life and death

"Every surgeon carries within himself a small cemetery, where from time to time he goes to pray."
- Rene Leriche


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83 year old gentleman admitted with episode of syncope at home, reported feeling dizzy, clammy then lost consciousness for 10 minutes with rapid recovery and no further episodes of syncope. Reports suprapubic tenderness, sudden onset and severe intensity immediately preceding syncope. Bloods showed an AKI with a potassium of 6.0 with no T wave changes on ECG. Palpable bladder, tender and dull to percuss on examination. Seen by my consultant and diagnosed as vasovagal syncope and AKI secondary to acute urinary retention. Plan was to catheterise, treat the potassium and repeat the U&Es afterwards. At least that was the plan - before he started going vacant in the resus cubicle.

'We have a vacant episode over here!' One of the nurses yelled in my direction. Entering the cubicle, I find my man, who 5 minutes ago had been sat up, alert and talking, smiling and and asking questions, now staring off into space and acting like a robot that had its batteries taken out. Something was seriously wrong - and it was my job to find out what.

Stepping up to the plate, I tried to see if he would respond. "MR X... MR X! CAN YOU HEAR ME?" "WUH, WOUHHUHhuhh" he said. His eyes were still open, unfocused. His body splayed out on the trolley.

Another syncopal episode? Absence seizure? Acute stroke? "MR X???" No reply this time. I hold one of his flaccid arms in the air and then let go. It falls back onto the bed like a wet noodle. Same on the other side. Acute stroke causing syncope and affecting both sides?

All this time the nurse says to me, "He looks bad. I've seen patients like this before. Right before they're about to go off. Majorly."

The med reg happens to be passing by. He looks at me quizzically through a slit in the curtain and makes a palm upward motion with his hand as if to say, 'what's going on?' I bring him up to speed. We both stand there for maybe a minute, looking at his pupils, assessing his neurology, watching GCS drop and trying to work out why.

A passing A&E consultant glimpses our man and the complete lack of action being taken and, with a concerned expression, asks, 'What's going on with this man?' I tell him he's having a syncopal / vacant episode. "Has he had any atropine?" "No," I say. "Well, let's give him some atropine. Where's the defib machine?" The consultant's voice ramps up a notch in both volume and urgency, having decided he was now in charge of this acute scenario. He drags the defibrillator from a resus cubicle two beds down and applies the pads to my patient's chest. His heart rate reads 33, 34, 41, his systolic blood pressure which was previously 120 is now 60. We speed up his fluids and give the atropine and his heart rate goes up to 100. Within the next 3 minutes, his systolic BP goes up to 100 and the patient wakes up wondering what all the fuss is about. I struggle to find a viable vein to insert a second canulla for the insulin dextrose infusion and the sister in charge offers to have a look, which is the diplomatic way of saying, here, I'll do it. You're taking too long.

Life and death scenarios. That's what we're here to deal with. The whole point of medical training is being able to spot when something is going wrong, working out exactly what is going wrong and how severely wrong it is, and then being able to correct it. Contrary to popular belief, there aren't that many things that make you go from alive to dead in under five minutes. One of them is a blood pressure too low to provide oxygen to the brain, the heart and the kidneys.

Later on, I tried to debrief myself. If only, I thought, if only I had kept my head and gone through ABCDE I would have stumbled upon the answer in C. Instead I stood there, scratching my head. Not even thinking to ask for a set of observations.

The confounding factors were that I had looked at the observations 10 minutes ago - and not realised they may have changed drastically since. Secondly, we - and by we I mean the consultant - had provided a diagnosis. One that didn't fit with the current presentation. I didn't think to revisit the diagnosis again. And lastly and most worryingly, I hadn't recognised the acuity of the situation. I had in the back of my mind the knowledge that the last episode of syncope lasted for 10 minutes and ended with spontaneous recovery, and assumed that this would turn out the same.

I can't stop thinking about how, if that consultant hadn't stepped in, that man would have probably arrested - and died. From sat up, chatting and smiling - to not moving, not breathing, not living. Irreversibly, irrevocably, indefinitely dead. I had never been so close to that threshold before. That razor fine border between the two infinitely opposite states. An indiscernible event horizon, a turning point as invisible as the molecules that make up the universe, where on the one hand you have thought, emotion, relationships, identity, a past and a future, on the other, stark and absolute nothing. In ancient greek mythology, Atropos was the goddess who ended the life of mortals by cutting their thread with a pair of shears. The idea that human life was something as fragile and tenuous as a stretched out piece of thread. Liable to snap at any moment, without warning. Maybe they were trying to tell us something.

In an alternate reality, that patient would have arrested and we would have commenced CPR and shocked him, and maybe he would have regained circulation, but he would have also sustained cracked ribs and most likely a degree of hypoxic brain injury. If he hadn't regained circulation, his case would have gone to the coroner seeing as he had only been in hospital for five hours. And maybe I would spend the next five days, five years, fifty years asking myself - what if? What if I had done more? What if I could have done something to save him?