The Gathering Dark

Some shifts you just want to go home and stand under a hot shower...



La Belle Fille has been away this weekend, living it up in the country. I have missed her, perhaps more than I expected. Which I actually think is a good sign, at least for our future. We seem well suited, despite the fact that what I intend as gentle teasing oft emerges as slightly insensitive / poor humour. My boss thinks she's to good fro me, and she might be right. Still, I am assured that she acquitted herself admirably both on guitar and vocals (in Rock Band.)



I am proud.



The Department was generally quiet today; but the BatPhone trilled its urgent call to shatter all that. Normally the figures Control relay to us are all business - pulse rate, blood pressure, Glasgow Coma Score... tonight, they added another - the patient's weight. 30 stone. (420 pounds, or 190 kilos) The raw details - respiratory arrest, found by his ex-wife; she'd been worried about him as he sounded off on the phone. His medical rap sheet made for grim reading. COPD, startlingly poor mobility; his house a veritable shrine to the machinery we gather to force the breath of life into us; deus ex machina if you will.

Too late, too late. Somehow the paramedics had managed to get a tube down, and his heart still struggled on. But he'd had no drugs, and showed no sign of wakening. As we tried to gently ease the news into his family's consciousness, he showed his hand. Harder and harder to bag him, higher and higher airway pressures. Pneumothorax - a collapsed lung - is always a possibility in these cases, and worse, because we were ventilating, the collapse progresses, air displacing heart and lung, literally squeezing his life out.

Needle decompression not feasible through such a massive chest wall, we set to thoracostomies. An elegant word for a bloody, violent procedure. They push the knife into my hand. It's a 15 blade, a tiny knife, a child's blade, but proves adequate to my task. Skin and fat offer no resistance, and my finger worms down to his ribs. I thought they'd be bigger, somehow, but they seem tiny inside his bear-like chest. The last push is blunt, brutal, with forceps. A gush of air greets my penetration of his pleura, the thin, greasy membrane that lines his chest cavity; the diagnosis is confirmed. Sweeping my finger between his ribs, his lung feels stiff, and is stuck to the chest. I feel a rent in the tissue of the lung, and a wave of nausea nearly overcomes me.

Have I slipped in too far? It shouldn't be possible, if the lung was fully collapsed, but maybe it has remained stuck to the chest wall in a few critical places? Maybe it is the lung itself that has yielded under my finger? My act is repeated across the chest from me, a distance that seems absurdly far. We place drains with shaking hands, and the water sealed drains bubble vigourously, angrily. Too much air, there must be an ongoing leak, and I know I've done something, something to add to his misery. If he could feel it.

He ventilates better for a while, then slackens off again. On my side, his chest is inflating, the soft tissues distending; under my fingers it feels like bubble wrap, and I know air is forcing its way into the fat under his skin, despite the angry bubbling of my drain. I check the holes - they're all inside the chest cavity, but still air leaks out elsewhere. Did I make two holes?

I've lost focus now. Fortunately, my colleagues have not, for our patient is circling the drain. I'm fixated by the drain. My mind is running overtime, replaying the act, searching, searching for the thing, the one thing that I might do, that I kid myself will make any difference; but I can't find it, and I know I've failed him.

My boss taps me on the shoulder, urging me to go and clean up. I look dumbly at my hands and arms. Somehow they're stained with blood; I don't remember it getting there; I clean up, scrub up, quickly. Things are moving apace now, and a crossroads rapidly approaching - one road leads to ITU... and one dose not. Wiser men and women than I will help him now. Another boss sees I'm running on empty, and ushers me out, to check the rest of the Department.

I turn, and walk slowly out of resus, my failure complete.

It is no surprise to learn later that he exceeded to limits of support we could offer him, and was finally allowed to complete his short journey. I hope someone was there to hold his hand, at the end.

La belle fille didn't ask about my day that evening, and I think I'm probably glad of that.