In the Midst of Life

by Jennifer Worth

  He continued with his checks and adjustments, saying as he did so, ‘New techniques for resuscitation are being pioneered in America. Some of our teaching hospitals are using them. Statistically, they are more effective. I would like to try them myself, but we don’t have the equipment here in this backwater.’

  He’s a good man, I thought, and a dedicated doctor. He can’t have had more than a couple of hours’ sleep, but still he felt the need to see his patient before starting the day’s routine.

  He patted Dr Hyem’s hand. ‘Well, you’re doing nicely, Dad. I’m pleased with you. We’ll have you running around again in a few days. I’m off to get some breakfast now, and I’ll come in and see you later in the day.’

  As he left he said, ‘I’ve got a morning in theatre. Tell Sister Tovey I’ll be here around lunchtime.’ Then to Dr Hyem, ‘Doing nicely. You’re doing well. Keep it up.’

  Such energy, such confidence, is invigorating.

  Sister Tovey, the ward sister, to whom I gave the night report, felt differently. She was a woman about twenty years my senior and was nearing retirement. She had been nursing throughout the war, with two years spent in Egypt, receiving casualties from the fighting in North Africa, a great many of whom died for want of adequate medical attention. She was a woman of vast experience and few words.

  ‘Dr Hyem told me he wanted no resuscitation,’ she said.

  ‘He told me that also.’

  ‘And he told the cardiologist. I know, because I was there at the time.’

  ‘It must be recorded on his notes, then.’

  Together we looked, and there, written quite clearly on about the fourth or fifth page, were the words, ‘In the event of cardiac arrest, do not resuscitate.’

  ‘I suppose they didn’t see that,’ I muttered.

  ‘More likely didn’t look! These resuscitations have to be carried out at lightning speed. There’s no time even to think. Just get on with it, that’s the message. I don’t like it. Not a bit.’

  ‘Well, he’s alive,’ I said.

  ‘What for?’ she demanded.

  The question seemed callous. But was it? Or was it realistic? My first doubts, momentarily dispelled by the registrar’s breezy confidence, returned. I did not reply.

  ‘What for, I say? Congestive heart failure? Renal failure? Liver failure? I must speak to the cardiologist about this. I don’t like it.’

  ‘Well, he seems to have recovered and his condition is stable. There is nothing more I can say or do. I’m worn out. I must go home and get the children off to school. Then I must go to bed.’

  We parted, and my mind was in turmoil as I drove home. The events of the night were screaming in my poor tired brain. Had it been a triumph, or a tragedy? The registrar’s confidence and Sister Tovey’s doubts were struggling with each other. That dreadful cry, like all the ghosts and ghouls of Hell, kept sounding in my ears. But it was probably not a conscious cry, I told myself, just the involuntary emission of residual air in the lower lungs escaping through slack vocal cords. He was alive, and his condition stable, that was the main thing. One should not drive after a night like that, when the mind is in such a state. It was surprising I did not have an accident.

  The children restored my equilibrium. I defy anyone to get too serious when there are children around. Their laughter, their squabbles, their endless questions, their intense passion if a crayon or a book is lost, flying around the house to get a pair of gym shoes – all these little things brought me back to normal. We ate breakfast together, and I found, to my surprise, that I was hungry. Then there was a knock at the door, and a little friend arrived, then another, and the girls raced off together to the primary school down the road. I went to bed and slept, reflections on life and death eclipsed by the vitality of children.

  Dr Hyem did not die, but he did not live, either. His heart had been in failure for a long time, and now all his vital organs began to fail too. The slow gradations of decay set in.

  Failing circulation, caused by a congested heart, creates ‘back pressure’, affecting all the organs of the body. In Dr Hyem’s case it caused congestion of the lungs, so he had great difficulty in breathing. Fluid collected in his lower lungs, creating a bubbly, rasping sound with each breath. The fluid became infected and pneumonia developed, which was treated with antibiotics.

  The back-pressure from inadequate cardiac output puts added strain on the kidneys, which were struggling to excrete the body’s waste products. Uraemia, or blood poisoning from renal failure, was kept at bay by intensified doses of diuretics.

  Back-pressure put new strain on the liver, already grossly distended and striving to cope with the rising acidosis caused by diabetes. The pancreas, the gall bladder, the intestinal tract – all of them were congested.

  Back-pressure forces fluid to leak out of the arterioles, the smallest blood vessels, into the surrounding tissues. They become waterlogged, a fluid swelling known as oedema. Ascites developed in the abdomen. Dr Hyem was totally bedridden. He sat there, day after day, with his legs, thighs, buttocks, scrotum, and belly swollen with oedema and ascites. However hard we tried, bedsores could not be prevented.

  Had back-pressure affected his brain, or was it something else? Dr Hyem hardly spoke during the last weeks of his life. When he did attempt to mumble a few words, they were slurred and barely audible. His eyes were usually closed, but when open the pupils were dilated and fixed. The resuscitation, although quick, may not have been quick enough. Small areas of the brain may have been starved of oxygen and died during the minutes that had ticked by during resuscitation.

  All the medical staff in the hospital took a great deal of interest in Dr Hyem, for open-heart resuscitation was a sufficient novelty in a small suburban hospital in the 1960s to attract attention. The registrar who had led the team became something of a celebrity. The staff all crowded around the bed, studied the notes, and regarded the machines and dials and drips with scientific interest. The cardiologist spoke to the lung specialist, the urologist to the gastro-enterologist, and the diabetic specialist to the dietician. They took brain scans (EEGs), heart scans (ECGs), recorded blood count and electrolyte balance (electrolytes were all the rage at the time), took X-rays of his chest, aspirated his lungs, measured his insulin levels and the mounting acidosis in his blood, changed his drugs, increased the changes, tried new drugs, changed them again and increased them again. They held special meetings to discuss the case; they could not have done more.

  But, as the days stretched into weeks, the doctors visited less frequently and departed more quickly. Did they just lose interest, or had the passion for progress spent itself? Was there no more scientific or biochemical excitement to be gleaned from Dr Hyem? Doctors tend to regard a dying patient as a personal failure, and frequently withdraw if the process goes on for too long. Dr Hyem was dragging on and on. Perhaps the reality of a slow, lingering death was more than they could stomach.

  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 t
ime, 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.

  FAITH

  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

  CARDIO-PULMONARY RESUSCITATION (CPR) IN HOSPITAL

  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 corre
ct 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.