by Leah Hazard
That being said, midwives themselves have actually developed a very specific and highly accurate way of diagnosing flu: ‘There could be a tenner on the ground next to you,’ as one colleague put it, ‘and you wouldn’t even have the energy to drag yourself off the couch and pick it up.’ This is a pretty clear-cut diagnostic tool for the averagely hard-up midwife, whose wages have slid so much in real terms over the past few years that a spare tenner would normally prompt a miraculous, Lazarus-like recovery. Differentiating your ‘worried well’ pregnant woman from the genuinely sick patient can be less straightforward, however, and any midwife runs the daily risk of Getting It Wrong. Given the sheer volume of women who phone and attend the unit during every shift, and the inescapable fact that midwives are (I’ve said it once, but to drill home the truth of it, I’ll say it again) only human, there is a small but inevitable group of patients whose concerns will be dismissed, misdiagnosed or mismanaged.
That morning, it seemed as though every patient attending their routine appointments in the antenatal clinic had flu-like symptoms, and although I’d satisfied myself that there was nothing seriously wrong with the five patients I’d seen so far, I’d also drained the bottle of hand gel on my desk after being sneezed on, sniffled at and sprayed with five different flavours of mucus. I was gazing at the computer screen, waiting for the online records system to muddle through its own winter fug and rubbing my red-raw hands absent-mindedly, when the clinic’s clerkess popped her face round the door.
‘Your last patient is here,’ she said. Her lips twitched as if she were trying to suppress a giggle.
I looked up from the computer. It was unusual for the clerkess to come and announce a patient; the waiting room was full of women in various stages of pregnancy, boredom and frustration – you just had to grab a set of case notes from the pile by the wall, call out a name, and one of the crowd would follow you dutifully to your room.
‘OK, thanks for that,’ I replied with a brief smile, looking back at the computer.
The clerkess hovered inexplicably by the door. ‘And she’s wearing a dog lead,’ she said with unconcealed delight, as she tossed a thick blue file onto the desk and disappeared back into the throng of the waiting room.
Well, I thought as I sat back in my chair, if that’s what you’re into … At one time or another, I had looked after women with all kinds of personal proclivities and a patient in full bondage gear – dog lead, leather mask, the lot – would hardly have surprised me. In fact, that kind of get-up would be a bit vanilla compared to some of the stories I’d heard in the staff room. Never mind, I thought, as I pulled the case notes towards me on the desk. Let’s see what you’re up to … Justyna. I flipped open the notes and scanned the documentation inside: she was a twenty-nine-week primigravida with a history of cardiac surgery as an infant, but nothing remarkable since then. She’d recently been to the ultrasound department for a scan, which had shown a well-grown baby and a placenta in the right place. All pretty standard. I glanced at my fob watch as I rose from the desk; it was 12.46, and with any luck I could finish Justyna’s appointment quickly and bolt down some lunch before heading back to Triage for the usual afternoon rush.
There were still a few stragglers in the waiting room – rosy-cheeked women of various gestations, rifling through the piles of well-thumbed magazines that had been donated to the department many moons ago – but there was only one woman wearing a dog lead. I realised when I saw her that the clerkess had used the word ‘wearing’ for dramatic effect: the lead, a length of muddy yellow cord, was actually draped around Justyna’s shoulders. Given the fact that she also wore a knee-length down jacket and a battered old pair of wellington boots, I surmised that my patient had come directly from the park or the woods to the hospital. Perhaps she’d been in too much of a rush to realise that the lead was round her neck, or that her mop of black curls was crowned with brambly twigs. It was a marvel she didn’t have a Labrador with her to complete the picture. Dragged through an actual hedge backwards, I thought to myself, and then called out loud, ‘Justyna?’
Nobody looked up. Had I got it wrong? Certainly, there was only one woman wearing a dog lead – I scanned the room again to be sure. The woman who I presumed to be Justyna was gazing intently at the floor, wild hair obscuring her face. ‘Justyna?’ I called again in her direction, louder this time.
