In the Midst of Life (3 page)

I was still taking off all her black clothes, revealing an emaciated body. Staff nurse was a thoughtful girl, and remarked, ‘She looks half-starved, as though she has hardly had a good meal in her life. How did she come to be with you?’

Then Slavek told us the story of her astonishing lone journey across Europe to England. Staff nurse wrote it all up in the notes. ‘Amazing,’ she said, ‘hardly credible. But she is here, so she must have done it. Why did she come?’

‘She told my sister, Olga, that she was going to die, and that she must see me first.’ Slavek could scarcely get the words out, his voice catching as he choked back the tears.

‘Her dying wish, eh?’

‘I suppose so. She told me that she was happy to go now that she had seen me.’

Staff nurse was kind and optimistic. ‘Don’t worry. Your mother is in the right place. We can treat this sort of thing. She will soon be well again.’

‘Thank you so much. You are wonderful.’

The house surgeon arrived. He was very young, about twenty-four, and this was his first house job. Like me, he was nervous and a bit hesitant. He checked Mrs Ratski’s heart and lungs, looked into her eyes, ears and throat, and checked all her involuntary reflexes. He took blood for crossmatching, set up a glucose/saline drip, and put the gastric suction machine in readiness, but he did not insert the gastric tube. He examined the abdomen, which was hard and distended, and applied his stethoscope to listen for abdominal sounds. ‘Hmmm,’ he said, looking very wise, ‘I will call the registrar.’ With that, he left.

I was told to give the old lady a blanket bath, and to put a surgical gown on her. She was so thin, I thought she might break
if I moved her. She could scarcely have weighed more than seven stone. Her distended abdomen, hard and shiny, contrasted strangely with the rest of her. I wondered what kind of life she had had back in Latvia.

The registrar came, accompanied by the houseman. The registrar was only about thirty, perhaps less, but five years’ experience in medicine can make a great deal of difference. There was no careful hesitation in
him.
He was quick, confident, and arrogant. He tapped the abdomen and listened.

‘What do you make of it?’ he demanded of his junior.

‘Well, em, I, er, could hear abdominal sounds.’

‘And what did you make of them?’

‘Well, I found, er …’

‘Can’t hear a damned thing that means anything. We’ll have to open it up to see what’s going on. Go and book theatre. Laparotomy, with exploration. Possible gastrectomy, resection, won’t know till we get in there. I’ll go and talk to Carter. See if he wants to do it, or if I should.’ They left.

Mr Carter, the consultant, arrived with an anaesthetist. He examined Mrs Ratski and read the notes. The anaesthetist was concerned about the patient’s emaciation and her state of shock. He ordered a gastric tube to be passed and suction to be commenced immediately. He commented that she would not need a pre-med, because she had had morphine. He said, ‘We must have a consent form, and she can’t sign it. Is there anyone here who can?’

‘Her son is with her,’ replied the staff nurse.

‘Get him to sign, will you, Staff?’

The two consultants left, and Staff took a consent form to Slavek. ‘Your mother must go to theatre for an abdominal exploration. Would you sign the consent form for her, please.’

‘Of course,’ said Slavek, and signed.

There had been no discussion with Slavek about his mother’s condition; no mention of what an exploratory laparotomy means, still less of what a gastrectomy or resection could entail, nor of the post-operative complications that can so easily arise in old people
after major surgery. There had been no hint that perhaps the surgery could lead to a death more agonising, and certainly more prolonged, than the abdominal crisis that had occurred in the early hours of the morning. Neither the doctor nor the nurse discussed with Slavek his mother’s dying wishes, nor her certainty of her impending demise, her astonishing resolution to get to England to see him, and her acceptance of death once she had achieved this. No one asked him, quietly and sympathetically, if he could project what his mother might want. Whilst all the decisions were made about and around her, Mrs Ratski was in a deep, morphine-induced, sleep. But no one suggested waiting until she roused so that she could speak for herself.

That was when, at the age of eighteen, I started to contemplate
death.

