Thursday, October 20, 2016
Saturday, October 15, 2016
rest in peace
"Are you sure it's not urethrostomy?"
"I'm sure."
"How do you spell urethrotomy?"
"U - R - E --" *BZZZZZZZ*
*BZZZZZZZ*
*BZZZZZZZ*
'Hey is that the crash--'
I don't have to complete my sentence. Before I know it we're already in the corridor. A flock of nurses all sprinting in the same direction confirms it and based on where they're headed I know exactly who has died. A nurse reaches the door of the side room before me and turns abruptly. Her eyes are wide with panic. 'Does she have a DNAR???' She asks. "No, she doesn't." I say, brushing past her to get to the arrest.
She had been in hospital for 3 months, suffered two bouts of pneumonia, had bled from her gut and now her heart had become so starved of oxygen that it was struggling to pump blood around her body and to her kidneys, which were slowly shutting down, causing potassium to build up and mess with the electrical activity of the heart.
We were this close to sending her home last week, before we had diagnosed her heart attack, and before her nursing home had decided to shut down, leaving her stranded here.
"She's going to die. You know this, right?" Our reg told us four hours ago in the privacy of the doctor's office. "The only question is when." And yet only an hour ago she was sat up in bed talking to the med reg, shaking his hand, asking if she could go home.
Now, entering the room - it takes me a moment. I know I should spring into action but I hesitate. I stand there, paralysed, trying to make sense of the situation, trying to comprehend the uncanny slackness of her jowl, her mouth agape and eyes like glass, staring past ceiling and into oblivion.
"HAS THE CRASH CALL BEEN MADE. SOMEONE CALL THE CRASH TEAM." Bristol yells and starts chest compressions. "WILL SOMEONE SECURE AN AIRWAY."
His voice snaps me out of it. I squeeze past Bristol to get to the head of the bed and perform a jaw thrust. It's my first time not doing it on a mannequin, but the training kicks in and my hands seem to move on their own, fingers slotting in snugly behind her mandible, palms resting on her temple as if they belong there.
"Can I have a bag valve mask please." I say, and one materializes within seconds. I clamp the mask down onto her face. I struggle to keep her head from rocking wildly as her torso bucks under the force of Bristol's chest compressions. "Is that 30?" I ask.
"Yeah."
Two breaths, watching for the chest to rise.
My mind is all numbers. I don't notice that the other house officers have arrived until one of them swaps with Bristol. All I can register are a pair of hands pumping furiously up and down a dead person's chest.
27... 28... 29... 30...
Pause. two breaths. Not too fast now.
One... Two... and the countdown begins again.
It's incredibly quiet in the room. Dead silent except for the creaking of the bed in time with the laboured breathing of whoever is doing chest compressions. By now, the anaesthetic SHO has arrived, relieving me of the mask and pressing it against the patient's face with undeniably superior technique. The med reg has also arrived and is stood at the foot of the bed, keeping track of how many cycles we're doing, what drugs have been given, what the heart monitor is showing. The on-call house officers take turns doing chest compressions. Fluorescent light envelops the room in stark, unwavering whiteness. There is a palpable discrepancy in the ratio of bodies in the room to the amount of activity taking place. It feels like strangers waiting in line at a bank, attentive and idle. The med reg is the teller, but instead of 'next please' he says 'listen to her chest,' or 'give her a shot of adrenaline.'
The trace shows electrical activity, but neither the anaesthetic SHO nor myself nor the other house officer can feel a pulse. We do another 2 cycles of CPR before stopping. Although there's no pulse she gasps intermittently, laryngeal muscles in visible spasm. "Agonal breathing," The anaesthetic SHO says by way of explanation.
At some point the med reg says "good job everyone," and it's over. "Time of death: 8:03." The crowd disperses and we vacate the room for the nurses to dispose of the detritus and get the body ready. Pattern, the patient's next of kin is already on her way.
The med reg tells me he'll speak to the family and I agree to scribe. When Pattern arrives, she is in tears. She's ushered into the doctor's office, where Bristol, myself and nurse K are present, listening to the med reg telling Pattern that she passed quickly and with very little pain. Pattern is still sobbing, thanking the med reg for being there, thanking the staff for their patience and kindness. "I know... you did your best to do what was right for her. And... I'm glad she's not suffering anymore." Nurse K offers Pattern more tissues and escorts her to the day room.
"I'll get the listing forms." Bristol says to me.
I'm instantly aware of the irony in that remark, and a day later I'll be able to articulate it. Now that the fuss and commotion has died down, we just carry on right where we left off. No ceremony or moment of silence to mark the occasion. To treat a patient's death as the expected interlude between two acts of a play. A minor interruption.
The med reg says to me, "I've certified her and documented the time of death. Thanks for your help." "Thank you so much," I say. "Thank you for coming."
The notes are sat on the windowsill in the doctor's office. It's 8:30 now, three and a half hours since my shift ended. Out of curiosity, I look to see what he has written -
"I'm sure."
"How do you spell urethrotomy?"
"U - R - E --" *BZZZZZZZ*
*BZZZZZZZ*
*BZZZZZZZ*
'Hey is that the crash--'
I don't have to complete my sentence. Before I know it we're already in the corridor. A flock of nurses all sprinting in the same direction confirms it and based on where they're headed I know exactly who has died. A nurse reaches the door of the side room before me and turns abruptly. Her eyes are wide with panic. 'Does she have a DNAR???' She asks. "No, she doesn't." I say, brushing past her to get to the arrest.
