

Over the last couple of weeks, I've been penning a short story. I think one day, I'd like to write a proper novel but I think that this is something that can wait until I'm a bit older. I thought I'd try writing a few short stories just to have a go at something a bit more substantial that a blog post. So here is my first attempt.

I must stress that this story is fiction and that I am not the main character in the story. I also must warn that this is not a cheery story at all. See what you think.

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For whom the bell tolls

- A junior doctor’s tale

I’m awoken from my sleep by that noise. The piercing klaxon of the cardiac-arrest pager shatters my peaceful slumber like a claw hammer meeting a precious china vase.

I gasp. I’m confused and disorientated as, for a second, my brain attempts to make sense of the unfamiliar surroundings in which I find myself. Instantly, a dozen questions rush into my head, each vying for supremacy in the limited space of my semi-conscious mind. Where am I? What time is it? What’s that noise? Why am I awake?

It only takes a second for me to regain my bearings. I’m on the sofa in the doctor’s mess at the hospital. An hour or so earlier, the anaesthetic registrar on call had taken pity on me and told me to go and try and get some sleep. Fat chance. I didn’t think I would be able to but, despite my reservations, unconsciousness had quickly enveloped me with its unknowing caress. I had gratefully welcomed its loving arms and drifted off into a long, deep, unsensing sleep - the sort of sleep that you only get when you’re truly exhausted. As a house officer, I used to joke that this was the sort of sleep that was only ever experienced by junior doctors and the dead.

But that was over now.

This screeching klaxon is a truly horrific way to be awoken from such peace. I’m aware of my heart hammering inside my ribcage and, as I sit up, I have to pause as a wave of nausea passes over me. I take a breath. I know what that sound means. Somewhere in this hospital, somebody has died. Right at this second, nurses on one of the wards are scrambling around, gathering pieces of equipment in a last, desperate attempt to revive him or her. The klaxon of the cardiac-arrest pager is the final tolling of the bell for this patient. Whoever it is has finally come face to face with their own mortality and, as their bell tolls, they stand before their destiny. Whether they stand before St Peter and the pearly gates to heaven or before Cerberus and the gates of Hades, only they shall know. Regardless of what destiny awaits them, it’s our job as members of the cardiac arrest team to try and rescue them from their final judgement, or at least delay it for a little while longer.

The klaxon finally relents and the tinny, dismembered voice of the switchboard operator comes through to my pager.

“…Cardiac Arrest, Beeches Ward… Cardiac Arrest, Beeches Ward…

Cardiac Arrest, Beeches Ward… Cardiac Arrest, Beeches Ward…”

I feel for my second shoe and shove my foot into it. My body feels heavy and lethargic and I stagger as I stand. I ignore the irritated grunts of the surgical registrar who was attempting to sleep on the other sofa and head towards the door, towards the rest of the hospital, towards Beeches Ward.

I stumble into the corridor outside the doctor’s mess and the brilliant fluorescent lights cause pain to my sleepy, darkness-adjusted eyes. I squint, then screw them closed and rub them and start to make my way down the corridor. The initial shock of waking up has now subsided and my body is starting to respond to what I’m urging it to do. I start to run. A gentle jog at first, but I slowly pick up the pace, rounding corners and sidestepping linen trolleys as I hurry towards where I am needed.

As I run through the bowels of the building, I become aware that I am not alone. Up a head of me, I can hear of one of my fellow team members running to the same place that I am. Each of his footfalls echoes down the clinical, deserted corridors of this hospital at night time and I can hear his rasping breath as he struggles to get to Beeches Ward as quickly as he can.

I arrive at my destination and pull open the doors to enter the ward. Inside, a surprisingly calm and serene scene greets me. The ward is illuminated only by a dim, yellow glow from the desk lamps at the nurses’ station towards the far end. The darkness feels oppressive, like it’s somehow clinging to me as I make my way through it. I walk further inside, catching my breath and pulling a pair of rubber gloves from their wall-mounted box as I go. I wonder if there’s been a false alarm. Perhaps, there’s been a mistake and there was no real reason for me to dash round the hospital at all. Maybe I’m still asleep and all this is a nightmare, the sort of twisted joke that my sub-conscience plays on me more and more often these days.

My hopes of a last-minute reprieve evaporate as I venture deeper into the ward. I hear the electronic triple-salute of the defibrillator and, as I approach, I can make out a female voice breathlessly counting out chest compressions.

“… 26… 27… 28… 29… 30… and breathe…. and breathe… 1… 2… 3… 4…”

I enter the four-bedded bay where this drama is playing itself out. The curtains are drawn around the bed of the patient in question, a soft pool of light spills onto the floor underneath them and I can make out silhouettes moving around the bed. The torso that the voice belongs to bobs up and down hypnotically in time with her counting.

