Hard Times...

Sometimes shit just happens.
I know this to be true, and mostly use it as a defence, to protect my fragile mind, but sometimes, sometimes, things leak through. No man is an island, and this man certainly isn't a rock.

The Christmas period was as horrendously busy as I've ever seen it, and I've worked a few Christmases. The rest of the hospital seems to operate a fingers-in-ears policy; interestingly, a few weeks after Christmas, when all the patients we'd seen had been admitted, and the burden of care was shifted up a level, 'they' sat up and took notice.

Suddenly we were flooded with extra staff, and, as is so often the way, they came on a day when we had precious little to do, having admitted all the sick patients in the area.

Until, of course, after 6 p.m., when everyone goes home.

Except, me.

We've seen a lot of very sick folks in their 20s and 30s, with awful, awful pneumonias. At first I though it was all 'flu related; the histories seemed to fit, and indeed some of them tested positive, but more of them are testing positive for strep. pneumoniae, which I haven't seen before.

Anyway, this shift, the BatPhone went off, twice in quick succession, forewarning of 2 such patients; one slightly older, one younger. The older of the two arrived first, and looked o.k-ish, just confused, in a lights-on-no-one-home sort of way.

The second, a young 'un, looked really sick. All numbers awful, half-dead in the bed already. I had to take no. one to CT, so left her in the more than capable hands of my Registrar and the ITU team.

No. one's CT checked out ok; I'm still not sure what was going on there, but when I came back, no. two had active CPR ongoing. The guys had been trying to site a central line, when her BP dropped from bugger all, to fuck all. A subtle, but important distinction.

Well, we worked as hard as we could, for as long as we could, but nothing worked, not even a flicker.

I hate losing the young ones, especially when I'm not sure why.

The conversation with her dad, was as hard a conversation as I've ever had.

Cases like this leave no-one untouched. They spread ripples of shit everywhere; they can destroy families, and ruin perfectly good clinical staff, like the Reg I left in charge of the case, who is more than capable, but will be asking himself what more, what else he could have done for weeks.

Maybe it's selfish to think of ourselves, but we can't help it.

We're not supposed to lose these ones, and it hurts.

It hurts, but I suppose it's not so much the falling down, as the getting up again afterwards.

Spare Chaynge

Our attitude to death, or Death, if you will, constantly fascinates me. I suspect it is, at least in part, related to the secularisation of society. I think people fear death considerably more now they aren't assured that it means going to paradise to meet one's maker. Coupled with the idea that we can do so much to stave off death, this seems to me to have resulted in a world where we no longer accept that death comes to us all, and devote much time and money to prolonging the inevitable.

Even when this has been accepted, people seek to transfer the responsibility to someone else, usually the medical profession, often me, because I stand by the front door.

Last week, among the throng that seems to be increasingly the norm at South Coast General, and this is only the beginning of Winter, were two elderly patients who spent their last minutes in an overcrowded, noisy ugly room surrounded by strangers.

The first, an elderly lady, from a Care home. Her quality of life sounded poor, heavily dependent, demented. This is an all too familiar story. We are not evolved to live so long. Her family had seen her deterioration, and seemed to have made the sensible choice, that if she should become ill, she should be kept comfortable at what had become her home, and allowed to die. So when she did become ill, and collapse, the Ambulance was called. Once they arrived the Staff told them of the families wish that she should not be actively resuscitated. No 'formal' documentation of this plan existed: the fabled DNR, or Do Not Resuscitate. This leaves the Ambos with little, or no, choice. If you don't want someone resuscitated, don't call an Ambulance. Why call someone, to tell them you don't need, or indeed want them?

I suspect they wanted validation of their decision. Or maybe they just panicked. I don't know, but the end result was a crumbly, frail woman intubated and ventilated in my Resus room. Yes, her heart was beating again, but she showed no sign of purposeful neurological activity.

Next door, an elderly man, not quite so dependent, but a cardiac cripple, a man so determined to be at home he had taken his own discharge from hospital that very morning. He was unwell, and had been told so; much time had been expended counselling him, warning him of the risks he was taking. He understood, he was clear about that. He didn't care, he wanted to be at home.

He lasted a few minutes.

Now, I respect people's rights to give the NHS the big "fuck you". Many members of the public avail themselves of this right in my face, on an almost daily basis. Adults have to have the right to choose; I must confess to being slightly frustrated when this happens. We spend time counselling someone of the risks, they give us the big "fuck you", we spend money (taxpayers money!) getting them home, then whist we said would happen, happens, and they call an ambulance to come back again. (MORE taxpayers money!)

He, too was dying, and I think he knew it. His resolve to do it at home had crumbled.

They died on trolleys next to one another, both with plans to do so with dignity, at home, in comfort, in tatters.

Is it possible to have a good death? I think it is, but not in an overcrowded ED. I wonder if my nerve will hold when my time comes?