A Time to Die

Nights were finally coming to an end and I had almost survived, that was the important thing to remember. I hadn’t made any stupid mistakes (as far as I knew) and no one had died because of me (as far as I knew). You see that was the big thing about becoming a doctor, at some point in your career someone was more than likely going to die because of you. They may have died anyway but they might die a few hours sooner because you gave them too much IV fluid or maybe you didn’t write them up for the medication they needed in time. People die on hospital wards and that is just the way it goes but until you get use to that, you always worry that they died because of you.

Part of a junior doctor’s role is to confirm death in patients on the ward who have recently passed away. Not everyone expires in a flurry of activity with crash alarms going off and people jumping up and down on chests, this is in fact more of an unusual way to pop your clogs while in hospital, some may argue anyway. Being resuscitated is an undignified, messy and violent way to die and if it can be avoided at all, it should be. Why would you want to have the ribs of your elderly granny fractured into pieces and tubes rammed down her throat if it was unlikely to help her in the long run anyway? Depending on which article or study you read, only 10-15% of crash calls are successful. That is why when a lot of elderly patients, or maybe those at the end of a long terminal illness, are admitted the have a piece of paperwork signed by a senior doctor stating that they are “Not for Resus”. This is a decision made between the medics and nurses as well as taking into account the wishes of the patient and their family. We are not being ageist or discriminating, I feel we are being kind by sparing them a terrible ending that would probably have little effect on the outcome anyway. If I was at that stage of life, I would happily sign the form.

It was on my final night shift that confusion struck me. It was around 5.30am and it had been a terrible night. The bleep had never stopped going off and every ward had been hit by one admission after another of very poorly people. We were all exhausted and were praying for the end of the shift. I had finally found a moment to sit down and get something to eat for the first time since the shift began the night before. I hid myself away in an empty office at the end of the deserted admin corridor hoping that I could have half an hour undisturbed break where I could recharge my batteries before the final burst of energy that would get me to the finish line. I was halfway through my second chunky kitkat when my bleep went off. Now I’m the first to admit that when tired, my brain does not function correctly. What should be incredibly simple suddenly becomes a terribly complicated task and no matter how hard I try, I just can’t seem to get my head around it. This was the perfect example of one of those times for both myself and the harassed nurse on the other end of the phone line.

“Doctor, you’ve got to come immediately! Mrs Jennings has stopped breathing!”

“Why are you calling me? Put out a crash call!”

“No, she’s not for resus.”

“So she’s dead?”

“No, she’s just stopped breathing and I can’t get a pulse. You’ve got to come, we need help.”

“But she’s dead?”

“You need to do something, it’s urgent.”

“I’m really sorry, I’m very tired and very confused but if she has stopped breathing and she’s not for resus, then she is dead.”

This was met with silence on the line and I could almost feel the embarrassment seep down the phone to me. I knew from past experience when I had done similar things that the poor nurse just wanted to hang up and pretend the conversation had never happened. Many time as a medical student I had dug myself into holes deep enough to bury a small horse in through my lack of engaging my brain, either through exhaustion or stupidity. I had been sent from theatre on numerous occasions with my head hung in shame and my cheeks burning red. On this occasion however, the nurse couldn’t hang up as despite the patient being dead, we still had a job to do.

“Yes,” her voice broke the silence, “that’s right. She’s dead. So it’s not urgent.”

She sounded absolutely exhausted, probably just like I did, and I’m sure she was waiting for some arsey retort over what had just happened. I simply told her I would finish my coffee and head over shortly to confirm death.

This was going to be the first time I had confirmed someone as newly dead. I had seen dead bodies before, I had even cut one up in our anatomy classes at Medical School however they had been dead for some time and held little resemblance to a live human being. The only other time I had seen a recently deceased person was when I went to see my grandfather after he had passed away in hospital when I was a small child. This was clearly different. I had never met Mrs Jennings while she was alive, I knew nothing about her, I didn’t even know if she had family as I walked on to the darkened ward. I made my way towards the nurses’ station which was the sole source of light in the pitch black ward entrance. A health care assistant sat behind the desk filling in paper work. She looked up and smiled at me warmly. Her grey hair reflected the light and cast what looked to me in my delirious state, like a halo around her head.

“You’ve come to see Mrs Jennings.” She said more as a statement than a question.