74 year old female, admitted with a blocked right nephrostomy. Nephrostomy exchanged and now draining well. Prolonged hospital stay due to social issues.
Background of CKD stage 3, type II diabetes, staghorn calculus, bed bound, morbidly obese, chronic lymphoedema and cellulitis, both legs.
Admission complicated by hospital acquired pneumonia, haematemesis, and most recently acute coronary syndrome and heart failure.
Over the last three days, eGFR has dropped from 13 to 9. Persistently hypotensive - systolic of 70 - treatment resistant hyperkalemia: potassium > 6.0 for past 2 days despite multiple dextrose / insulin infusions.
Assessed by renal, cardiology and ITU consultants, deemed not a candidate for dialysis, coronary artery catheterisation or escalation to ITU. DNAR discussed and refused on multiple occasions. For cardiopulmonary resuscitation despite poor prognosis
She had been in hospital for 3 months, suffered two bouts of pneumonia, had bled from her gut and now her heart had become so starved of oxygen that it was struggling to pump blood around her body and to her kidneys, which were slowly shutting down, causing potassium to build up and mess with the electrical activity of the heart.
We were this close to sending her home last week, before we had diagnosed her heart attack, and before her nursing home had decided to shut down, leaving her stranded here.
"She's going to die. You know this, right?" Our reg told us four hours ago in the privacy of the doctor's office. "The only question is when." And yet only an hour ago she was sat up in bed talking to the med reg, shaking his hand, asking if she could go home.
Now, entering the room - it takes me a moment. I know I should spring into action but I hesitate. I stand there, paralysed, trying to make sense of the situation, trying to comprehend the uncanny slackness of her jowl, her mouth agape and eyes like glass, staring past ceiling and into oblivion.
"HAS THE CRASH CALL BEEN MADE. SOMEONE CALL THE CRASH TEAM." Bristol yells and starts chest compressions. "WILL SOMEONE SECURE AN AIRWAY."
His voice snaps me out of it. I squeeze past Bristol to get to the head of the bed and perform a jaw thrust. It's my first time not doing it on a mannequin, but the training kicks in and my hands seem to move on their own, fingers slotting in snugly behind her mandible, palms resting on her temple as if they belong there.
"Can I have a bag valve mask please." I say, and one materializes within seconds. I clamp the mask down onto her face. I struggle to keep her head from rocking wildly as her torso bucks under the force of Bristol's chest compressions. "Is that 30?" I ask.
"Yeah."
Two breaths, watching for the chest to rise.
My mind is all numbers. I don't notice that the other house officers have arrived until one of them swaps with Bristol. All I can register are a pair of hands pumping furiously up and down a dead person's chest.
27... 28... 29... 30...
Pause. two breaths. Not too fast now.
One... Two... and the countdown begins again.
It's incredibly quiet in the room. Dead silent except for the creaking of the bed in time with the laboured breathing of whoever is doing chest compressions. By now, the anaesthetic SHO has arrived, relieving me of the mask and pressing it against the patient's face with undeniably superior technique. The med reg has also arrived and is stood at the foot of the bed, keeping track of how many cycles we're doing, what drugs have been given, what the heart monitor is showing. The on-call house officers take turns doing chest compressions. Fluorescent light envelops the room in stark, unwavering whiteness. There is a palpable discrepancy in the ratio of bodies in the room to the amount of activity taking place. It feels like strangers waiting in line at a bank, attentive and idle. The med reg is the teller, but instead of 'next please' he says 'listen to her chest,' or 'give her a shot of adrenaline.'
The trace shows electrical activity, but neither the anaesthetic SHO nor myself nor the other house officer can feel a pulse. We do another 2 cycles of CPR before stopping. Although there's no pulse she gasps intermittently, laryngeal muscles in visible spasm. "Agonal breathing," The anaesthetic SHO says by way of explanation.
At some point the med reg says "good job everyone," and it's over. "Time of death: 8:03." The crowd disperses and we vacate the room for the nurses to dispose of the detritus and get the body ready. Pattern, the patient's next of kin is already on her way.
The med reg tells me he'll speak to the family and I agree to scribe. When Pattern arrives, she is in tears. She's ushered into the doctor's office, where Bristol, myself and nurse K are present, listening to the med reg telling Pattern that she passed quickly and with very little pain. Pattern is still sobbing, thanking the med reg for being there, thanking the staff for their patience and kindness. "I know... you did your best to do what was right for her. And... I'm glad she's not suffering anymore." Nurse K offers Pattern more tissues and escorts her to the day room.
"I'll get the listing forms." Bristol says to me.
I'm instantly aware of the irony in that remark, and a day later I'll be able to articulate it. Now that the fuss and commotion has died down, we just carry on right where we left off. No ceremony or moment of silence to mark the occasion. To treat a patient's death as the expected interlude between two acts of a play. A minor interruption.
The med reg says to me, "I've certified her and documented the time of death. Thanks for your help." "Thank you so much," I say. "Thank you for coming."
The notes are sat on the windowsill in the doctor's office. It's 8:30 now, three and a half hours since my shift ended. Out of curiosity, I look to see what he has written -
Pupils fixed and unresponsive to light
No heart sounds on auscultation
No central carotid pulse palpable
No breath sounds on auscultation
Sincere condolences. May her soul rest in peace.
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