“… 14… 15… 16… 17… 18…”

I glance to my left and catch the eye of one of the other patients in the bay, an elderly gentleman in a burgundy nightgown. He stares at me and in his eyes I see fear in its purest form.

I look away.

I step inside the curtain. I have a job to do.

The scene that greets me is a scene that I have seen several times before and my heart sinks as I comprehend the futility of the situation.

On the bed lies the body of a man. My initial glance tells me that this man is was in his eighties and had obviously been unwell for a long time. His small, withered body lies lifeless and unmoving in the middle of the vast sea of his ward bed. As I glance over his cachectic form, I can clearly make out each rib, each bone, each sinew. The low lamplight turns the hollows of his eyes into deep crevasses, adding further to his skeletal appearance. He is wearing nothing but incontinence pants and even these are too large for his puny frame. His little legs stick out in an almost comical fashion, like those of a new-born baby. As we enter this world, so we shall leave it.

A student nurse kneels next to him and towers above him. She has both hands planted in the middle of his emaciated chest and with an unremitting, metronomic rhythm, she pushes the weight of her upper body onto the dead man’s chest, crushing his lungs, his blood vessels and his heart together in a desperate attempt to prevent the last, solitary ember of life from extinguishing completely.

“… 22… 23… 24… 25… 26…”

I know that it’s already too late.

“… 27… 28… 29… 30… and breathe… and breathe… and 1… 2…”

Her voice is husky and breathless as she pants out her count. I briefly pause to regard her as I move towards the old man’s head, picking my way round the scattered detritus that accumulates during these events. Her face is flushed and shines with the perspiration caused by her exertions. As she bounces up and down, her ample figure undulates mesmerisingly and her long, auburn hair succeeds in its bid for freedom, escapes from her hair band and cascades down to obscure her young face. Her vigour and her youthful glow contrast starkly with the man that she is crushing beneath her hands - yin and yang; hope and despair; life and death.

I put on the latex gloves that I picked up on the way in. Typically, they’re too small and the right one splits as I push my clammy hand into it. Nevermind.

I take the oxygen mask from the ward sister and push it firmly onto the man’s face. I look down at him as I do so and his eyes stare back at me, unblinking, unknowing, unliving. He has vomited. It strikes me that this was the very last thing he did before he died, a final parting shot to life that left him in this state – “good bye cruel world,” indeed.

I reach round behind me and pick up the plastic suction tube. I shove it unceremoniously into his mouth, dislodging his false teeth as I do so. The suction tube thirstily slurps up the vile red-brown fluid that foams out of his mouth with every chest compression that the student nurse does. I satisfy myself that I’ve drained his mouth sufficiently and clamp the oxygen mask back on the man’s face. As I do so, I can feel his face through my torn glove. His course stubble bristles beneath my fingers. His skin is cold and waxy but the vomit that’s running down his cheek is still warm. This sensation provokes a visceral reaction within me. Revulsion slithers through me and I have to close my eyes and concentrate on stopping myself from retching.

“… 29… 30… and breathe…”

I snap back from my personal reverie and do what I came here to do. With my left hand, I tighten my grip on the old man’s face and with my right, I squeeze the bag that forces oxygen into his lungs.

“…and breathe…1… 2… 3… ”

As she recommences the chest compressions, more blood stained vomit pours out of his mouth. I sigh as I push my fingers onto his mouth and pull his false teeth out.

“Two minutes is up,” comes the voice of one of the other junior doctors.

“Okay, let’s have a rhythm check,” says the medical registrar, who is presiding over this whole sorry charade.

He squints at the monitor which is displaying chaotic wiggly lines. He frowns and then concludes, “It looks like VF. We need to shock. Charge to 150 please.”

The defibrillator whirrs into life as it charges itself and prepares to deliver the electrical pulse intended to restart the octogenarian’s heart.

“Everybody stand clear… Shocking now.”

The old man’s body convulses at the electricity surges through it. It’s back arches heavenward as if it’s performing one last, grotesque dance. A glance back at the defibrillator tells me that the wiggly lines on the monitor have smoothed out into one flat line - asystole. Just when you think that things can’t get any worse, they inevitably do.

“Let’s give him some adrenaline and continue CPR.” instructs the medical registrar and the student nurse tucks her hair behind her ear and resumes what she was doing before.

“1… 2… 3… 4…”

CRACK. A loud sickening snapping noise emanates from his chest and causes the student nurse to pause.

“5…?”

CRACK. It happens again. Under the pressure of her compressions, the old man’s ribs have snapped, like twigs carelessly trodden underfoot. His emaciated body is literally crumbling in front of us.

