life and death ii

"Doctor can you come now? This lady is having a seizure."

It's an hour after I should have gone home. I am hunched over in the doctor's office scribbling furiously in the notes of a patient who had fallen and hit his head and is now unresponsive. This is the fourth time I've been interrupted now. This is also one of those requests you can't really say no to.

Without looking up I say, "Sure," tersely, then toss my pen onto the desk with the unnecessary flourish of a disaffected teenager.

As I make a beeline for the emergency, the osce / acute scenario adrenaline rush is beginning to kick in. Mentally I pat my pockets, making sure I've got everything I need. Okay, let's make sure someone is timing it. She might need lorazepam. Maybe a valproate infusion. This is going to be straightforward, I think to myself. No big deal.

I draw the curtains back and see the sister in charge standing over the patient with a very worried look on her face. I immediately register two things: 1. that the patient is motionless and 2. that her lips are a shade of blue that in an unconscious patient generally means that you should be very worried and need to act very quickly.

"Is she still seizing?" I hear myself say. "She isn't breathing," sister says, visibly alarmed. "Is she still for resus?" Sister asks. The A&E nurse who brought her up says there isn't a DNAR form in her notes. My fingers reach for her carotids. No pulse. Agonal breathing, but no pulse. "Should we start CPR?" Sister's eyes are wide. Urgent. Time seems to slow down for this bit. I look at the A&E nurse and ask, "Is she definitely still for resus?" The nurse indicates yes. I look back at the patient, then at sister. "OK, let's start CPR," I say, my voice sounding surer than I feel. It's been two and a half years since I last participated in an actual arrest.

Everything seems to happen all at once after this. Sister is performing high quality chest compression and I'm doing a decent job of maintaining oxygenation and securing her airway. I look down and note a bright red streak of blood staining the left corner of her lower lip as her torso rocks with the force of each compression. I wince internally. What an uncomfortable, traumatic, terrible way to go. The crash call has been put out and 6 other nurses and a surgical doctor have materialised, marshaled miraculously from neighbouring wards. The on call medical SHO appears beside me and takes over the oxygen mask. The pads are now attached. Sinus rhythm but no pulse. We continue compressions.

Half a minute later, while trying desperately to remember whether to give adrenaline now or the next cycle, someone points out that her arm is moving - that she is moving. I look down and the arm is indeed moving. Her neck is straining and as she exhales I feel an increase of pressure in the airtight chamber of oxygen we're attempting to force into her lungs. "It looks like she's breathing for herself... " Realising that no one has contradicted me, I say, "Let's check the rhythm." Sinus rhythm, rate 68 bpm. "Is there a pulse?" Three people check, including myself. "I've got a carotid pulse here," says one of the nurses. I feel simultaneously incredulous and relieved. I feel her radial, just to be sure -- and it checks out. "We got her back," somebody says, the tone is similarly half congratulatory and half surprised. By now, the med reg has arrived.

The other medical SHO has also arrived. He had clerked her in downstairs. He informs us that her old notes show she apparently had a DNAR in place in 2016, but none had arrived with her and the care home aren't sure if she still has one in place. He discusses it with the medical registrar and they decide to sign one now so she doesn't undergo CPR again. It doesn't really feel like a victory; we bought her just enough time to die of something else next time.

I'm asked to speak to the carer and explain what has happened, which I do. The carer seems unfazed by the fact her patient was dead a few minutes ago. She's a prim looking forty year old woman dressed in a business skirt and woolen blazer. She accepts my facts and explanations attentively and without fuss. "Sure, I'll let the care home know."

I get back to my notes which are waiting for me in the office, on the desk where I had left them half an hour ago. I finally complete the entry and hand over to the on call team, telling them about the gentleman in the side room who has probably got an intracranial bleed and a neck of femur fracture. I finish the day by requesting bloods for patients tomorrow. I register the irony to appreciate later. Now that the emergency is over, the mundane tasks need tending to. All in a day's work. Other patients still need looking after. The gentleman in the side room may never wake up, but there's no time to dwell on that either. It's time to go home.

In the hospital carpark, I reflect on what has just happened. I was ostensibly part of a concerted and successful effort to revive someone from death... Is this what it feels like then? There is strangely no euphoria, no endorphin driven impulse to high-five or back-slap or fist pump. Just the general vague sense of having done something challenging and good, like inserting a difficult cannula or reassuring a worried relative.

My housemate is leaving today and she is holding a party where I will be expected to make small talk. Hours later I am at the party meeting strangers, feeling out of place as usual and trying not to offend anyone. Nobody asks if I have saved anybody's life today. I am hopefully being appropriately inquisitive and jokey, wishing there were an ALS algorithm to follow for social situations like these. And life goes on.