(2013) Looks Could Kill

by David Ellis

  Emma bent down, grasping and closing his nose with one hand and pulling his jaw down and forward with the other. She tentatively applied her mouth to his. Something solid moved beneath her lips. She realised with revulsion that he had dentures. She’d been told that dentures were always the first thing to check for before doing mouth-to-mouth resuscitation and she’d failed at her first attempt. She inserted a couple of fingers into his mouth and removed the dentures which came out with a sucking, squelching sound. She deposited them in a pot handed to her by a nurse. Emma reapplied her mouth to his, taking a deep breath and then blowing into his edentulous mouth, turning her head to check that his chest was inflating. It wasn’t. She tried again and saw his sunken cheeks inflate but not his chest.

  “Come on, doctor, put some effort into it,” demanded matron, whose pumping was vibrating the bed and much of the ward. Just as she started again, the curtains parted and the crash team appeared, out of breath after running down numerous corridors.

  The team stared in amazement at the site of matron appearing to be virtually in flagrante delicto on top of the patient. “Glad to see you,” said matron, “and relieved to see some true professionals to take over the CPR.” Emma blushed.

  “This is an 84-year-old four days post-op with a perforated DU and no complications until now,” matron announced to the crash team.

  The crash team registrar turned to Emma: “Have you anything to add - he looked at her badge - Dr Jones?”

  “Sorry, I’ve never met the patient,” said Emma, mainly addressing the floor.

  The crash team took over and Emma left the bed area, feeling as deflated as the patient’s chest. She returned to where she’d left the blood specimens and checked that she’d completed the labelling correctly. She marked the forms ‘urgent’, added her bleep number, and put them in the out-tray for the porter to collect. She found the porter’s number and asked him to make an urgent collection for the labs. This was greeted with the usual lack of enthusiasm.

  She thought she should write up an alcohol detox for Mr Edwards to be on the safe side and consulted the hospital formulary. Chlormethiazole four times a day sounded about right and she wrote this up on Mr Edwards’s drug chart. He didn’t seem to be on any other medication, but she thought the anaesthetist might want to start him on something for his high blood pressure.

  The rest of the afternoon passed relatively uneventfully. Mr Edwards was off the ward for a suspiciously long time. The patient with the dentures didn’t make it and the curtain remained around his bed. She wasn’t sure of the protocol but imagined that someone would whisk him away without other patients seeing anything. She clerked the other three patients, who turned out to be straightforward without anything unexpected in their histories or examinations. She found a blank operation list and completed it for her four patients. She wasn’t sure whether the Professor or anyone else in the team would be coming to the ward this afternoon but thought that they’d probably leave consent for their patients until the morning. She wondered about bleeping the senior registrar to let him know about Mr Edwards but thought better of this as she hadn’t got his blood tests back yet.

  Just before 5:00 p.m., Emma phoned the labs for results. As expected, everything was normal until they got to the results for Mr Edwards. His red cell volume was well above the normal range and two of the liver enzymes were elevated. And his gamma GT liver enzyme, which she remembered was an indication of heavy drinking, was sky high. This confirmed that he was a chronic drinker and heading for liver damage. She was relieved that she’d started him on the detox.

  As she was walking around the corner to her flat in the nurses’ home, she tried to sum up her experiences from the first day of being a junior doctor. Overbearing personalities loomed large and she felt something like loss when thinking about the patient with the cardiac arrest, but she felt she’d done something good and clinically intelligent when it came to Mr Edwards.

  August 1987, the following morning

  Emma made sure she got to the hospital well on time for the ward round and she went through all her patients’ notes before the team arrived. She noted that the registrar had been in after she’d left yesterday to do the consenting for the operations.

  The team arrived precisely at 8:00 a.m. Matron made it abundantly clear where she saw herself in the pecking order of the ward and almost retied the Professor’s bowtie for him. The bustle on the ward was electric and Emma wondered how patients avoided choking on their cornflakes.