“Yeah, just to confirm the death.”

“Laura, the staff nurse, is on the phone to the family asking them to come in.”

“Oh, okay. Do I need to talk to them when they get here?” I asked warily.

“No, not unless you want to. We can deal with everything tonight and if they have any questions we can point them in the direction of our own team when they get in at nine.”

“That’s great.” I said with a sigh of both relief and appreciation.

“Busy night?” She asked as she moved around to my side of the desk.

“Very.” I said humourlessly. “At least it’s my last one. Feel like I could sleep for a week.”

“You got much time to recover?”

“Two days, then I’m back doing long days.”

“You must love it here.” She said with a wink.

“Must do.” I said as I rolled my eyes. “Either that or I really have started to loose it!”

She led me down the black corridor towards a side room that had the bedside light switched on and pointing down towards the floor giving the room a softer glow than the usual burning overhead strip lights.

“She’s in there love. I’ll leave you to it, let me know if you need anything.” She said as she turned and made her way back to the paperwork.

“Thanks.” I said, wishing that she would come in with me.

I entered the room and was instantly struck by how peaceful it all seemed. Mrs Jennings was laid out in the bed and the pillows and sheets had been arranged neatly around her. All around her there was evidence of life, Photos of relatives stood on the bedside table filled with smiling faces looking down on the departed elderly lady. Next to these stood various ‘Get Well Soon’ cards and a big bunch of flowers. Her book and glasses had been placed neatly next to her wash bag, all lined up and in order. For some reason it was the book the captured my attention. I just kept thinking that she would never find out how the story ended. I moved closer to the bed and reached out to feel for a pulse. The skin was still warm but there was no steady rhythm of the pulse to be found. I reached over to check the other wrist – still nothing. I looked up to the face which displayed no hint of emotion, no pain or distress was evident. I gently moved the eyelids up and shone my pen torch into her eyes. Fixed and dilated. Finally I placed my stethoscope against her chest and listened for any evidence of breathing. This was the hardest part because the body is far from silent in death. The gurgling of escaping gases and the creaking of relaxing muscles filled my ears but no air swept into her lungs. They had been switched off for the final time. This lady was dead. I should have felt something as I stood over the lifeless body but all I could think was how nice it was to be in a quiet room for a few moments in the middle of such a hectic shift. I suppose that is what makes us good doctors, not getting over involved. I was going to see many dead bodies over my career and I would see many of my patients die and if I were to become emotionally involved with each one of them, I wouldn’t last long in the job.

I made my way back down the darkened corridor to the light at the end. Someone had already laid out the notes for me to make my entry;

Asked to see patient to confirm death. Noted by N/S to be non responsive at 05.15am.

Pupils fixed and dilated.

No breath sounds present and no pulse palpable.

Patient confirmed as deceased.

Rest in peace.

As I signed my name it felt like I was ending this person’s story. No one would write after this entry, the large volume of notes had come to and end. I looked around to see if the nurses were around but everywhere was quiet. I thought she was probable avoiding me after our awkward conversation on the phone.

The final ward round of my weeks of nights was just as bad as the shift had been. It was getting closer and closer to 11am and there was no sign of an ending just yet. We were seeing a patient who had been admitted after a first seizure. Due to the busy nature of the night shift, this lady’s bloods hadn’t been written in the notes before the round so I had been sent to the computer to download them from the results server. It may sound very high tech being able to ‘download’ results – it wasn’t. The connection was terrible and the sever would reset at least five times before you could even log on and then, if feeling temperamental, the computer may decide that it didn’t like your password, even though it was right, and send you back to the beginning again. It would have been quicker to just phone the lab but we couldn’t do that. Since the results server was set up the staff in the lab had been banned from giving the results out over the phone and so we all had to curse and shout at computers for half the working day. It was half way through this process I must have fallen asleep. One moment I was waiting for my password to be accepted, the next I was being shaken awake by the ward sister. I jumped out of fright at waking up so suddenly when I had been unaware of being asleep and managed to slam my knee into the underside of the desk with such a thump that I almost screamed. The ward sister was trying her hardest not to laugh.

“He’s waiting for the results and getting more pissed off than usual so you better hurry.” She said with a chuckle. “I’ll tell him the computer crashed but get a move on and then you might be able to get home!”

