The moment was one that always felt as if a switch had been flicked, when emotions at opposite ends of spectra came into play, transferring from one person to another. When a doctor became worthy enough to debut holding the medical registrar bleep, it was both a frightening yet proud occasion. But that usually changed by the second shift, when the fright lingered but the pride became repulsion every time the burden of doom within that matchbox-sized device was received. For the one passing the bleep, it was never anything but sheer relief.
‘Is that the medical reg?’
‘Yes, speaking.’
‘It’s Kristen, one of the A&E SHOs. Sorry, I have a referral for you.’
Another… ‘Go ahead.’
‘Do you want the details first or the story?’
‘Details – wait – it doesn’t matter; just tell me… anything.’
This was her third bleep since that external call and Philippa had been given no chance to even consolidate what had happened. There must be a far less sinister explanation to the threat she had received? In fact, had it even happened or was she for some reason hallucinating?
‘Her name is Mary Surrey and she’s ninety-two-years-old from a nursing home. She was only discharged from hospital two days ago but is back in. That time she was admitted unwell with pneumonia but improved after a four-week hospital stay. It seems that she’s picked up another pneumonia. She’s a regular attender; this will be her fourth admission in the last three months. Past medical history includes a heart attack in 2012 and two strokes. She’s bedbound and fully dependent on nursing care for everything from dressing to feeding.’
What are we doing here? These people shouldn’t be admitted, they have no quality of life and we’re just prolonging the inevitable. It’s cruel!
The A&E doctor continued. From her accent, she must have originated from Canada although after her misjudgement with Alfred during Handover, Philippa could not be certain. ‘She was found with reduced responsiveness, coughing up green sputum and when the ambulance arrived, her temperature was 39.5 and oxygen levels were 70% on maximum oxygen…’
‘Can I stop you there for a second,’ Philippa said, ‘70% oxygen on what?’
‘Fifteen litres non-rebreather.’
‘With those oxygen levels, it sounds like she’s not got long…?’
‘Well we’ve initiated antibiotics and some fluids.’ She sounded troubled.
‘Any discussions with her family?’
‘You mean resuscitation?’
‘Resuscitation and ceilings of care; whether we would take her to intensive care etc.’
‘Not yet.’
‘Could you?’
‘I was going to but I’ve spoken to my consultant and he wants you to consider other means of ventilation first.’
Philippa nearly choked on her saliva. ‘Other means of ventilation? The lady is dying and it sounds like this is her final illness. I don’t think other means of ventilation will save her.’
‘I know; I completely agree but my consultant doesn’t want to rush into that decision. He thinks you should decide whether we palliate her or not.’
‘Consultant being…’
‘Dr Balsack.’
Even though she knew the answer to her question, Philippa’s shoulders tensed and she had to massage her stiffening jaw. ‘Does she have any family?’
‘A daughter but she’s gone to get a coffee.’
‘Can we call her back now? I’ll need to chat with her and soon from the sounds of it.’
‘Sure. I’ll do that now. Sorry.’
‘Not your fault,’ Philippa told Kristen. ‘Which bed is she in?’
‘Resus One.’
‘I’ll be there in five minutes.’ Pass the buck Dr Balsack, thought Philippa angrily.
Resus was a four-bedded bay within the A&E department where the sickest patients were transferred as soon as they entered the hospital. That was providing they had a decent chance of making some form of recovery. After Intensive Care, it had the sharpest facilities for monitoring key parameters.
Without the luxury of natural light, it was easy to get muddled between night and day inside the A&E maze. Resus was full and outside the bay, paramedics were trying to squeeze in more people. Along the busy corridors, patients were practically hanging off walls and ceilings some moaning from pain, others calling out with advanced dementia. With an ever-increasing and ageing population, the sight of endless streams of patients was a fatiguing but common one.
Philippa winced as the aroma of detergent against vomit tickled her nostrils. Her mind danced between the impending difficult conversation and that external phone call. Put to the test…
Mary Surrey looked as though she had knocked on Heaven’s door several times in the past. On this occasion however, she had returned with a battering ram in a bid to force the door open, and with the radiant light above the bed, she must have been closer than ever.
Curled up in a ball on the ebony trolley, every breath seemed to hit her for a home-run. The oxygen mask was not in an optimal position; hanging off one ear like a picture frame on its last screw. Her eyelids were scrunched up like closed Venus fly-traps, as if she was in permanent suffering.
Every so often, Mary reached up with her quivering right hand and tried to claw the mask away from her face but her feeble body no longer mustered the strength to do so. Besides, she was also under the watchful eye of the no-nonsense nurse. Her left arm and leg, immobile and as stiff as copper pipes evidenced her previous stroke as the referring doctor had relayed. An invasive pressure sore chewed away at her lower back.
Bless her, thought Philippa as memories of her grandmother moments before she passed away floated into her mind, replacing the coarse mental enquiries over that phone call.
‘Mary? Mary?’ she said, shaking the elderly lady gently at first but then a little harder.