  “Good morning, Dr Jones. I hope matron here has been helping you settle in,” said the Professor.

  “Yes, Professor,” said Emma. “I’m finding my feet, but I’m afraid we had a death yesterday.”

  “Ah yes, one of those things, but he had a good innings; part of life’s rich tapestry, one might say. Now who do we have for our list today?”

  Emma presented each of her new patients in turn. She thought she did reasonably well. The team arrived at Mr Edwards’s bed. He was visibly shaky. “Mr Edwards is a 54-year-old man with a one year history of epigastric pain, made worse by fatty food, that you saw in outpatients four months ago and he has been admitted for an elective cholecystectomy. On examination, he has tenderness in the right epigastrium and his liver edge is palpable. Blood tests show…”

  “Yes, yes, we know all that,” said the Professor impatiently. “Let me see the drug chart,” he demanded. “Who started him on this?” he asked, pointing at the chlormethiazole Emma had written up.

  “I did, Professor,” admitted Emma. “Mr Edwards has a history of excessive alcohol consumption and his liver function tests are abnormal. And he may have problems with his memory.”

  “Nonsense,” said the Professor. He turned to the patient: “Mr Edwards, this young doctor here thinks you drink too much. What do you think about that?”

  “No, sir, I promise I hardly touch drink, just the occasional beer with my lady wife.”

  “There!“ exclaimed the Professor. “He’s no more a drinker than I am.” Matron and the rest of the team laughed. He turned to the drug chart and put a line through the chlormethiazole with a dramatic flourish. “And he won’t be requiring that again,” he added.

  With the ward round completed, the team left the ward. Thankfully, Emma had been excused assisting in theatre. After checking on the one remaining post-op patient, she retreated to the library to revise the symptoms, signs and treatment of alcohol dependence. She knew she was right to have started the detox.

  There wasn’t an operating list the following day, so the ward round had a different focus. Unfortunately, the cholecystectomy patient went totally doolally overnight, trying to stab both his neighbour and a nurse with a ballpoint pen, and had to be sedated. Emma tactfully suggested to the senior registrar that that could have been due to alcohol withdrawal, but this was swiftly pooh-poohed.

  “I’ve never heard of such a thing, it was just the anaesthetic, that’s all,” he said.

  Emma started Mr Edwards back on the chlormethiazole and hoped that no-one would notice.

  Just after lunch, Emma was bleeped from the mortuary. “Good afternoon, doctor, we need you to do a crem form on one of your patients, a ‘Mr Michael Johnson’. Can you come now so that the undertaker can collect the body before the weekend?”

  Emma said yes without really thinking, but it then dawned on her that ‘Mr Michael Johnson’ must have been the patient who arrested the previous day.

  Emma excused herself from the ward and went in search of the mortuary. Unusually, it was well signposted, which she thought must reflect the volume of traffic through the hospital. Again, medical school hadn’t really equipped here with what she needed to do in this situation, although she’d gathered that one had to check that the patient was no longer alive.

  The mortuary turned out to be a haven of peace and quiet and Emma could easily imagine spending time there. Unlike on the ward, the mortuary staff seemed polite and respectful. The patient in question was the man with dentur
es and Emma was relieved to see that they were back in place, now adding a rictus grin to his sunken face. He was clearly still quite dead. The mortuary attendant pointed Emma in the direction of an impressive ledger where she had to write his details. This included writing the primary and secondary cause of death, and confirming that her patient wasn’t fitted with a pacemaker, as pacemaker batteries tend to explode when subjected to high temperatures. She contemplated writing ‘Death by compression from a heavy object’ for the secondary cause, but limited herself to entering the succinct and very final ‘Cardiopulmonary arrest’.

  The mortuary attendant handed her an envelope with Mr Johnson’s name on it. She opened it and was surprised to find £40 in crisp, new notes.

  “What’s this for?” she asked.

