In the Midst of Life (33 page)
Read In the Midst of Life Online
Authors: Jennifer Worth
The doctors made all the decisions affecting the physical condition of Dr Hyem, but they did not see the details of what this would entail: the reality and the humiliations endured by Dr Hyem were witnessed only by the nursing staff.
Daily hourly we treated bedsores that developed quickly because of immobility oedema and a watery diarrhoea that poured from him in the early days. The sores quickly became great, stinking holes, which we packed with flavine but which became black around the edges from lack of blood supply. The diarrhoea cleared up, and chronic constipation replaced it, which aperients and enemas could not shift, so a nurse had to remove, manually, lumps of impacted faeces from his rectum. When I read
that
in the day report, I hoped fervently that Dr Hyem’s sensitive mind had been so damaged that he was not aware of what a young nurse was doing to him.
Spoon-feeding a little semi-solid food was always difficult, and was frequently regurgitated, trickling out of the corners of his mouth, over which he had no control. The amount of food and fluids and the quantity of glucose in the drip had to be monitored all the time, and balanced against his insulin injections to control his diabetes.
His breathing was always laboured and painful to see. His cough reflex was seriously depressed and he could not bring up the sputum that collected in his lungs. A frothy exudate bubbled from his mouth sometimes. A physiotherapist came in to try to help him to cough by palpating his chest, but this caused so much pain to his broken ribs that the idea was abandoned. With stagnant, infected fluid in his lungs, his breath became foul smelling. Pleural aspiration was ordered to drain off some of the fluid and a cannula was inserted into his lower lungs, and a little watery stuff drained away. This relieved the pressure for a while, but it did not halt the accumulation. It seemed that Dr Hyem would drown in his own bodily fluids.
A
catheter was in place all the time, and this avoided incontinence of urine, which would have made the bedsores worse, but it had to be changed every few days, and kept clean, which was unpleasant and possibly embarrassing for Dr Hyem. Unless we cleaned his mouth every two hours with glycerine, his tongue became so dry that the skin peeled off, and ribbons of grey, stringy stuff could be pulled from his throat.
The doctors saw none of this. Junior doctors sometimes get an idea of the suffering and humiliation that patients endure, and what nurses do, but a consultant seldom does. The more senior a doctor, the less he knows of the unpleasant details. None of this will appear in medical textbooks, which are written by academic and scientific medical experts, who spend much of their time in laboratories and libraries. Only nurses are at the bedside. And nurses don’t tell.
The end came for Dr Hyem because his renal failure and longstanding diabetes could no longer be controlled, and acidosis developed over a few days, first with abdominal pain, and a decreased volume of urine. Then his blood pressure dropped and his pulse became thin and rapid, his ocular tension was low and his skin became very dry. The doctors decided not to attempt treatment, and he drifted into a diabetic coma from which he could not be roused.
Dr Hyem died peacefully, five weeks after a successful resuscitation from cardiac failure.
I need no assurances – I am a man who is pre-occupied of his own soul;
I do not doubt that whatever I know at a given time, there waits for me more which I do not know.
I do not doubt but the majesty and beauty of the world is latent in any iota of the world;
I do not doubt there are realizations I have no idea of, waiting for me through time and through the universes – also upon this earth;
I do not doubt I am limitless, and that the universes are limitless – in vain I try to think how limitless;
Did you think Life was so well provided for, and Death, the purport of all Life, is not well provided for?
… to die is different from what anyone supposed…
— Fragments from
Faith Poem
and
Song of Myself
by Walt Whitman
In 2008 I was visiting a friend who was in an acute medical ward of a large county hospital. I walked directly into the single room where I expected to find her, but she was not there; she had been moved to the main ward. In the bed was an old, old lady who looked as near to death as anyone I have seen. Her skin was as white as the sheets, her eyes sunken and rolled up towards her forehead; her cheeks were hollow, her mouth hung open, and her breathing came in ragged gasps. In my nursing days, we would have assessed that she had only a few hours to live and the ward sister would have instructed a nurse to sit beside her, just to hold her hand or to stroke her hair, or to whisper a few words now and then.
There was not a nurse in sight. Two gently humming machines were her only companions. Monitor pads were stuck to her arms with wires leading to one machine where lights flickered and a graph line was being traced. The other machine had wires attached that disappeared under the bedclothes. An oxygen cylinder hissed continuously, and a transparent catheter was attached to her nose with sticking plaster. A saline drip running into her arm and a urine drainage bag hanging from the bedside completed the picture.
I stood gazing at her for a couple of minutes thinking,
Poor old lady. What have you done to deserve this?
She was a total stranger to me, and I knew nothing of her medical history, but as the bed was in acute medicine, the likelihood is that she had collapsed from acute coronary failure caused by a heart attack. Someone had found her and called an ambulance, and this was the result. Nearly
dead, surrounded by advanced medical technology, and not a soul around, except a stranger who had walked in by mistake.
This is what most of us can expect, unless we are very lucky. If anyone collapses, from whatever cause, at home or in a public place, the chances are that they will be taken to hospital. Only the medical team involved knows what goes on in the resuscitation room of a hospital, because lay people are excluded. When my mother died, I was pushed out and the doors were locked on the inside. There may be good reason for this, such as the risk of introducing infection into the room, but I suspect it is more because a relative may try to stop what is going on.