The other ladies glanced at each other and returned to their magazines. There was a long pause, and then slowly, painstakingly, as if every incremental movement was causing the vertebrae in her neck to crumble with the effort, Justyna lifted her head and fixed me with a hollow stare, the blackness of her pupils appearing to recede into a void deep within her head. Her cheeks were drawn, her lips pale and tight. She coughed – a deep, rattling hack – and pressed her eyelids closed as a shiver ran through her body: rigours, an unmistakeable sign of infection. She opened her eyes again, squinted at me as if from a great distance, and whispered, ‘I am Tina,’ and then, ‘That’s me,’ as if to remind herself of her own name.
I took Tina’s arm and guided her into my little room, where she gazed uncomprehendingly from the examination bed to the desk to the breastfeeding posters on the wall. I gestured to the chair, and she eased herself into it, her puffa jacket breathing an audible sigh as it crumpled around her.
‘Justyna – Tina – I understand you’re here for your routine appointment and a review of your ultrasound scan, but you don’t look very well. How are you feeling?’
She turned her head towards me – a slow, grinding swivel – and winced. ‘I have not been well since four days,’ she said. ‘It is just cold, I think, or little flu.’ Her voice was thin, halting and delicately accented – Polish, I guessed. Recently, a number of Polish shops or skleps had opened around the city to cater for a growing immigrant population; Tina’s listless demeanour was a stark contrast to the strong, sturdy girls I often saw stacking crates of indigo plums and richly braided breads outside my local sklep.
‘I have headache and cough,’ she continued. ‘And very tired. And my …’ She raised a wilting hand towards her collarbone, the dog lead still swinging listlessly around her neck.
‘Your throat?’ I suggested.
‘No, my chest. My chest is hurting. But Monday morning is very busy time for me – I walk dogs, you see, for people when they work – and I am out in the park very early this morning, very cold. I am rushing here for scan and clinic. I need only sleep now. Is just little flu.’ She smiled feebly, and I raised a false, fleeting smile in return while I pulled the blood-pressure cuff and thermometer closer to me on the desk.
‘Tina, can you slip your arm out of your jacket, please, so I can check your blood pressure?’
She obliged with no small amount of effort, heaving her arm out and pushing the sleeve of her sweatshirt up to reveal waxen-white skin. As I lifted her hand to pass it through the blood-pressure cuff, I realised with a chill that her fingers were icy cold; even her nailbeds were tinted wintry blue. The rigours, the poor circulation, the hollow stare: If this is ‘little flu’, I thought, then I would hate to see what ‘big flu’ looks like. The automated cuff buzzed into life and the machine echoed my thoughts with its own insistent alarm: blood pressure 90/48, pulse 51. I slid the thermometer under Tina’s dry, frothy tongue and watched the rise and fall of her chest, counting her respirations at a worryingly high rate of 33 per minute until the thermometer bleeped with its result: 38.7 degrees Celsius.
It is said that moribund patients experience a sense of impending doom, in addition to all of the more obvious, painful symptoms of whatever disease has brought them to death’s door. What is less widely known is that midwives also experience this same sensation when their patients begin to deteriorate. Midwife and patient are bound by circumstance, like the hapless stars of an old movie, tied together to a railroad track while a locomotive roars blindly towards their star-crossed embrace. As I scribbled Tina’s numbers on the chart in front of me – each one of them flagging a �
��red’ for urgent action – that fatalistic feeling became very real to me for the first time in my career; I could almost hear the rumble of that oncoming train.
12.58, I wrote. Preparing to transfer patient to Triage.
‘Tina,’ I said, with what I hoped sounded like unwavering confidence, ‘I think you may well have the flu, and I think you’re very sick. You’re my last patient in the clinic, so I’d like to take you back round with me to Triage where we can give you whatever urgent treatment you need.’
‘Now?’ Her eyes rolled towards mine as she considered my suggestion – my voice seemingly coming to her through a pool of cognitive treacle – and I could almost hear her tired brain wading through this turbid sludge as she tried to process the situation.