Mrs Ratski was taken to theatre within an hour of the ambulance arriving at Slavek’s house, and Mr Carter took the case himself, with the registrar and houseman assisting. The abdomen was incised, and a volvulus was found to be causing the obstruction. Volvulus is the term applied to the twisting of a loop of bowel on itself. The pelvic colon is most commonly involved, and the patients are usually elderly. Manual untwisting of the bowel was performed after deflation of the loop with an aspirating needle, then the gut was examined, and no other abnormality was detected. Gastric suction was continued throughout the operation, and a saline and glucose drip continued. To relieve the pressure on the pelvic colon, a left inguinal colostomy was undertaken, which was intended to be temporary. A colostomy is when a loop of colon is brought out through the abdominal wound on to the skin surface, and retained in position with sutures. An opening is then made into the bowel, and the contents will drain into a bag or bottle.

The operation itself was relatively straightforward, but difficulties arose because of the anaesthetic. The patient was old, undernourished, and in deep shock. Her blood pressure was very low, hardly sufficient to maintain circulation, so cardiac stimulants and oxygen were given. The patient did not have adequate respiratory drive to breathe, so a tracheotomy was performed. The anaesthetist made an artificial opening through the windpipe, and passed an endotracheal tube directly down the trachea for oxygen and gases to be delivered under positive pressure. The gas used was ether, and Mrs Ratski went into an ether convulsion, which is a serious complication. Antidote drugs had to be given intravenously, the gas was stopped, and a mixture of oxygen and carbon dioxide administered instead. The patient was in theatre for three hours,
and for most of that time the anaesthetist was battling for her life. Several times the theatre staff thought she had died, but each time the anaesthetist resuscitated her successfully.

Mrs Ratski returned from theatre to the ward. Post-operative intensive care units did not exist in the 1950s, so the ward sister and her nurses took that responsibility. We had been alerted that the patient’s condition was grave, and a small side ward had been prepared. The ward sister received the patient and checked her condition, and a nurse was told to stay with her. There were no monitoring machines in those days. A patient’s post-operative condition was maintained entirely by nursing observation and assessment.

Slavek had been obliged to go to work. He had been told to ring the hospital at midday, and that he could visit in the evening. When he telephoned, he was told that the operation had been successful, but that his mother was still under the anaesthetic. He came to the hospital directly from work, but she still had not regained consciousness. The breathing tube in her throat frightened him, so he asked the sister about it, and she told him that it was only temporary and would be removed when his mother had enough strength to breathe normally. He asked about the blood transfusion entering her arm. What was wrong with her blood? The sister quietly explained that it was normal procedure after major surgery to give blood. An oxygen cylinder hissing away beside her bed alarmed him, but at the same time it reassured him – everything possible was being done for her. Everything would be all right. She was sleeping and looked comfortable, so he slipped away.

On the second evening, he was alarmed to find his mother’s hands tied to the side of the bed. The sister explained that it was necessary, because his mother had tried to pull the tube out of her throat. His mother turned her head and looked at Slavek, her eyes full of anguish, but she could not speak because of the tube in her windpipe. He stroked her hand and kissed her forehead, whispering, ‘You’ll be all right, mother. They know what they’re
doing.’

On the third evening the oxygen cylinders had been removed, but the tube was still in her throat, and her hands were still tied. Slavek asked about the tube, and the sister said that there would be a ward round tomorrow, so a decision would be made then. He felt reassured, and told his mother that the surgeon would see her the next day, and that everything would be all right.

But everything was not all right, and we, the nursing staff, knew it.