I limped back to the round with the print out in hand. The Med Reg had a look of confusion on her face as she noted my limp.

“What did you do?” She whispered. “Was that crashing sound you?”

“Yeah,” I mumbled quietly, “I had a fight with a desk.”

Difficult Decisions

Nightshifts are hell. There is no other way to describe the way they completely wreck your internal body clock, deprive you of natural light and take away all social contact from your life.

When I started this job we still did seven night shifts in a row each lasting twelve hours, however in reality you were often there for thirteen or even fourteen hours as you couldn’t leave until the Post Take Ward Round was over. In my hospital, this round starts at 8am run by the consultant on call and reviews all the patients that were admitted the night before, which on a weekend night could be over fifteen people. The one good thing about leaving work a bit later was the sunlight. If you do these shifts in the winter, it is completely possible to never see the sun. It hasn’t risen by the time you get home and go to bed and it has set by the time you wake up. Let me tell you, this is beyond depressing. Leaving at 11am at least meant that I could walk home with the sun on my face, not that it was exactly strong in the north of England in November time.

Despite my complaining, by night three you do start to slip into a routine. You get home around 11.30am and get straight into bed feeling too tired to even think of having something to eat. The alarm then goes off at around 7.30pm. I would force myself out of bed, shower and eat whatever was in my fridge that didn’t require much preparation. At 8.30pm it was time to set off for work again, on the way I’d stop at the corner shop and stock up on cheese and onion crisps, chunky kitkats and Pepsi to keep me going through the shift and then handover started at 9pm. There was no time for friends, fun or any type of life during this week and seven days like this can really drag.

The best part of nights for me was getting to know the nurses on the different wards I covered. They were always the first ones to make the coffee when I looked about ready to drop, the ones with a funny story when my mood lowered and the only other person to ever offer to answer my never ending bleep for me when I had my hands full. It was this week of nights that made me realise that the nurses weren’t to be feared like we were led to believe at medical school. As long as you weren’t an arrogant idiot (which unfortunately couldn’t be said of all my colleagues) and were able to take a joke, the nurses could be one of your closest allies as a junior doctor. God help those arrogant idiots however! I think they forgot who had access to their bleep and if you were going to be rude, then that bleep wasn’t going to stop all night. I always thought it was amazing how stupid these people could be, they never seemed able to put the two things together. They would just assume it was the same for all of us. I never corrected their assumption.

Nights always gave you access to the crazy side of the patients as well. I don’t mean true psychiatric illness by this, I wouldn’t be so simplistic as to label this ‘crazy’. No I mean the type of elderly patient who by day is lying in bed with a smile on his face offering Toffees to the staff, patients and visitors and then by night turn into a weapon wielding maniac. On night four I was bleeped to go and help a ward deal with one of these situations. A 79 year old man being treated for a chest infection had woken up at 2am and become confused as he did not recognise where he was, this confusion melted into fear which led him to feeling the need to defend himself. He had jumped out of bed, grabbed the drip stand at the side of him and started to swing it around like a sword, in the process he had pulled out the other end of the drip that was attached to his hand and sprayed blood over the wall and floor. As I arrived on the ward Mr Thompson was standing by the nurses’ station, holding the drip stand in an attack position. There were two nurses on each side of him trying to calm him down in a gentle voice and behind them they had a security guard each. Security stood there looking suitably gruff and angry, as you would expect from 6ft of security guard. Every time someone got too close to Mr Thompson he would swing the stand towards the perceived threat using all the energy left in his frail body. I have to say, I was impressed with the energy and power behind the swing. I wasn’t surprised to learn later that he had been in the army for much of his working life.

“Mr Thompson?” I asked. “My name is Dr Randal and I’m the on call doctor tonight, can we have a chat?”

“Fuck off!” He barked back at me.

“Do you want us to disarm him?” Mr Security Guard asked with a glint of excitement in his eye.

“No! He’s not a professional gunman! He’ll get hurt.” I said, a little shocked at their gung-ho attitude.

“Mr Thompson, have a look at my ID badge, I’m a doctor and you’re in hospital.”

“I can’t see that!” He said as I passed him my badge, just ducking in time to avoid the stand as it rushed over my head. “I want to go home!”

“You’ve not been well sir, you need to get back into bed and let us look after you.”

“I want to call my wife.”