‘Now,’ I replied, and with my hand clutching her arm in an adrenaline-fuelled grip, I guided Tina to standing and steered her out the door. We moved together through the waiting room, along the corridor, past the hospital canteen with its sickeningly dense scent of synthetic beef gravy and, finally, into the din of Triage. On we trudged like some ghoulish four-legged creature, trailing Tina’s puffa jacket, case notes and dog lead behind us, oblivious to the stares of the midwives and patients we passed on our way. Tina tripped and sloped along beside me, but I was on a mission, winding a path through the lunchtime crowds until we had reached the relative safety of one of the eight curtained bays in the main Triage treatment room. I helped her onto the bed, where she lay with eerie silence as I slid off her coat and her boots. It was as if, on reaching Triage, she had finally surrendered with mute, easy relief to the illness that had been draining her for days.
While Tina closed her eyes, mine widened with fear. I hustled around the bed, switching on the monitors and punching buttons on the machines, setting them to repeat their observations every few minutes. Blood pressure 86/45. Oxygen 92 per cent. Pulse weak and thready at 49 beats per minute: the slow march of a desperate heart. Worse and worse.
‘Excuse me a moment,’ I said to Tina, and then I pulled the curtain back and called to Martha, one of the midwives I’d seen at the desk as I’d dragged Tina through the department. ‘Page the SHO,’ I said, referring to our Senior House Officer, the junior doctor usually responsible for doing initial assessment and basic treatment, and then, looking at Tina’s ghostly pallor, I added, ‘and the registrar. Sepsis.’ A patient as unwell as Tina would need senior review, with a decisive plan and prompt treatment. Martha nodded, set down the notes she’d been reading, and lifted the phone. No further explanation was needed. She and I had battled through dozens of shifts together, and such was our mutual respect and appreciation that we’d developed an easy professional shorthand. A word from me, a nod from Martha; like so many of the bold, ballsy women I worked alongside, I knew she had my back.
As I returned to Tina and watched my machines bleep and beep with progressively worrying numbers, I could feel my own pulse skipping nervously skywards. I was only a few years qualified and it was as if a patient was ticking every box I had been warned about in training; it was almost too horribly perfect to be true. Infection? Tick. High temperature? Tick. Slow pulse, low blood pressure, and cold extremities, as the exhausted heart struggles to pump in the face of an immune system in overdrive? Tick, tick and tick. I knew with an aching certainty that the last box on this morbid checklist was the one marked ‘death’. In fact, during my training, death was such a ubiquitous consequence of pretty much every obstetric emergency in the textbook that it became a running joke among the student midwives. Uterus turned inside out as a result of some particularly vigorous cord-pulling? Result: shock, bleeding and death. Allergic reaction to the wrong type of donor blood? Result: shock, organ failure and death. Black coffee with one sugar given to the ward sister instead of the requested tea with milk and two? Result: deep embarrassment, public humiliation, ejection from the hospital aaaaand death, we used to giggle, the prospect of Sister’s disapproval seeming much more real to us at that time than the threat of an actual moribund patient. Although I had dealt with some very unwell women by the time I met Tina, none of them had been this far gone. With fresh horror, I realised that I might actually be watching my patient die. Please not today, I prayed silently to the Midwifery Gods. Not on my shift.
Martha popped her head back round the curtain. ‘Both registrars are busy,’ she said, as Tina coughed and curled into a tight ball on the bed. ‘Labour ward’s running two theatres; there’s a crash section with twins at thirty-one weeks, and a trial of forceps, with two third-degree tear repairs waiting in the wings, so don’t hold your breath.’ She looked over at Tina and seemed to register her shocking condition for the first time. ‘Fuck,’ Martha whispered to me with characteristic bluntness; her assessment of the situation was no less accurate for its brevity. ‘I’ll see if I can find the SHO.’
I hovered over Tina’s bedside, flitting from one monitor to the next, frantically switching off an alarm only for another to start bleeping, until finally the SHO appeared. By this time, Tina’s numbers had become even worse: the ones that should have been high were dropping dangerously low, and the ones that should have been low were making an inexorable climb to disaster. Even more worryingly, Tina’s attitude had changed from one of dazed exhaustion to acute agitation. Now I wasn’t the only one with that textbook sense of impending doom: Tina began to writhe on the bed, her eyes suddenly wild but unseeing.
