Monday, 8 August 2011

Pronounced.

When my fingers curl softly over the wrist lying limply at the side, it's always surprising to feel the warmth. As I press against the flesh, feeling between my index and middle fingers for the thick radial pulse, there is always - always - a feeling of fleeting confusion when I can't. The heat of the skin surprises me, as if something momentous should have happened at the time of death and left a cold shell behind. As if warmth somehow equals life.

I hate putting my stethoscope against a chest that stubbornly refuses to rise or fall, and the stillness is eerie. Like children playing games. As if I'm waiting for a wink and a smirk and a "gotcha" moment. And yet the skin as I brace a hand against a shoulder is still warm. Cells still doing their lively thing even though the whole has shut down. The last of the workers hurrying home out the gates even as the lights are turned off.

I don't like the sensation of prising open eyelids to check for a pupillary reflex. It feels grotesque somehow, to force this person that is no longer a person to suffer this last indignity. But it gives me a chance to close them again, which when someone hasn't died with their eyes closed makes me feel better. I don't like the cloudiness that shadows beautiful irises that looked at me and laughed a few days before.

I have rarely had to pronounce someone who I have cared for. Through some odd twist of fate those who I have grown close to have died when I was not there, and I have not been called to touch their still warm skin. I have performed this ritual for many now, but mostly it has been for those I've never met, except perhaps to write up something for pain. And it has often been relief I've heard that a favourite patient has died, and that their suffering is now ended.

Two weeks ago today, on a crazy Monday with too much to do, I was called to see a patient who may or may not have been unwell. The nurses were a bit concerned, but not panicky, and I strolled over to the outpatient area to see this patient who was a bit short of breath. He was braced in the bed, holding the rails, and gasping into his hudson mask, distressed by the sensation of not getting in enough breath. The nurses were pottering around nearby, but were not overly concerned. Me though, the second I met this man, my adrenals kicked in as if someone had given me a punch to the back.

After examining him I had taken his blood, called for a CT scan and had started writing out the forms to take to radiology. I had given him some medication to help him breathe and had organised for him to be admitted to hospital. His ECG and his radiology forms clamped in my hand, I started doing some of the other jobs on my list and stopped for a moment to chat to a friend, conscious of my unwell patient and waiting for his bloods to become available so that I could request his scan.

20 minutes later, unheard of for my busy hospital I was called on my mobile, by a frantic radiology registrar because of the not good things on the scan that needed to be dealt with right now. It showed a pericardial effusion - or fluid around the heart causing tamponade. Essentially the fluid builds up so that the heart can't fill and contract so it feebly lists like a deflated balloon, the chambers collapsing in on themselves between times. I had found out why my man was breathless, and had diagnosed something that most had just attributed to his cancer. I had found something fixable - at least for the short term.

I watched in grim amazement later, in semi darkness as a Cardiologist did a bedside echocardiogram and watched his heart flutter in this pool of fluid and hoped that they would offer him something. This was a man that wanted to be treated, and I wanted him to be treated to. He was young, young by cancer and hospital standards, and though we were never going to cure his disease, there was something wrong about him dying like this, without trying. He wasn't at peace, he didn't have a loving wife gripping his hand as they made the decision to go... he was fighting. For every laboured breath.

They drained that fluid - dark, bloody and full of cancer, and I saw him again 3 days later when he left coronary care, minus nearly a kilo and a half of pericardial fluid and he was talking. Smiling. Sitting up out of bed and calling me Sunshine. Delighted that I'd worked out what was going wrong and giving him these days of sitting out of bed, reading the paper and breathing. Not thinking about it, not working for it, but breathing.

We had a few chats, even though he was brusque and obnoxious with most of the staff who tended to him. He liked me, waxed on about all I'd done for him, and it embarrassed me. He still had his moments, and the Sunshine name was a joke, because everytime I saw him it seemed I was giving him crap news, but I was even more delighted than he was to see him sitting out of bed. He had one single wish, and that was to go and walk on the beach just one. more. time. And I believed I could give it to him. I fervently wanted to. I had been to that same beach he was talking about just a few weekends before with my girls and I wanted him to have that last late afternoon heat off the sand and the crash of the waves and that wintry blue. All of that, just one more time.