“It’s 2am.” One of the nurses pointed out calmly. “You don’t want to wake her up and worry her at this time do you?”

“Rubbish, you’re just saying that!”

I edged around him, all the while fearful that I was going to have to explain to my SHO that I was going to have to go down to A&E after receiving a head injury from an elderly patient with a drip stand, and switched on the TV at the side of the nurses’ desk, turning the channel over to the all night news feed that had a clock at the side of the screen. Mr Thompson watched me and came over to see what I was doing. He stared at the screen.

“Terrible,” He said as he placed the drip stand on the floor. “no fluids on a flight. I like to bring a drop of scotch with me to Spain each year, but now…”

It took me a moment to realise he was commenting on the story being shown on the news. He turned to look at me and smiled; “Any chance of a cup of tea?”

Difficult decisions have to be made on nights. Not long after I had left Mr Thompson, my bleep went off. A ward at the far end of the hospital had a middle-aged gentleman, admitted the previous day with chest pain, who had just started vomiting large amounts of fresh blood. His pulse and blood pressure had started to fall and he was still vomiting. At the same time, a ward at the opposite end of the hospital informed me that a 28 year old woman, admitted due to poorly controlled asthma, had started having an asthma attack fifteen minutes ago and there was no sign of it easing. She was fighting to breathe and her oxygen levels were falling. What should I do in that situation? Once again, I found myself dealing with something that Medical School had never taught me, how to choose between two life threatening situations in two separate parts of the hospital. Everyone will have an opinion on what to do but when this happens at 3am on your fourth night shift, you can’t always think through every option and you just have to do what you think is right. Both of these people needed a doctor with them, straight away, and I could only go to one of them. The best way of getting a doctor there fast at this time of night was to put out a crash call. I asked the nurse who I was speaking to at the time to hang up and call for the crash team as I was already on my way to a patient in need. What else could you do?

As I ran down the corridor towards the vomiting patient my bleep went off informing me of the crash on the ward that I had just spoken to, so I knew they had done what I asked. I ignored it and kept running towards the patient vomiting blood.

When I got there, I saw that the ward nurse hadn’t been exaggerating. Fresh blood covered the sheets and pooled in vomit bowels scattered around the cubicle. The patient looked as pale is ice and was fighting to catch his breath. Every few seconds he would heave as if he was about to vomit again but nothing came out. I slipped into auto pilot and did what my training told me to do. I got a line in, took out blood at the same time, cross matched his blood to prepare for a transfusion and set up fluid to keep his blood pressure and pulse up while we waited for the blood. All the time I was praying that this wouldn’t turn into an arrest situation as well as I knew the crash team were already busy and it would leave me totally on my own here to deal with it if it did.

There is no clear line between who belongs to medicine and who belongs to surgery. If you have ever worked in an emergency department you will have seen the debate over who the patient belonged to on many occasions. The surgeons insist it is not their problem and so refuse to admit the patient to one of their beds, have you tried the medics? The medics insist it is not their problem and so refuse to admit the patient to one of their beds, have you tried the surgeons? In our hospital, vomiting blood most definitely counted as a surgical problem. I bleeped their team and asked for immediate assistance and I got no argument back, in fact they were more help than my own team. Maybe my opinion on surgery was completely wrong! They were so helpful. I was starting to think that all my views on the hospital teams were wrong.

By the time the surgical team arrived on the ward we had stabilised him. His vital signs were no longer falling and the lab was getting suitable blood ready to replace what he had lost. (My urgent bloods had shown a massive drop in haemoglobin since they had been checked earlier in the day.) The surgical registrar even said “well done” to me, which took me by surprise. They wheeled that patient off to theatre to find the cause of the sudden bleed and I made my way back towards Medical Admission to explain what had happened to the Med Reg. It felt good to have managed a situation like that, the patient was stable and another team were now going to investigate. I had done all this without having to get help or advice, maybe I was learning. As I entered MAU and saw the anger on the face of the Med Reg, that all came crashing down.

“Where the hell have you been?!”