“Carry on.” Instructs the medical registrar sternly.

“6…? 7…?” Her voice is quieter now, she’s barely whispering. I’m sure she can feel bone crunching against bone beneath her fingers and she continues to press into the pensioner’s chest. I look up at her and see tears in her eyes. They drip down her nose and fall onto the dead man’s neck where they mix with his bloody vomit and form a river running onto the bed.

A friendly hand touches her shoulder and the ward sister gently says, “I’ll take over now, dear” and gestures for her to step aside.

“What are his pupils doing?” the medical registrar asks me.

I don’t need to look, but I do so anyway, just to be sure. His eyes are half open and I peel back the lids to regard the state of what lies beneath. All I see are hollow, empty globes, whatever life was once there has definitely departed. “Pupils are fixed and dilated.” I tell him.

“Could be the atropine,” says the medical registrar, more in hope that expectation. We both know the reasons are more profound than temporary blockade of his parasympathetic nervous system. We both know that to carry on would be futile.

“I doubt it,” I say. “I think that this man’s ship has sailed. Even if we get him back, he won’t be coming to the intensive care unit. I think that carrying on is pointless.”

I look around. The house officer is studiously staring at his watch, timing things and trying his hardest not to look at the corpse in front of us. The student nurse still has tears streaming down her face and is being comforted by one of the staff nurses. Bless her, she’s probably never seen anything like this before. She probably gave him his last supper earlier in the evening. She probably still thinks that most people get better and those who don’t die peacefully. If continues working in the hospital, she’ll soon have such idealistic notions stripped out of her psyche. She’ll soon learn.

The medical registrar looks at me and holds my gaze for a couple of moments. He sighs. “You’re right, I guess. Does anybody disagree?”

There are no dissenters.

“Okay, let’s stop.”

My hands fall to my sides and the whole team looks at one another.

“Thank you everybody,” says the medical registrar. “We tried our best.”

His words are of no comfort to the student nurse who can no longer contain her crying. She is lead away towards the coffee room by the ward sister. Her sobs grow quieter as they leave and I pause for a moment to look at the old man in front of me.

Is this how it ends for all of us? I wonder. Is this how we die? Covered in our own vomit with our body broken by a stranger’s hands? Whatever happened to dying with dignity?

That last thought causes a wry smile to play on my lips. “Dying with dignity,” There’s a quaint notion. There is no dignity in death, only pain and suffering right up to our last breath and, as tonight proves, sometimes the pain and suffering continues even after we have died.

I peel off the torn latex gloves and wash my hands. I wash my hands again, and again, and again, in a perverse homage to Lady MacBeth, as if by cleansing them, I can scrub the memory of the last ten minutes from my soul.

I turn to leave, and as I do so, my eyes meet those of the gentleman in the burgundy nightgown. It’s like he’s looking all the way through me. Perhaps he and the dead man had become friends during their stay in Beeches Ward. There is an almost pleading look in his eyes, as if he’s hoping against hope that we were his pal’s salvation. I feel an irrational pang of irritation as I look back at him. There is no salvation here. I give a short, curt shake of the head and see him slump back down into his bed in response. I wonder if I should offer some words of condolence, but I quickly think better of it. I have no words to say. The bloody vomit that still stains my shirt says everything that needs to be said. I straighten up and walk away.

The student nurses muffled sobs play on my ears as I leave Beeches Ward and walk back into the impersonal, fluorescent-lit corridor.

I enter the warm darkness of the doctor’s mess and retake my position on the sofa. The surgical registrar stirs as I disturb him from his slumber.

“Did they make it?” he asks me.

I snort in response. “Of course not. Don’t be silly.”

As I lie down, I can feel the adrenaline slowly leaching from my body. The energy is ebbing away like ripples on a lake and it leaves me feeling tired, so tired. I feel sleep start to envelop me again. As I descend once more toward that tranquil oblivion, a thought occurs to me: I never even knew the old man’s name.

17 comments:

Oliver Devine said...
This comment has been removed by the author.
Siva said...

That's one good piece of work..Keep it up. I have been following your blog for a long time now and imagined you might have written a book already. I would like to suggest you something - whenever you combine medicine with philosophy, the combination becomes irresistible as it tells you the truth we face in our everyday work. I hope I get to read your book when it comes out!

Jach said...

I've been following your blog for over a year and loved that story!!

More please!

doctorz said...

Hi

I'm Z from FtM Doctor, you've posted on my blog a few times ;-)

I've been wanting to do more creative writting as well recently. I've done an OU course in creative writting (a 10 credit 10 week affair, that was pretty interesting.

