Sunday, January 27, 2008

Si Tu Dois Partir

The nights roll on...

I am failing in my duty to one of my SHOs. They are not working fast enough for the ED, and I am not showing them how. It is mkaing very unpopular with the Nursing staff. I will have to try harder.

Last night seemed to bring an unwelcome reminder of our limitations as doctors. Perhaps as people, too. Two patients, both ED 'bread and butter'; the first a 'blue bloater'; long term COPD, unwilling or unable to give up the cigarettes that have done this to him. Reluctant attender, as so many of them are, knowing all too well the poking and prodding that awaits. But tomight he was tired, too tired. His CO2 levels, always high, are creeping higher, slowly anaesthetising him, in front of our eyes. He has been here before, been judged in the eyes of the Intensivists, and found wanting. He is not for ITU, not for invasive ventilatory support. We all know that once attached to the vent, he will likely not get off it.

I offer him what we can, nebulisers hissing softly in the quiet of resus, steroids, i.v. because he cannot swallow, theophylline coursing through his veins, salvation in a plastic bag?

Not this time. His chest remains tight, each breath an effort, hardly lifting his chest. Non-invasive ventilation is next, an uncomfortable mask, held awkwardly on the face with a Heath Robinson-esque collection of straps, designed by the lowest bidder.

None of it does any good. His numbers stay the same, low, low oxygen, and high carbon dioxide, creeping slowly, slowly higher. He himself slips away as I watch him. The light has gone from his eyes, his defiant humour, that he held onto at the beginning is gone. All of his being is breathing now, and even that is an effort. He is exhausted.

The next, an elderly lady. Suddenly ill, suddenly very ill. Almost no warning. A little breathless, then she slipped away. By the time the Ambos get there, she is gone. But not so gone, as to be beyond us. Slickly, professional, she is resuscitated, her angry, irritated myocardium teasing them with hints of life. She is still slipping back and forth when she is delivered to us. A few more rounds, and she comes back, and sticks. Something we have done keeps her heart in synch this time. We wait a minute. Have all seen this before; false hope. A sort of 'dead-cat bounce'. But she stays with us.

How long? Long enough to call the intensivists. Long enough for us to gather and decide that although we have restarted the clockwork, the soul is long gone. We will keep watch, standing guard against the unlikliest of returns, but we all know it is futile.

Have we achieved anything?

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