Sherwin B Nuland was a consultant surgeon at Yale University Hospital and teaches surgery and the history of medicine at Yale. In his remarkable book,
How We Die,
published in 1995, he has described the process of hospital resuscitation as accurately and objectively as any medical man can for the lay readership:
Having countless times watched those teams fighting their furious skirmishes, and having often been a participant or their leader in years past, I can testify to the paradoxical partnering of human grief and grim clinical determination to win that actuates the urgencies swarming through the mind of every impassioned combatant. The tumultuous commotion of the whole reflects more than the sum of its parts, and yet the frenzied work gets done and sometimes even succeeds.
As chaotic as they may appear, all resuscitations follow the same basic pattern. The patient, almost invariably unconscious because of inadequate blood flow to the brain, is quickly surrounded by a team whose mission is to pull him back from the edge by stopping his fibrillation or reversing his pulmonary oedema, or both. A breathing tube is rapidly thrust through his mouth and down into his windpipe so that oxygen under pressure can be forced in to expand his rapidly flooding lungs. If he is in fibrillation, large metal paddles are
placed on his chest and a blast of 200 joules
*
is fired through his heart in an attempt to stop the impotent squirming, with the expectation that a regular beat will return, as it frequently does.
If no effective beat appears, a member of the team begins a rhythmic compression of the heart by forcing the heel of his hand down into the lowest part of the breastbone at a rate of about one stroke per second. By squeezing the ventricles between the flatness of the yielding breastbone in front and the spinal column in the back, blood is forced out into the circulatory system to keep the brain and other vital organs alive. When this form of external cardiac massage is effective, a pulse can be felt as far away as the neck and groin. Although one might think otherwise, massage through an intact chest results in far better outcomes than does direct manual compression.
By this point, IVs [intra-venous drips] will have been inserted for the infusion of cardiac drugs, and wider plastic tubes called central lines are being expeditiously inserted into major veins. The various drugs inserted into the IV tubing have assorted purposes: They help to control rhythm, decrease the irritability of the myocardium, strengthen the force of its contraction, and drive excess fluid out of the lungs, to be excreted by the kidney. Every resuscitation is different. Though the general pattern is similar, every sequence, every response to massage and drugs, every heart’s willingness to come back – all are different. The only certainty, whether spoken or not, is that the doctors, nurses and technicians are fighting not only death but their own uncertainties as well. In most resuscitations, those uncertainties can be narrowed down to two main questions: Are we doing the right things? And should we be doing anything at all?
Far
too often, nothing helps. Even when the correct answer to both questions is an emphatic ‘yes’, the fibrillation may be beyond correction, the myocardium unresponsive to the drugs, the increasingly flabby heart resistant to massage, and then the bottom falls out of the rescue attempt. When the brain has been starved of oxygen for longer than the critical two to four minutes, its injury becomes irreversible.
Actually, few people survive cardiac arrest, and even fewer among those seriously ill people who experience it in the hospital itself. Only about 15 per cent of hospitalised patients below the age of seventy and almost none of those who are older can be expected to be discharged alive, even if the CPR team somehow manages to succeed in its furious efforts.
It has probably been known for centuries, even millennia, that the heart can stop, and be restarted, although nothing was written about it for posterity. Nearly two hundred years ago, a Dr Silvester described how it could be done, by laying the patient on his back and raising the arms, to aid inhalation, then lowering the arms and pressing them against the ribs, to aid exhalation. It is not recorded whether anyone believed him in the early 1800s.
A century later, the idea was taken up by several doctors, and a similar technique described, combined with mouth-to-mouth resuscitation. This technique was included in
Scouting for Boys
by Baden-Powell, published in 1908. Few other people took it seriously, and certainly not the conservative medical profession, who always take decades to accept a new hypothesis. But, for the whole of the first fifty years of the last century, it was vaguely known that if you fished someone out of the canal, or something like that, mouth-to-mouth puffing and rubbing the chest could sometimes be effective in restoring life.
Eventually, in the 1950s, the medical profession got on to the idea, and the modern techniques of cardio-pulmonary resuscitation (CPR) were developed at the Johns Hopkins Medical Research Faculty in Baltimore, USA – although many other medical teams in other countries were working on the same theories. Within a
decade, their findings and teaching had gained widespread acceptance throughout western medicine.
Different techniques were developed and experimented with. The open-heart resuscitation that I witnessed being applied to Dr Hyem, was the first method adopted by the medical profession, and its popularity lasted for around ten years. It has been replaced by electrical impulses, or shocks, directly administered to the heart, which are no less violent, but more effective. The giant international drug and engineering companies started competing with each other for the huge financial gains to be accrued from producing ever more powerful cardiac stimulants, and manufacturers of surgical equipment bent all their efforts into resuscitation technology. It was big, big business.
From the 1970s onwards in the UK (earlier in America), the intensive care unit and resuscitation became central to clinical practice, and no hospital could afford to be without the latest techniques and equipment. ‘Crash’ was all the rage. Everyone was very gung-ho about it and cheerfully tried it on almost any dying or dead patient. Young doctors, nurses, and technicians had to be taught the techniques and older ones needed to practise. Pompous old consultants and starchy old ward sisters who questioned the technique were told to get up to date and live in the real world. Those who warned about ‘playing God’ were told they were religious fanatics and everyone would be better off without them.
Those were exciting days to be in medicine. Anything was possible. We could conquer death itself. Job vacancies appeared in the
Nursing Times: ‘Be in the Front Line. Be a Life Saver. Join the
Resuscitation Team. Work in the Intensive Care Unit at Hospital.
Apply in writing.’
Adverts like this were quite common, and I attended a conference where this type of wording was strongly condemned by the RCN.