‘What’s happening?’ she demanded. ‘Am I dying? Why do I feel like this?’
I turned to the SHO, who was witnessing this scene with undisguised terror. Raymond was a trainee GP who had not long started his obs and gynae rotation in our hospital; with his gangly physique and a babyface dusted with the sparse beginnings of a beard, he was often mistaken for a medical student by both patients and staff.
‘Where the hell have you been?’ I hissed.
Raymond clutched nervously at his ID badge. The photo on it was of an even younger, and much happier, Raymond, grinning broadly on what had probably been the first day of his NHS induction.
‘I was in the tea room, updating my Tinder profile,’ he whispered as Tina began to clutch wildly at her hair. ‘Martha said my picture made me look like a sex pest.’
‘For God’s sake, Raymond, you could have at least made something up.’ I felt a pang of sympathy as Raymond looked duly chastised, but not nearly enough to override my concern for our critically ill patient. ‘Tina’s a prim at twenty-nine weeks, septic, query flu. She’s hypotensive, bradycardic and now … delirious.’
By this time, Tina was back in the fetal position, arms wrapped around her head, eyes tight shut. Another coughing fit shook her body; even the metal bedframe clattered against the wall with the force of the spasm. ‘I can’t – I can’t catch my breath,’ she gasped, her chest heaving. 36 resps per minute, I guessed, counting silently to myself as she began to chant in a low, urgent voice, ‘Make it stop, make it stop, make it stop.’
‘I’ll need two cannulas, full set of sepsis bloods including culture bottles, a stat bag of fluids, IV paracetamol, a Foleys catheter with urometer, and facial oxygen,’ Raymond said.
‘You don’t say,’ I replied, as I showed him the equipment I had already assembled on the bedside trolley. We are well drilled in the assessment and treatment of sepsis; I had done what I could, and needed Raymond to do the rest.
‘And amoxicillin.’
‘Seriously, Raymond?’ I asked, aghast. ‘I don’t know what they taught you in medical school, but flu is viral. Antibiotics are going to be a waste of time.’
‘Just the amoxicillin, please,’ he repeated calmly. ‘In case this is pneumonia. I’ll get on with things here if you and Martha can organise the IVs,’ he said, as he unwrapped the various packets required to cannulate Tina and begin the battery of blood tests.
‘But it’s sepsis secondary to flu,’ I said weakly, standing at the end of the bed, now looking at Tina with fresh eyes. ‘Or at least … I’m pretty sure it’s flu.’ Yes, it was flu se
ason; and yes, Tina had initially presented with all of the symptoms we would have expected with flu – she had even, very helpfully, diagnosed herself – but in my rush to do my basic observations and summon the necessary help, I had missed the fact that the clinical picture was rapidly changing. The rapid breathing, low blood pressure, cold hands, burning fever and delirium: I had missed the pneumonial wood for the proverbial trees.
Within the next twenty minutes, we had stabilised Tina and initiated the appropriate treatment. Martha had gathered the IV paracetamol, fluids and antibiotics, and started running them through the cannulas Raymond had sited in both hands. With the situation now under control, I had finally managed to listen in to Tina’s baby (whose heartbeat was remarkably steady and clear, under the circumstances) and Raymond had updated both registrars, and was now on the phone to one of the senior medics in the general hospital adjoining our building. Tina was to stay with us until a porter became available to transfer her to the main receiving unit, where her care would continue under specialist guidance. Everyone had played their part, the team had pulled together, and although Tina was by no means out of danger, things were moving in the right direction.
While Raymond was making his phone calls and almost a dozen little multicoloured vials of Tina’s blood were winging their way to various branches of the hospital laboratories, I sat at the foot of Tina’s bed. Triage had emptied out, as it sometimes does in the lull between the lunchtime rush and the late-afternoon deluge, and beyond our little curtained bay, the department was quiet save for the distant ringing of a telephone and the gentle smack of Martha’s trainers across the floor. As another bag of IV fluids dripped steadily into her veins, Tina had once again settled into stillness, eyes closed, body soft and slack on the bed.