I certainly enjoyed your story - and I found that the cardiac arrest is such a

I've got an idea - fancy a medical 'crit each other's work yahoo group' - for reflective medical writting, or non-medical. But lets face it the drama in our lives is probably going to be most of the inspiration.

But it could be interesting. Time could be an issue - but we could go very very slowly - with much less frequency than other crit groups. Ie infrequent enough to be accessible to people on horrible rotas.

doctorz said...

Hi

I think I have your e mail address from a comment on your blog... if you're interested I can e mail you.

I don't think I can leave an e mail addy on here.

But my anon e mail is z at DNUK.

madsadgirl said...

Nice piece of writing. But then your blog posts are always well written.

Anonymous said...

very interesting!
I enjoyed that

except for the bit at the beginning where there is a paragraph about waking up an being disorientated. This goes on a length, then you say, but it was only for a second?

The Shrink of Virtue said...

Vividly depicts the horror that is that sound. You really hit your stride as you got further into the story. There are several little touches which accentuate the realism, the detail in the recus scene is just right.

376 said...

As another junior doctor, who *hasn't* been in that situation, time and time again? Who hasn't shared that story in the pub, in bed with our loved ones, far away from all the death we're faced with?

It felt very real to me. The only bit I didn't like was 'claw hammer meeting a precious china vase', which I felt was a bit of a clumsy simile.

Cardiac arrests are weird aren't they? Sometimes suddenly in the middle of one, you get that sense of everyone in the room- the anaesthetist, the doctors, the nurses, all feeling the exact same thing, all strung together to save this man's life, whilst all silently agknowledging the futility of it. Then it's over, and it's hard to step back to the living, to the ordinary tasks of fluids and relatives, and procedures, and bleeps.

Anyway, it felt very real. I don't know if that's a compliment, because I don't really enjoy the real ones, but it's as close as I can get!

donall forde said...

hey man young nchd here, that story really hit home with me, doing a care of the elderly job at the moment, would like to hear the anti-euthanasia peoples response to that, people in fact I would go as far to say everyone that has not been at one of the above first hand are under an illusion that death in hospital is always with dignity and painfree, anyway sorry for rant, really like the story well written

claire said...

wow made me cry sometimes we get death rightr or we think we do care of the dying dnrt etc and sometimes we don't.
I felt for the student nurse very descrptive and for the fellow pt when all going pearshaped sometimes we end up doing mop up care.
After all some satff have seen mulptipe crashes know the routine and the crash team don't know the pt involved (not their role) it might help not feel so saddened a a life lost.
another commentor metnioned euthansia from my pov mdt(pt consultant) needs to be realtistic in decsion about how agressive treatment with the patient.

Anonymous said...

One word....Amazing!

Geneviève said...

Awesome!
I eagerly await your book... please write it soon ;)

Anonymous said...

I'm so glad you were realistic about the force we use on a body during CPR.

I am a final year midwifery student & until 3 weeks ago I had only ever resus'd babies.

I was walking down the street in a major southern city when a man collapsed in front of me. I will never forget what it felt like to dig about in his mouth with my fingers, hoping SO much that there was a bit of food stuck. No such luck. I dialed 999, propping the phone between my ear & shoulder whilst I carried on. I had a cracked mirror in my handbag & I checked his breathing with it - unable to believe that not only had someone arrested in front of me - but that I was the only person stopping to help him. In a busy city.

I checked his head for injury - he had a close buzz cut with grey stubble. He could only have been about 50. His head was a perfect shape - not a mark on him. I checked his neck, nothing, his wrist, nothing, I dug about in his trousers - no femoral pulse either, then, ripping his shirt open, I knew that I was going to have to begin my first adult CPR.

It was such hard work. Later, looking at my phone, I realised that I did it alone for 6 minutes, then with the help of a passer-by who did the breaths for a further 2 minutes, then another 14 minutes with the paramedics as they gave adrenaline. He did not have a shockable rhythm.

I never knew his name, his job, anything about him. But for 22 minutes i so badly wanted him to be alright. Of course, he was dead before he hit the floor.

The whole time I was doing chest compressions, even as he turned purple, I was terrified that I was going to hurt him. He has brown eyes & was immaculately dressed. He had been drinking a coffee & I still can't get the stains out of my jeans.

Grace said...

At this time a week ago, I was sitting at that man's bedside. Seeing the same decaying limbs and indulging my teacher tendencies to read random headlines to an Alzheimered mind. You didn't know that old man's name, my Grandfather didn't know mine.

Grace said...

At this time a week ago, I was sitting at that man's bedside. Seeing the same decaying limbs and indulging my teacher tendencies to read random headlines to an Alzheimered mind. You didn't know that old man's name, my Grandfather didn't know mine.

peace said...

Get me out of med school, please.