  “It’s your crem fee. Everyone gets it. You’re meant to put it on your tax return but most don’t,” said the attendant. “Some call it ‘ash cash’. Useful for beer money, I don’t wonder,” he added with a chuckle.

  What a strange job, Emma thought. You remove a total stranger’s dentures, attempt to breathe life into them and you’re rewarded with £40 when you’re unsuccessful and they're destined to end up a pile of ash. There’s a lesson in that somewhere.

  October 1987

  A couple of months had passed on A1 and Emma was quite settled into the daily routine of admissions, clerkings, operations and post-operative care. The redoubtable matron now seemed happy to call her by her first name, although matron herself would clearly never be addressed by any title other than ‘matron’. Emma wondered what she put in her passport: ‘nurse’ just wouldn’t cut it.

  Professor Cuthbertson’s idiosyncrasies remained an irritation to all, but Emma had a way of appealing to his vanity which by and large meant that she was excused duty in the operating theatre. One thing they did share in common was an interest in lepidoptery and she discovered that his favourite UK butterfly was the Brimstone. The reality was that he was a misogynist through and through and couldn’t comprehend how a woman could be a doctor, let alone stand up to the pressure of surgery and the operating theatre. Fortunately, pharmacology remained something of a mystery to him, so he rarely questioned what Emma wrote up on the patients’ charts.

  “Emma?” called matron.

  “Yes, how can I help?”

  “Would you have a look at Mr Simmonds in bed 5? He’s complaining of being in a lot of pain and you might need to check his analgesia.”

  “Will do.”

  Mr Simmonds was a man in his 70s who had cancer of the prostate with metastases in his spine. That wouldn’t usually be a reason for him being on a general surgical ward, but he also had a large inguinal hernia which was adding to his discomfort. He was now a few days post-op and should have been going home, but pain management was posing a problem and the hospital’s pain team hadn’t been to see him. He was on patient-controlled analgesia but this didn’t seem to be very effective. He also lived alone and had no known relatives.

  “Hello, Mr Simmonds, is it alright if I have a chat with you?” Emma asked.

  Mr Simmonds nodded and removed the headphones he was using to listen to his cassette player. There was a pile of classical music cassettes on his bedside table.

  “I see you like music,” said Emma.

  “Yes, doctor, it helps take my mind off the pain, but it makes me a bit maudlin if you know what I mean.”

  “Matron wonders whether your pump needs some adjustment,” explained Emma

  Emma checked the settings on the pump and it seemed that the morphine was on the lowest level.

  “Well, the level of painkiller is at the lowest setting, so that’s probably why you’ve been in so much pain. Let me show you what you have to do to increase it.”

  Emma gave him the control and showed him how to use the buttons to increase or decrease the infusion.

  “Thanks, doctor, I appreciate that.”

  “And perhaps try something a bit more uplifting than Verdi’s Requiem?”

  “Point taken, doctor.”

  Before going, Emma glanced at him. Pain was ingrained into his face. She caught his eyes briefly and felt an intense wave of despair wash over her. She gasped and had to take a couple of breaths.

  Mr Simmonds looked at her, puzzled by her reaction. “You’ve been working too hard, doctor.”

  “Perhaps. I’ll see you tomorrow, Mr Simmonds.”

  Later that afternoon, as she was leaving the ward, she glanced at his bed and noticed that he seemed to be sleeping peacefully, the headphones still on his head.

  February 1988

  Emma breathed a sigh of relief when she finally collected the sign-off from the Professor’s secretary. She didn’t know how she’d coped with his arrogance for the past six months, but at least the sign-off was the first step to getting her full registration. As expected, he’d made some comment about “presumptuous” prescribing.

  Today, Emma was heading for her next house officer post at St Edwards’ Hospital, but this time it was well away from any so-called ‘centre of excellence’ and it was medicine rather than surgery. She’d always thought she’d feel more comfortable treating illness without cutting into the patient.