On Thursday night when I stopped by to see how he was doing, he had the oxygen back on. He was still speaking in sentences, but he needed the prongs on, and I should have known then. I think I kind of did. I know he certainly did. But there had been nearly a week of improvement. Of getting stronger every day. And I just wanted him to see his beach. Friday though I knew, I couldn't even pretend. As he spoke in short phrases, broken by gasps to bring air into his lungs, I knew what it was. And I got everyone to see him I could. I weathered the cranky abusive call of a registrar on a Friday afternoon who liberally dropped expletives when I asked him to come and see him.

And he knew. He knew he'd had enough, knew that we were fighting the losing battle, and even though I could give him more days, that just wasn't enough. He wasn't going to see his beach, so what was the point? We offered, he said no thanks, and took the braver route.

Sunday morning I saw him, in pain, so breathless that he could do nothing but writhe in bed and tinged with the yellow that heralds multiorgan failure, and I stepped up. Sunshine might not be able to cure him, but I sure as hell could take away that pain, and that horrible feeling of not getting enough breath, and that rattle in his chest. And so I did, and by Sunday afternoon he was sleeping. Still going to die, still not getting in enough oxygen to feed his cells, but no longer distressed, no longer in agnoising pain. And I sat there, in the quiet darkened room, as the shadows played on the walls beside the bed, and held the hand rail. Watched the rise and fall of his chest, not quite as rhythmic as those that are going to live, but gentler than the morning when everything had hurt.

This morning he needed more pain relief. And as he opened his eyes to my voice, he gasped out a few answers to questions. He was Cheyne Stokes breathing and the apnoeic periods and the shudders between them gave me a flashforward of the next few hours. We called his sister, and his Mum and asked them to come. I knew it would not be long. It was as if having given up hope of the last thing he had to live for he just couldn't be bothered any more. And he was pissed that it was taking so much effort to die. And he held my eyes for a moment, before turning his head to the side, away from me and my eyes. Told me not to look at him like that. And I sat quietly for a while, not liking him being on his own, hands loosely clasped in my lap and bit my lip.

It was the last time he ever saw my eyes, and the last time I ever saw his. A few hours later, after 2pm when I'd raced away to scoff some lunch, I got the call that he'd died. His family was with him, and according to them, just suddenly, he'd stopped. One minute peacefully sleeping, his breathing settled, and then his chest had stopped rising and falling. They were a bit in shock at how fast it was, and saddened that they'd left it too late for the son and grandson that I'd never heard of before that moment to be told what was going on. And I bit my lip then, so hard that it bled, and I blinked my eyes a few times as I curled the soft cool tips of my fingers over his warm wrist and waited for the throb that would not pulse between my fingertips. And auscultated the warm chest where no air stirred. And quickly, opened and closed eyes that no longer saw me, and would never again see the beach.

And I excused myself to write paperwork, sat down at my desk, and stared forwards for 10 straight minutes. Numb.

And just for you, Greg. Here's the beach, just one last time.





4 comments:

Melissa said...

Don't know why, but I'm sobbing. I've been thinking tonight (for some reason) about Mum's final days. And I remember the tinge and the rattle and the gasping. I remember the exact moment she decided she was done.

I remember giving the Midazolam so she'd stop feeling so scared, and the morphine to ease her pain. And I remember our surprise that it still took her body 5 whole days to finish the job. Her heart just wouldn't stop, when everything else was trying.

I wish we'd had someone like you, who cared like you. Who would have remembered her name, even for a little while.

You really do inspire me Jenn, whether you like to hear it or not. Patients are priveleged to be in your care. I'm so pleased that Greg knew this. I'm so pleased that you gave him just a little bit of Sunshine.

Daisy, Roo and Two said...

That is possibly one of the most beautiful things I have ever read. Thank you for sharing, and thank you for caring xx

Melissa said...

I just got Joel to read this (he's been too ill) and he bawled. You're such an amazing writer and doctor, Jenn.


xxxx

Dean said...

Simply beautiful post. We need more doctors (and writers) like you.

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