In the first instance, our patient’s recovery from anaesthetic had been abnormally prolonged. She had not shown any signs of consciousness for more than twenty-four hours, and when she did recover, she seemed excessively agitated. She had attempted to throw herself out of bed, and had to be restrained by two nurses. She tried to shout, but could not make a sound, because of the tube in her trachea, so she tried to pull it out. We nurses had to prevent her from doing this, and we explained that it must stay in place for a few days. Only then did we realise that she neither spoke nor understood English, and it took us some days before we appreciated how difficult this was going to be. She watched us carefully, and when a nurse’s back was turned she tried to pull the tube out again, and had to be restrained. The naso-gastric tube, which was attached to a machine for continuous suction, was another focus of worry. Then Mrs Ratski discovered the blood drip entering her arm, and had a go at that, too. The night sister had ordered her hands to be tied to the sides of the bed, because during the night when fewer nurses were on duty she would have undoubtedly succeeded.

Mrs Ratski lay immobile, hands restrained, in terrified silence. Soundless sobs racked her body, and tears streamed from her eyes. She could not swallow, because of the pain in her throat. Her mouth became completely dry and crusted, and had to be moistened and cleaned every hour, but even so her tongue was ulcerated and cracked. She did not pass any urine, so a nurse had to catheterise her, but she held her body completely rigid, to prevent anyone from parting her legs. Did she think she was being raped? I wondered. Maybe she had been, in a prison camp? A muscle relaxant
was injected, which she could not prevent, and the catheter inserted.

The house surgeon, registrar and anaesthetist visited frequently to check her condition. On the fourth day Mr Carter did his ward round. These were always elaborate affairs – the consultant, accompanied by the ward sister, followed by his team of doctors, and another team of nurses who were there to do or get things. It was highly ritualistic, like a visit from royalty. The consultant would go round the beds of his patients, asking questions of the sister, checking notes, ordering another test or another path lab analysis, changing a drug, or the dosage of a drug.

Mr Carter approached Mrs Ratski’s bed. She lay still, her lips compressed, only her eyes moving, as they flickered from one white coat to another. Mr Carter read through the notes. ‘I hear you have had trouble with her, Sister.’

‘Yes, sir. She keeps trying to interfere with the dressings.’

‘That is why you have tied her hands, I suppose?’

‘Yes, sir. It was the only way.’

‘Hmm. Well, we can discontinue gastric suction and start fluids by mouth. The blood drip can be removed after this bottle. That will help you, won’t it, Sister? I can’t give any instructions about the endotracheal tube. That’s a matter for the anaesthetist. Everything else satisfactory, Sister? Urine, faecal discharge?’

Yes, sir. Do you want to see the wound, sir?’

Yes. Get a nurse to remove the dressings.’

I was at the back of the entourage, so I came forward and removed the dressing. Mr Carter looked at it.

‘Hmm. Satisfactory. You can remove one of the drainage tubes, Sister. We’ll take the other one out when we remove the sutures – we’ll have to take her back to theatre when we close the colostomy. You can do that, Ryder,’ he said to the registrar.

Yes, sir.’

‘Well, everything satisfactory, wouldn’t you agree?’

‘Yes, sir, very satisfactory.’ said the registrar.

And they moved on to the next bed. As they went, the tension in Mrs Ratski’s body visibly
relaxed.

After the round had finished, Staff nurse told me to assist her in the removal of the naso-gastric tube. The blood had very nearly run out from the bottle, so she removed that also. With the removal of the suction machine and the drip stand Mrs Ratski looked more like a human being.

The anaesthetist came and said that he would remove the endotracheal tube under local anaesthetic. Staff nurse assisted him, and I was told to accompany her. The young house surgeon also came to watch, because he wanted to know how it was done. At the sight of another surgical trolley and several doctors and nurses, Mrs Ratski became visibly distressed. She could not make any sound, and her hands were still tied, but all her body language was that of panic. The anaesthetist took up a syringe of local anaesthetic, and, as she saw the needle approach her neck, Mrs Ratski’s skin lost all colour, and sweat poured from her brow. The anaesthetist retreated. He took her pulse rate.

‘It’s gone up to one hundred and twenty. I can’t proceed like this. She will have to have a general.’

So, for a second time, Mrs Ratski was prepared for theatre and given a pre-med and muscle relaxant. Removal of the tube and suturing of the trachea and outer muscle and skin only took a few minutes, and then the patient was back in her bed.