  Walking into the hospital’s postgraduate centre, she was struck by how different it all seemed from her first job. Rather than long corridors and dark, wood-panelled walls, this hospital was laid out around a light, spacious atrium and the glow of winter sunshine seemed to spread everywhere. There seemed little chance of a Carry On remake here. The other house officers seemed similarly buoyed by the environment, although the fact that a free lunch was provided wasn’t an insignificant factor. And on top of that, there was no dogmatic, authoritarian lecture with a minimum of practical information, but instead a properly constructed induction with a variety of speakers all of whom were keen to impart what the house officers really needed to know. This bodes well for the next six months, Emma decided.

  Following the induction and lunch, Emma ventured to the Coronary Care Unit in K block. She had a pretty good idea of what to expect having been attached to a cardiology firm when she was a medical student. That was professorially-led though and she expected this district general hospital to be low-key in comparison.

  She found a staff nurse sitting at the desk with a bank of cardiac monitors in front of her.

  “Hi, I’m your new house officer, Emma Jones,” she said.

  “Oh, yes, we were expecting you, you’ve had your induction then?” asked the nurse.

  “Yes, really good, and a nice lunch too,” replied Emma. “Is there anything that needs doing?”

  “Would you mind looking at Mr Williams in bay 3? He came in yesterday with an inferior MI and he’s just gone into AF. You can see it on the monitor here. Troponin was sky high. Oh, and he was given aspirin when he came in.”

  “Of course,” said Emma. She checked the monitor and then went over to the bay.

  He wasn’t what she’d expected. Most patients who’ve had heart attacks are older or elderly. This patient must have been only in his 30s and he was good-looking, too. She remembered a similar patient when she was a medical student who was admitted on a Monday and dead by the following weekend, leaving a wife and two children.

  “Hello, Mr Williams, I’m Emma the house officer,” she said. “How are you doing?”

  “Pretty ropey, doctor, and dog-tired,” he said. And he looked it, with a sallow tinge to his skin. “I’d never have thought this could happen to me. I don’t eat meat and I go to the gym every day.”

  “Sometimes it just happens. Genetics, that sort of thing.”

  “I just feel so tired, that’s the thing. Do you have any idea when they’ll be here for the ward round?”

  “I’ll check. Your heart is beating a bit irregularly, so we may need to add some extra medication. But I think it’s best to wait until the ward round.”

  “Okay, doctor, I’m sure you know best.”

  This was one patient Emma didn’t want to lose, but
with the arrhythmia there was quite a risk that he could have a second heart attack. Being new to the job, she felt a bit out of her depth and didn’t want to start him on medication she hadn’t prescribed before.

  So, Emma waited, but no-one arrived. Eventually, she bleeped the registrar who told her that the consultant was away and he was stuck in clinic. She told him about the patient, but she got the impression that he’d never met him. The registrar recommended starting him on amiodarone intravenously. Emma checked with the staff nurse who shrugged and said: “That sounds okay. I’ll help you.”

  So, after checking the starting dose in the formulary, Emma put in the cannula and set the drip going. The staff nurse said she’d keep a close eye on the monitor and hand over to the night shift.

  The following morning, Emma arrived on the CCU to find the same nurse looking downcast. She looked at Emma and burst into tears.

  “It’s Mr Williams in bed 3,” she said. “He arrested last night. There was nothing that could be done. Would you have a word with his partner? His name is Tony. He’s in the relatives’ room.”

  Emma spent a few seconds trying to think about what to say. Dealing with death is another topic that isn’t high on the medical school curriculum.

  Emma went into the relatives’ room. A young man very similar in looks to the patient had his head in his hands. God, they must have made such a handsome couple, she thought.

  Emma held out her hand to him. “I’m Emma, the house officer… I’m just so sorry, Tony,” she said, feeling some tears brimming up. “How long had you been together?”

  He looked up, his eyes red with crying. “Thanks, it would have been six years in September… we were planning to buy a house together…” He turned away.

  “You must have made such a nice couple.”

  “People were always saying we looked like twins. Christ, I loved him so much…”