(2013) Looks Could Kill

by David Ellis

  Emma left some silence between them.

  “Is there anything you’d like to ask?” she said.

  “Doctor, can you tell me what happens next? Like whom should I call, the funeral, things like that...” He turned away again.

  “Look, I’ll just leave you for a bit and then get the nurse to come in and go through what needs to happen next. I really am very, very sorry.” She touched his arm briefly.

  Emma left the relatives’ room, closing the door behind her. She went in search of the registrar but discovered that he’d already left for the clinic. He said he’d be back at lunchtime. The staff nurse had already spoken with someone from Patients Affairs who said they’d be up to talk with the partner.

  Christ, it’s a bugger, Emma thought: deaths on the first day of two jobs and she couldn’t help feeling responsible.

  But over subsequent weeks she learnt that deaths on the CCU are commonplace and almost become a matter of routine for medical and nursing staff. Weekly support meetings helped a lot, although it was notable that the senior registrar always tended to be ‘stuck in clinic’.

  So things did settle down, and Emma started to feel at home at St Edwards’ Hospital. Although it had a splash of modernity to it, there was a certain homely quality to the hospital that made her feel she was part of a much extended family.

  One fly in the ointment was that a coroner’s inquest was going to be held following Mr Williams’s death, as he’d died within forty-eight hours of admission. Emma had gone through her report with her new consultant and he’d been very certain that she’d be in the clear when the coroner made his summing up.

  In contrast to her six months on the surgical ward, where the endless throughput of patients had turned her days into working on a production line, the CCU allowed Emma to practice and refine her skills at a slower pace where there was more time for reflection. In fact, she found a mesmeric fascination in watching the ECG monitors at the nurses’ station, with all the life-force of the ten patients summed up on a few screens.

  Sometimes, when looking at her patients in their beds with drips and monitors attached, she was reminded of Mrs Brown’s beautiful butterflies pinned to the board.

  February 1989

  Two house officer jobs behind her, Emma was now fully registered with the GMC, and she’d succeeded in getting on a general medical training as a senior house officer at the John Michael Hospital in Rochester.

  Looking back at her last house officer job, Emma thought she’d coped pretty well after the trauma of the first week and had actually learnt quite a lot. Her final sign-off also seemed to have reflected that. Apart from on a couple of occasions, she’d kept her demons in check and her razor remained unused, although she’d been showing a little too much interest in the calorie content of convenience foods recently. But perhaps that was because of anxiety about moving on to a proper medical rotation.

  Emma’s first post was on a geriatric ward which had a good reputation for medical care and nursing. The consultant, Dr Ziegler, was said to be personable, with a particular interest in managing the multiple morbidity that goes with old age.

  Emma had just gone through the usual bureaucratic rigmarole of signing on with medical staffing, having a photo taken for her ID badge and collecting her bleep and white coat, but even all that was becoming relatively normal for her. At least no-one in medical staffing seemed bored, and she hadn’t encountered a security guard eating burgers and drooling fat whilst on duty yet.

  Arriving on the ward just after 10:00 a.m., Emma discovered that a ward round was just starting. Ward rounds starting at that later time seemed extremely civilised to Emma after the 8:00 a.m. start in her surgical job. Perhaps it’s because the elderly need to longer to eat their breakfast, Emma thought. Or more likely, because of coffee and croissants for the team. Emma joined the group who were just approaching a patient in the first bed.

  “Ah, good morning, you must be Dr Jones,” said her new consultant, Dr Ziegler. “We’re delighted that you’re joining our little team.”

  “Thank you so much, Dr Ziegler,” said Emma, “I’ve heard good things about this firm and I’m pleased to be here.”

  And so the ward round started. As befitted the designation of the ward, the majority of the patients they saw over the next two hours were elderly and some were very elderly. There were a few younger patients whom they didn’t see and she gathered that they were ‘outliers’ from other wards who didn’t have beds. Emma wondered what they felt like being surrounded by so much decrepitude.

