A 47-year-old gentleman presents to the emergency department at some point in December 2019 complaining of sudden onset, intense abdominal pain. He’s worked up by the A&E doctors where an erect plain radiograph reveals the presence of free air. He proceeds to emergency laparotomy where…
Let’s start again. This story needs to be told differently.
Gary is a young man, and he’ll scowl and tell you not to be fooled by any grey hairs – they’re just a trick of the light. He works an office job in the City, which he says is just to pay the bills, but secretly he likes the banter with his colleagues. Gary is good at what he does, but not so ambitious that he’s angling for a promotion. He gets the sixteen forty-eight train from the rail station like clockwork every day, except for the days he goes to the pub after work. So in reality, he’s normally home to his husband and dog by seven.
Gary’s husband is absolutely his soulmate, and that’s a good thing because they both plan to spend many more years together. Didn’t he tell you he’s young?
One Saturday, Gary and his Number One Fan are watching television when he feels a horrible cramping pain in his tummy. It gets worse and worse until he’s breathless and crying in agony. He can hear David frantically calling 999, but all he can do is focus on staying still – because every movement makes the pain worse.
It may have just been the pain making him crazy, but Gary reckons the paramedics can teleport, because they’re in his living room a few moments later. He’s curled up in the foetal position, and he can’t help but scream when they roll him onto his back, and again when there’s a sharp pinch on his arm. The pain gets a bit better, and it doesn’t hurt so much when they move him to the ambulance.
Gary doesn’t let go of David’s hand for a second.
The Emergency Department is a relentless cacophony of activity, and he’s reminded of the sweltering bazaar in Marrakech, only in blue scrubs and stainless steel. The thought of that grumpy looking doctor in a turban makes him giggle, and the flare of pain quickly makes him stop.
The doctor asks him some questions about the pain, which make sense, and other questions that don’t – like about how frequent his bowel movements are. Something must have shown on his face, because David answers that one for him. The grumpy doctor puts one hand on Gary’s tummy for a few seconds, and looks even grumpier. He says something about a hole in the bowels, and Gary’s Odyssey continues – this time to the X-Ray machine. Luckily the painkillers have done the job (so that’s what Morphine feels like), and he’s about able to stand up for the scan. Quite why he couldn’t stay comfortable in the bed he doesn’t know, and he doesn’t have time to ask because things start to happen very quickly.
A nice young lady (even younger than Gary) comes by and introduces herself as one of the surgical doctors. She says the same thing about a hole in the bowels, and considering his Life Plans, uses rather problematic words like ‘sepsis’ and ‘death’. When she says he needs emergency surgery, he signs the form.
As they’re about to put him to sleep, Gary gives his husband the best smile he can muster and tells him not to worry. After all, if he survived all those dodgy student union shots, he can survive anything.
He opens his eyes a few times, but the content always seems to be buffering and doesn’t make much sense. By the time reality finishes loading he’s in a big open room that’s actually quite tranquil, despite the constant beeping of machines. There’s a consistent dull ache from Gary’s belly, and he chances a look under the gown. A big dressing stretches from breastbone to groin, but he’s alive so he figures it’s not important.
A lovely nurse bustles around his beside and calls the doctor when she notices his movement. Dr. H looks eerily like Gary’s nephew, just with bigger eye-bags, and Gary tells him so. The doctor blinks in surprise before he laughs, and starts to tell Gary all about the inside of his abdomen. A shrill ringing alarm sounds from Dr. H’s bleep halfway through their conversation, and he hastily apologises and runs off. Gary doesn’t mind though, because after a little shuffling in the bed, he finds that he’s able to sleep with no trouble at all.
The real trouble begins that same week. Gary isn’t a skinny man, but he’s not too big either – David says he’s ‘just right’. So when his tummy starts to swell up more and more, as if he were pregnant, Gary accepts that he might not be home in time for Christmas. Still, he smiles cheerfully at everyone he comes across on the voyage back to the operating theatres.
The next time he wakes up on the ICU, it’s a bit harder to smile. His tummy, previously covered by a big dressing, now lies open to the world. A thin green plastic film covers the gaping hole – and thank goodness it’s not transparent, because Gary has no interest in seeing the inside of his belly. He feels a bit rotten, but Gary does his best to listen while the surgical doctor explains about swollen organs and ‘too much pressure in the abdomen’. He’ll need at least weekly operations to change the ‘vacuum dressing’ (ah, that explains the mechanical whirring coming from the plastic film), and hopefully they’ll be able to close his tummy in a few months. But he’s still alive, and David is here to see him, and when the curtain is closed he lets himself be vulnerable for a moment.
“I had to intubate Gary in bed 4 last night. Rapidly increasing oxygen requirement, his chest X-Ray looks like ARDS.”
