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.”