  Dr Ziegler’s approach was best described as soft and gentle, which seemed to suit her patients. Patients were smiled at and they smiled back. Beds were sat upon and bony hands were held. But it struck Emma that she saw very little actual medicine happening apart from the occasional listening to a chest or inspection of a leg ulcer.

  She thought back to the elderly lady she’d visited in the nursing home in her last year at school. If she’d been transplanted into this ward with all her medication and was under this team, would she still have wanted to die?

  Emma realised at that point that there was a type of medicine that can move at a slower pace and that that’s what she wanted to do. As she’d said in her interview for Oxford, she needed the time to think rather than always having to ‘do’.

  “Emma,” called Dr Ziegler, “would you like to join us for lunch?”

  The hospital canteen was pleasant enough, and there was a cordoned off area for medical staff with an even more private area for consultants. Emma sat down next to Dr Ziegler.

  “I hope you don’t mind me saying this, Dr Ziegler, but when you were doing the ward round, I was surprised how gentle you were with your patients. It was just so different from my two house jobs.”

  “Thank you, Emma,” she said. “I was thinking a similar thing about you when you were talking to Mrs Bascombe, the lady in bed 7. You really engaged with her, looking directly at her rather than at her notes.”

  “That’s just something I do, it sort of comes naturally to me,” said Emma.

  “Well, you have my permission to continue doing that,” said Dr Ziegler, smiling.

  Outpatients that afternoon started off in a similarly sedate fashion, with a variety of elderly patients, some with relatives, some on their own, and all with complex physical problems and on multiple drugs. It occurred to Emma that an audit of outpatient prescribing would be worth doing. Just at that moment, the receptionist put her head around the door:

  “Sorry to interrupt, Dr Jones, but we’ve got a rather irate gentleman out here who’s demanding to speak with a doctor about his mother on the ward. Is it alright if I show him in?”

  “I suppose that’s okay,” said Emma, “although I’m a bit new to all this.”

  The relative came into her room and he was clearly agitated about something.

  “Look, doctor,” he said. “It’s about my mother, Mrs Bascombe. She’s saying to me that she wants to die. I want to know what’s going on. What have you told her?”

  Emma put her hand out and he took it grudgingly. She motioned him to sit down.

  “I’m Emma Jones, Dr Ziegler’s senior house officer. Could you go through again what she said to you?”

  “She was right as rain yesterday. Well, apart from her diabetes and arthritis and so on. But when I went to see after lunch, she just looked at me and said: “It’s time for me to go, John. It’s time for me to go.” So someone must have told her something about dying.”

  “Well it’s true that we did see her on the ward round, but I can assure you that no-one said anything about her dying. In fact, she’s doing well enough for us to think about discharging her at the end of the week,” said Emma.

  “So why should she come out with all that stuff about her time to go? You tell me, doctor.”

  “Are you sure she wasn’t meaning about leaving hospital?”

  “No, doctor, the way she said it was meaning about dying, I’m sure of that.”

>   “As I said, Mr Bascombe, our plan is still for her to be discharged soon and we think there’s plenty of life in her still. But if it makes you feel reassured, I’ll have a word with her later. Is that okay?”

  “Yes, alright, thanks doctor, but will you let me know what she says?”

  “Yes, I’ll give you a ring this evening,” said Emma.

  Mr Bascombe left the room, somewhat reassured but clearly not happy. Emma pondered about the exchange and what had led him to get upset in the first place. It was true that she’d sat down and talked with the patient, and she also remembered Mrs Bascombe looking at her very intently. Perhaps Emma had given something away without her realising it.

  When the clinic was over, Emma returned to the ward to talk to Mrs Bascombe. She closed the curtain and sat down by her bedside.

  “Hello, Mrs Bascombe,” said Emma. “We met this morning on the ward round.”

  “Oh yes, dear, I enjoyed our chat,” she said.