The Night Shift Ghost

Fear. Cold hearted, steel gripping fear. That’s what I felt as I crossed the road towards work on my way to my first ever night shift. I was now a month and a half into my first job and I was starting to get the hang of it. I was basically a glorified secretary spending my time filling out paperwork and making appointments. I was given an order by a senior doctor and I carried out the task. Simple, it didn’t take a medical degree to do most of what I had to do. The few times I got to give my brain a work out were my weekly long day shifts. On these days, after 5pm I would cover all the medical wards until 9pm dealing with any urgent problems that came up and couldn’t wait. It was here that I was given the chance to practice medicine, interpreting blood results and examination findings, talking to patients and relatives and working with the nursing staff to keep things running smoothly. For some reason, going home at 9pm meant that those shifts didn’t seem so bad. It was only four hours and even I could hold things together for four hours. Nights were another story. It suddenly went from holding things together for four hours to doing it for twelve hours while the rest of the city slept. That was a daunting challenge. I knew what I felt like if ever I had to be awake in the early hours of the morning and it wasn’t a pretty sight. I was terrified that this would be when everyone would see me for the impostor I really was. I wasn’t good enough to be a doctor, by some miracle I had completed my course and got the degree but I couldn’t cope with twelve hours of making life and death decisions, I was much better with the paper work.

I had already heard the horror stories from my friends of the constant bleeps, numerous new admissions and lack of senior support that made up a night shift and these stories just added to my anxieties. So, the facts? I was to cover ten wards, all with approximately twenty five beds and the Medical Admissions Unit of twenty beds. If any of the wards had any problems, new admissions or emergencies, I would be the first point of contact for them and on top of that, I was also a part of the dreaded crash team. How hard could it be? How many things can go wrong in just twelve hours, and shouldn’t everyone be asleep anyway?

The day doctor looked on the verge of tears. He handed over five new admissions waiting to be seen, two sets of bloods awaiting review and an elderly man who hadn’t passed urine in the last two days, had a bladder the size of a football and would require a catheter to drain this. He also warned me of an outbreak of vomiting on one of the elderly wards and advised that if at all possible, I should avoid that ward and try to put off any problems until their own staff arrived at 9am. Just the way you wanted to start a Friday night? No, not me, you have the wrong man, I wanted to be down the pub, on my third pint with a pizza or maybe a kebab waiting for me at the end of the night. With my heart sinking into my shoes, I set off towards the nearest ward that needed my help. It was then that it started - the bleeping. The constant, high pitched, incessant bleeping noise that would invade my dreams and turn each sleep for the next week into a nightmare. Anyone who has been a junior doctor will know just how painful the constant sound is and what it can do to your sanity. Friday night had turned the wards into chaos and suddenly, everyone needed me at once but I couldn’t go anywhere or do anything because I was stuck at the desk in the doctors’ mess attached to a phone, answering my never silent bleep. The list of jobs grew by the second and all I could do was try and reassure the nurse at the other end that I would be there as soon as possible and yes, that noise was my bleep going off again so I better go.

My list now included;

1. A 33 year old man with chest pain wanting to self discharge as we wouldn’t allow him out to the pub for an hour

2. A 79 year old delirious woman who had tried to get into the wrong bed, realised there was someone already in the bed and thrown herself to the floor in fright and now couldn’t move her left leg

3. A 55 year old man who had started vomiting on a ward without the vomiting outbreak

4. An IV drug user who appeared to be now withdrawing from alcohol as well as heroin and needed detoxing

The list went on and on and on…

I don’t know how many of you have been to a hospital in the middle of the night but my view is that a hospital at night is very different to one during the day. The corridor lights were set to dim and the wards themselves were cast in darkness with just a glow being emitted from the nursing station. The thing that I hated the most at first was the silence. It was unnatural, these rooms and halls should never be so quiet but as you race to an emergency at 3am, all you hear is your own heart beating. By the end of the first nightshift however I had grown to love the silence and found it a welcome break as I walked from one job to the next.