“You did the right thing, let’s just focus on the sepsis now.”
I’m not supposed to have favourite patients. If there’s one thing I’m good at, it’s being detached and just getting on with it – but every so often you meet someone so disarmingly charming that you can’t help but root for them. Every doctor and nurse on the ICU refers to Gary by his first name (on his insistence), and every night handover starts with “how’s Gary doing?”. He’s been with us for over a month at this point, and for the first time I worry about his prognosis.
Every ward round is a reminder of how difficult saving him will be, but also strangely optimistic. The ‘Current Issues’ at the top of the document continues to grow, and yet Gary keeps fighting. This is his third episode of severe septic shock. The first needed the strongest possible antibiotics to resolve, and the second nearly irreversibly destroyed his kidneys. His blood is very prone to clotting, and it’s likely he’s had a small heart attack. Worse, part of his gut lost oxygen supply and the surgeons had to perform yet another emergency operation to remove the dead segments of bowel.
But as the weeks progress, somehow, by some miracle, Gary is still winning. We progress him from intubation to tracheostomy, and start weaning his sedation. After a month of anaesthesia, he finally wakes up. He can’t talk, but he practically beams at the team, as if he hasn’t been playing hopscotch outside death’s door for over a month. The toll on his body is obvious though, and I can see the weariness behind his mask more evidently than ever before.
On his birthday we bring Gary an enormous red velvet cake, and he pretends to scowl while David eats his slice for him. He swishes his hands like a conductor while we belt out an off-key rendition of ‘Happy Birthday’, and for the first time in a long time, he smiles a genuine smile.
“You got a haircut, it looks nice.”
“Seriously, you can talk for the first time in months and that’s the first thing you say?” I shake my head, unable to hide a smile.
Gary continues to be a non-walking miracle – he’s been immobile in bed for so long that his muscles have atrophied, and he still gets profoundly septic every other week. But despite that he keeps recovering, and the vacuum has been doing its job and making the abdominal opening smaller and smaller. The surgeons walk around looking more smug than usual, they carry out their plans and close up all four of our ICU’s open abdomen patients. David gingerly hugs him (taking care to avoid Gary’s newly inserted stitches) and you wouldn’t guess this was an unhealthy man.
January turns to February, and Gary is deemed fit enough to be discharged from ICU to the wards. Every member of the team comes to say goodbye, and a minor scuffle almost breaks out when deciding who’ll be escorting him to his new accommodation. With this novel coronavirus on the horizon and fast approaching, the Unit is preparing for war. And while we’d love to keep looking after him, ICU just won’t be the safest place for Gary.
That doesn’t stop me from stalking his chart every few days.
My colleagues seem to be taking good care of him, as is to be expected now that he’s under the care of the medics. I can’t help but worry every time his temperature creeps up, but it usually settles by the time I check again at the end of my shift. If it doesn’t, I use it as an excuse to pay him a visit on the ward. I still keep Custard Creams on my desk, because that’s Gary’s favourite biscuit – and because seeing him happy reminds me that we still Win sometimes.
Gary recognises what’s happening when it becomes harder to breathe. He’s fought off pneumonia twice already, and the other patients hear him telling David on the phone that a third time will be light work. The oxygen mask isn’t a worry either, compared to the breathing tube he had before. When the new doctors come by and tell him that he’s got that coronavirus that’s been on the news, he’s surprised. They tell him that the antibiotics won’t help this time, and if Gary is worried he doesn’t show it. He just wishes he could see David.
A few more days pass, and it’s becoming harder and harder to breathe. They give him different oxygen masks, and Gary recognises that the rest of his body isn’t behaving the way it’s supposed to. Dr. H and some of the other ICU doctors start to visit him more frequently, and at one point their consultant even comes to visit. He sits down with Gary and talks for a while, and a nurse in a special maroon uniform comes and joins him. She says her job is working with people that are approaching the end of their lives. Considering his Life Plans, they use extremely problematic words, like ‘dying’, ‘palliative’ and ‘comfort.’ Gary lets them talk, and just listens.
The medications they give him help with the feeling of constantly being hungry for oxygen. They make him sleepier as well, and he still falls asleep with David on the other end of the phone.
Dr. H stops by not long after. He sits on the side of the bed and holds Gary’s hand, like he did when Gary was sick all those weeks ago. He says he’s really sorry, for what happened to him, for David not being there, for not being able to do more and Win.
Despite everything, Gary gives him one of those cheeky looks, as if he’d just cracked one of his jokes on the Unit that makes all the nurses laugh.
“Didn’t you know, doctor?” He stops to catch his breath.
“Dying with a smile is the greatest win of all.”