  “It’s a bit funny, but your son came to the clinic and he seemed upset about something you said.”

  “Ooh, I was worried I might have said the wrong thing, he takes things very personally, you know.”

  “Do you mind me asking what you actually did say to him?”

  “I just said I wanted to go, that’s all.”

  “You mean go home?”

  “No dear, I don’t want to live anymore.”

  “Hmm, what makes you think that?” asked Emma, with some hesitation.

  “It was something in the way you looked, I think. It just seemed to help me understand that I didn’t have to put up with things any longer. It was nothing you said, dear.”

  Emma sat back in the chair and pondered.

  “You know we’re thinking about sending you home later this week, don’t you?” asked Emma.

  “I know, dear, but couldn’t you just give me something, you know to…”

  “Mrs Bascombe, I really wish I could help but I can’t. It’s just not what doctors are allowed to do.”

  “I understand, dear, but I wish there was a way,” she said, with tears in her eyes.

  Emma phoned Mrs Bascombe’s son after the conversation and explained that it was just some sort of misunderstanding, but he still didn’t seem convinced.

  Emma had a sleepless night, thinking about what had happened when she sat down to talk with Mrs Bascombe. She was so used to being in control of the situation that the idea of people picking something up without her realising it was very disturbing. She went into the kitchen for a glass of wine. That helped a bit, but in the end, she had to go into the bathroom and cut herself.

  The following morning, Emma sought out Dr Ziegler whom she was due to meet for supervision anyway.

  “Come in, Emma,” said Dr Ziegler. “How was your first day?”

  “Oh, okay,” said Emma, “There were a few problems, but at least no deaths.”

  “Interesting. Can you explain?”

  “Well, on the first days of my two house jobs, I had a death. One was a post-op patient who arrested and I had to do CPR, and the other was a young man who had a second MI in the CCU. Unfortunately, there’s an inquest coming up and I’ve been asked to attend. I’m really rather dreading it even though everyone has said I’ll be fine.”

  “I’m not surprised, that’s difficult for anyone. And a bit unfair on you really given that you were so junior. What about the problem on the ward?”

  “Well, I was in clinic and Mrs Bascombe’s son turned up rather angry and wanting to speak with someone. It was all a bit strange really. She’d said to him that she ‘wanted to go’, so I went up to talk with her. I thought she might be referring to going home, but she was adamant about not wanting to live anymore and seemed to be asking me whether I could give her something so that she didn’t have to go home.”

  “You mean, she was asking you to kill her?”

  “Yes, that’s what it seemed like, and it all seems to have happened after the ward round when I sat down to talk to her.”

  “What do you make of it then?”

  “Well, it’s strange, Dr Ziegler, but sometimes I do seem to have some sort of effect on people when I look at them. Sometimes it just starts with a wave of emotion. It’s something that I’ve felt since childhood really.”

  “Some sort of sixth sense, perhaps?” asked Dr Ziegler.

  “I suppose so, but it’s all a bit muddling at the moment,” said Emma.

  So Emma left her supervision session feeling some relief that she’d finally told someone about her strange feelings. She wondered whether Dr Ziegler experienced something similar when with her patients. Thinking back to the ward round the previous day, Emma was sure that’s what she picked up when watching her consultant.

  But that didn’t really help Emma to cope with a patient like Mrs Bascombe who was asking for a way out.

  Mrs Bascombe was discharged at the end of the week after Dr Ziegler rationalised her medication, much of which was probably making her feel worse than she should. The team learnt two weeks later that she developed a chest infection and then died. Her son made a complaint about her treatment, but Dr Ziegler met up with him and someone from Patients Affairs, which seemed to resolve any doubts that he had.

  August 1990

  “All rise for Her Majesty’s Coroner, Dr Henson,” announced the coroner’s officer.

  The coroner walked into the wood-panelled room and sat down at his desk. Those assembled sat down in the pew-like seats.