The old part of the hospital I worked in was rumoured to be haunted and these storied hardly surprised me. I have already mentioned the gothic architecture of the ward I’m based on, well the entire wing of the hospital looks the same. The main entrance hall of the wing is dominated by a sweeping stone staircase overlooked by a stern statue of the hospital’s founder. Great arched windows flank each side of the stair case casting the corners of the room in shadows and creating shapes out of nothingness. Many of the wards have high ceiling which cause an echo as you walk down them at night that would not be out of place on a sound effect CD for a horror film. I had been rewriting several drug charts on one of these wards and as a thank you, one of the nurses had made me a cup of coffee. I sat at the ward desk with the two night nurses drinking my coffee, hoping it would give me the motivation to walk to the far side of the hospital to see an old lady with recent onset diarrhoea. The nurses decided that this was the perfect time to fill me, the ‘new recruit’, in on the ghostly goings on that they had witnessed in their time on the wards at night. They spoke about hearing a crying baby in a room a new mother took her own life in, about feeling a hand on their shoulder whenever taking vital signs from a patient who is about to die, even of a patient being admitted who vanished into thin air once they got into bed! They told me the stories with such conviction I was completely drawn in to them. How was I to know they were having a laugh with me?!

Later that night, as I was walking down one of these old corridors, my mind started to go into over drive. The main lights were all switched off leaving just the occasional side light to illuminate my path and they left large parts of my route in complete darkness. The pipes above my head had started to rattle and the vacuum tubes that were used to transport bloods to the lab started to grown, normal noises in an old hospital but with my head filled with ghosts and ghouls, I could feel my heart rate increasing and let me tell you, as the clock reaches 4.30am and you’ve had only 10 minutes to yourself since you started at 9pm the night before, there is no logic left in your head! I felt myself walking quicker, pushed on by the tricks my exhausted brain had started playing on me. It was at that point I started to hear footsteps behind me. Now I realise looking back on this I was acting like I was some kind of extra in a bad horror film but this was not what I was thinking at the time. I decided to break out in a light jog, aiming for the far end of the corridor which would open out into the nice new state of the art, modern wing of the hospital. It was then that my bleep decided to go off. The noise was so sudden and so piercing as it echoed through the darkness that I jumped about a foot in the air, landed in a pile of clean bed linen sending it all crashing to the floor and shouted out “Fuck!” This was met with a roar of laughter as the source of the footsteps behind me ran over to check if I was alright. It was the nurse who had fed my head with ghost storied earlier that night. She was on her way back from the canteen with several rounds of toast and was not in fact a serial killer preying on junior doctors lost in the darkness of the old hospital. She found the sight of me sitting in a heap of bed sheets so funny that she dropped her toast. After helping me to my feet she finally stopped laughing and asked me if her horror stories had made me paranoid. She clearly decided that my denial was a lie and promised to make it up to me the next night be ordering a pizza and letting me share it. She told me it was a Saturday night ritual for her if ever she was on nights and told me that I was always welcome to join in. Feeling more embarrassed than I ever thought possible, I thanked her, told her I loved the sound of pizza and then ran off to answer my bleep.

“Doctor, I’m sorry to bother you but you have to come straight away. That patient you saw who was withdrawing from alcohol, well he’s picked up one of the nurses and he won’t put her down…”

I made my way over to the ward that had called me. The whole way there all I could think was how stupid it was that medical school had never prepared me for a patient refusing to put down a member of staff. What the hell was I going to do about it? Surely it would have made more sense for the ward to call security? When I got there I was confronted by the withdrawing patient not only holding the poor Filipino nurse over his shoulder but also standing on a rather insecure looking chair and occasionally letting out a small scream. The healthcare assistant came over to me with a look of sheer panic on her face. She informed me that the patient woke up screaming about spiders and when the nurse went over to check on him, he had grabbed her and made his way to higher ground. The nurse did not look happy. Fair enough, the patient hadn’t taken a bath in weeks and the smell of the street living mixed in with stale alcohol was enough to make me feel nauseous at a comfortable distance so I could only imagine what it was like for her being so up close and personal with him.

“Hello sir, I’m the on call doctor tonight, I need to ask you to come down off the chair and let go of our nurse.”

“Can’t do that.”

“Why can’t you do that?”

“The spiders will get us, can’t you see them? They’re all over the floor, they might be dangerous.”

“I can’t see any spiders sir. I think you’re not feeling very well because of not having a drink today. If you come down, we can get you some medication to help with that.”

It took ten minutes and a visit from security to talk him down. He let go of the nurse and was given enough sedatives to drop a charging rhino. I went over to ask the nurse if she was okay and offer my assistance in anything that she needed but within minutes my bleep was going off again summoning me to the far side of the hospital.

“Doctor one of our ladies is having trouble going to the toilet, she’s in quite a lot of pain.”

“I’ll be there as soon as I can.”