“We need a bed.” Even Jonny can’t muster an upbeat tone eleven hours into a night shift. He’s the ICU doctor on outreach tonight, the link between the wards and our ivory tower.
“You know what I mean, you’ve got about 30 minutes.”
A few nurses are preparing a trolley with cleaning solution and fresh sheets. One has tears in her eyes. Mr. B, a 45M that was successfully extubated two days ago – one of our ‘winners – just had a PEA cardiac arrest on our CCU, our ICU stepdown ward. His heart was generating a valid electrical rhythm, but wasn’t able to produce an output compatible with life.
Another perfect game ruined at literally the eleventh hour. Irene is going to tell me off for jinxing myself on WhatsApp.
My usual ritual of taking five after a mortality to close my eyes and reflect is a luxury I can’t afford, thanks to Jonny’s call. I wonder how many corners I can cut before all that’s left of me is a circle? Maybe that’s what they mean by ‘well rounded’.
I run through the options: The Unit has precisely zero unoccupied beds. We’ve just gained a new CCU bed courtesy of Mr. B, but that’s not appropriate for a new admission. I skim through my list, there’s nobody on the Unit I can step down to CCU within 30 minutes. That only leaves one choice.
People deserve longer than half an hour to die, but maybe i’m an idealist.
Standing on the middle of the Unit, surrounded by all the patients in extremis, it’s easy to see the contrasting threads of fate. The Winners lie there peacefully, in single organ failure responding well to the ventilator. They just need a helping hand to overcome COVID. The Losers progress further into multi-organ failure. This one’s kidneys have gone, and a haemofiltration machine circulates and cleans his blood outside his body. That one looks quite yellow now that his liver isn’t interested in functioning.
I can tell the Winners and Losers apart with my eyes closed. But truthfully, i’m cheating – I just listen out for the machines that alarm the most frequently.
Mr. N is 66, with grown up children and a healthy pension. He likes gardening and walks in the countryside with his wife. He’s been fit and well all his life, and apart from his current three-organ failure, has no medical issues. His kids sent a hamper of food to the Unit two nights ago for us.
Mrs. P is 43, with teenage children and a job she loves. She’s fond of her dogs and apparently likes motorcycle racing. She’s overweight, has high blood pressure and diabetes, the Holy Trinity of a crap outcome. Her heart is also biologically on fire, and two days ago she sensitised to the only medication I could give her for it.
I phone the boss and he agrees.
“Good morning, is that Mrs. N? I’m so sorry to wake you, it’s Dr. H calling from ICU…Yes, i’d like to talk to you about Mr. N’s condition.”
The words come easily, I have this conversation at least once or twice per day.
“As you know we’ve really been hoping he might respond to all the treatment and start showing signs of improvement. I’m afraid I don’t have good news.”
You never get good at the part when the tears come.
“Are your family with you? Ok, I can set up a video call like last time. You’ll all be able to see him, and say goodbye.”
I prop up the iPad that a generous donor gave our ICU onto a table in front of Mr. N and open the right app. The call comes a moment later, and Mr. N’s family start popping up one after the other.
“Hi daddy, it’s your daughter, I know you can hear me in there…”
I leave them to it.
Oxygen down to 21%. Positive End Expiratory Pressure that keeps the small airways open down to zero. Noradrenaline that supports the blood pressure off. Stop the nasogastric feed. Disconnect unnecessary lines. Silence the alarms. Remove most of the ECG leads. It’s all just muscle memory now.
It doesn’t take long.
“Time of Death, oh-seven-fifty”
“Hello mate, is that bed ready? Emergency intubation en-route to the Unit now.”