  “The case we are hearing today is that of Michael Edward Williams. Mr Williams was admitted to the Coronary Care Unit at St Edwards’ Hospital on the 2 of February 1989 and passed away during the evening of the following day. The purpose of this inquest is solely to determine the circumstances of his death and not to apportion blame. I understand that members of his family are present and that they have legal representation. I propose hearing evidence from the following: Dr Ravi Singh, Consultant Pathologist; Dr Emma Jones, House Officer; Julia Simmonds, Staff Nurse; and Dr Brian Odulele, Cardiology Registrar. I would like to call Dr Singh first to give evidence.”

  Dr Singh went into the witness box and swore on oath.

  “Would you please tell the court your name, qualifications, job title and place of work.”

  “My name is Dr Ravi Singh and my qualifications are Fellow of the Royal College of Pathologists and Bachelor of Medicine and Surgery. I am currently employed as a consultant histopathologist at St Edwards’ Hospital.”

  “Doctor, you carried out a post-mortem on the deceased on 4 February 1989. I would be obliged if you could take the court through your report.”

  “Thank you, sir. Externally, the deceased was a white male of average build in a good nutritional state and with no abnormalities or other distinguishing features. On examination of his heart, there were areas of ischaemia in the inferior and anterior myocardium, and thrombus completely occluded the right and left coronary arteries. I found no abnormality in his lungs. Examination of the organs in his abdominal cavity revealed no abnormalities. His brain was similarly unremarkable. My opinion was that the deceased died as a result of myocardial infarction.”

  “Thank you, doctor. I have no further questions for you. You are excused.”

  Dr Singh left the witness box and walked to the exit of the courtroom.

  The coroner turned to his papers and briefly wrote something. “Dr Jones, would you please come forward and give your evidence.”

  Emma was dressed in a black trouser suit and looked suitably professional. She walked forward confidently, entered the witness box, and swore on oath.

  “Would you please tell the court your name, qualifications, job title and place of work.”

  “My name is Dr Emma Jones and my qualifications are Bachelor of Medicine and Surgery. I am currently employed as a senior house officer in general medicine at the John Michael Hospital in Rochester.”

  “Thank you, doctor. I have your report in front of me. Perhaps you could take us t
hrough it.”

  Emma took a deep breath and started reading from her notes: “Mr Williams was admitted to the Coronary Care Unit at St Edwards’ Hospital on the 2 of February 1989 from the Accident & Emergency Department where he had presented with severe chest pain. An ECG was performed which showed changes indicative of ischaemia in the inferior myocardium, meaning that he had had a heart attack. This was confirmed by a high troponin level in his bloodstream. He was given aspirin in the A&E department to help dissolve clot in his right coronary artery and he was then transferred to the Coronary Care Unit for monitoring. I came on duty the following day as the new house officer in the Coronary Care Unit. I was asked by staff nurse Simmonds to see Mr Williams as the ECG monitor showed that his heart was in atrial fibrillation...”

  “Doctor, could you please explain to the court what that signifies?”

  “It’s when one of the chambers of the heart receiving blood – the atrium – stops contracting properly and starts fluttering. This may happen after a heart attack and it can result in further abnormal contractions – such as ventricular fibrillation – which can be fatal.”

  “Thank you for that helpful explanation, doctor. Please continue.”

  “I went to Mr Williams’s bed and asked him how he was feeling. He was very pale and complained of feeling tired. I told him that he might need to be on extra medication to control his irregular heart beat but said that I wanted to wait until the ward round, which was due to happen shortly. I waited for about an hour and then phoned Dr Odulele, the senior registrar. He told me that there would be no ward round as the consultant was on leave and he was in the outpatient clinic. He advised me to commence an intravenous infusion of amiodarone, which is a drug used for treating cardiac arrhythmia. I then spoke with staff nurse Simmonds and together we set up the drip. She told me that she would monitor his response to the drug and hand over to the night staff. When I came on duty the following day, I was informed by staff nurse Simmonds that Mr Williams had passed away during the night.”