She did not respond. Mary wasn’t living any more, she was merely existing…
Philippa adjusted Mary’s oxygen mask and straightened up one of the various tubes erupting from her body.
The patient’s cannula, a thin plastic tube anchored into her vein to supply her with fluids and medications had kinked under tension from her rigid position.
Philippa listened to the patient’s chest and heard signs consistent with pneumonia. Comparing Mary’s x-ray with one from her recent preceding admission, she noted serious worsening features not to mention the wayward blood results.
The monitor next to the ailing patient alarmed as her oxygen levels dropped to 65% before rallying back to 80%. But even 80% wasn’t enough to keep her comfortable. How could anyone think that putting this frail lady onto a ventilator machine was a humane thing to do?
‘Doctor?’
Philippa turned to address the nurse who had tapped her on the shoulder. ‘Yes.’
‘What do you think, doctor?’
She straightened her dress. ‘Well, I think this poor lady is dying and is not going to survive this pneumonia.’
‘Dr Balsack suggested –’
‘I’m not too bothered about what he thinks right now. Has he actually seen the patient himself?’
‘No.’
Philippa gestured as if to say: ‘well there we go.’
‘Can we move her to Medical Six, doctor? There is a side-room there.’
‘That would be a very sensible thing to do… and just Philippa is fine.’
‘Oh, I see Mary’s daughter coming back now.’
Between another two referrals and the scattered heart tracings, observation charts and notes on the workspace, Philippa managed to collate the papers specific for Mary Surrey. She had broken bad news so many times in her career, that the emotional roller-coaster associated with it no longer fazed her. She did harbour one concern however, as the Take was building up; she was unsure how many Karan could see overnight or how enduring his stamina was. What a night to be down a junior doctor. But then again, was there ever a better night to be short on staffing?
Mary’s daughter stormed into Resus and paced up and down frantically next to the monitors and wires. She was dressed in a dark suit as if she had just finished work and clearly spent a lot of time in front of the mirror, with a comparable number of wrinkles despite probably being twice Philippa’s age.
She felt almost underdressed approaching the lady. She clarified some details printed at the front of Mary’s notes – a name printed by NOK. ‘Davina?’
‘Are you her doctor?’
‘I’m Philippa, the medical registrar overnight.’
‘What’s happening to Mum?’
‘Just to confirm, you are her next-of-kin?’
‘What’s going on with Mum?’
‘Has anyone explained yet?’ Philippa found herself being drawn to the lady’s grey curls.
‘No, but you’re going to I presume?’
‘Look, I can see you’re agitated and I understand that. Can I just confirm some details please?’
The lady swallowed hard. ‘Yes, I’m Davina and I’m Mary’s next-of-kin. Now what’s wrong with her?’
‘Your mother is not well -’
‘I can see that.’
‘She has a nasty pneumonia,’ Philippa informed her.
‘Another?’
‘I’m afraid so. I’m aware she was in hospital very recently so I’ve looked at her chest x-rays both past and present. Her last pneumonia did get better before she was discharged but now it’s come back and affecting half her right lung. Her oxygen levels are 80% despite us giving her high-flow oxygen.’
‘Why does she keep getting pneumonia? It’s because you discharged her too soon last time isn’t it? I knew it.’
‘No, it’s not. Your mother is elderly and very frail; she could easily aspirate her own saliva – something we call an aspiration pneumonia.’
‘I said she wasn’t ready to go back to that nursing home.’
‘Davina, I know you’re upset, I understand.’ She was totally missing the point.
‘Do you?’
‘I’ve lost loved ones too.’
Davina backpedalled and bit her lip. ‘So, you will do what you can to save her won’t you?’
‘We will give her some antibiotics and fluids via a drip and see how she goes; take it hour by hour.’
‘Okay, good.’
‘Is there anyone else you might wish to be present right now?’
‘What, like my loser of a husband? No…’
Philippa sighed. ‘Davina, there is no simple way of putting this and I’m sorry to be the one who has to break it to you… but I think this will be your mother’s final illness…’
‘You mean…’
‘Your mother is dying.’
‘What are you talking about? No, this can’t be right; this exact thing happened the last time. I’ve heard this all before and Mum gets better, she always does. I know she’s ninety-two but she’s a strong ninety-two!’
‘I don’t want to give you false hope.’
Davina shrugged and for the first time in the conversation, steered her gaze away from Philippa. ‘Well do what you can,’ she muttered.
Do what you can? What did that mean? Had her words just taken some path of no resistance in one ear and out the other?
Philippa paused momentarily, hoping to allow Mary’s disengaged daughter to absorb the current events in order for her to move onto the next topic: one that often caused far greater conflict between healthcare professionals and patients’ relatives.
‘Davina, we need to talk about something else; another sensitive matter.’
‘Just stop!’
‘If I didn’t think it was important, I wouldn’t be bringing it to your attention.’
‘I’m going to grab another coffee. I’m not doing this until then.’
Philippa stared in disbelief as the figure of Davina petered out then looked at her watch, wrapped around her slender belt. If the call was not a hoax, she had under ninety minutes before the test.
Every few days... 