h2g2 The Hitchhiker's Guide to the Galaxy: Earth Edition

I've been inspired by Create to, er, Create something. I"m going to share stories of working in a hospital at Christmas. I've been working every Christmas since I graduated, expect where I'm in jobs that don't give me the chance to. This is because I fall for sob stories about why other people can't work Christmas. Baby's first Christmas? sure, Sister's wedding in India? I'm your man.

The following anecdote is fictional - identifiable details have been changed, but it is based on a number of real life incidents.

Christmas Night.

In the years before I was old enough to be left alone in charge of the hospital I worked nights over Christmas There weren't many admissions on Christmas eve, all seemed to be going well. I saw a couple of possible heart attacks that needed observing overnight, the usual sort of thing, Midnight came and we wished each other 'Merry Christmas' and toasted each other with lemonade in a plastic cup. Shortly after that the Reg Susie was called to one of the wards to see someone who had taken a turn for the worse, and our house officer, Vicky was on top of the admissions and I was checking she wasn't killing anyone, and helping her out.

Half an hour later I got a bleep from Susie,:

'I really need a spare pair of hands up here on Laural Ward, can you pop up and give me a hand'.

A flurry of activity was clustered in around a pool of light around one bed on the ward. Once I could see past the nurses I saw Lucy*. Actually the first thing I did was smell the sickly smell of half digested vomited blood.

At the centre of the crowd of nurses was a woman, she looked like she was in her early 40s, tinged yellow with jaundice and semi conscious lay in a pool of vomited up blood. Breast cancer, spread to liver and bone, things weren't looking great. Susie asked me to get another IV line in, to get more fluid in, to take some arterial blood for various tests, I sprang into action, grateful that Susie was their and I wasn't in charge. As I knelt down to get the IV in I saw that on the bedside locker, pushed out of the way, lay a pile of neatly wrapped Christmas presents, arranged around a framed photo of a small child. Young to be a Grandmother, but not unheard of, not around here.

It was a struggle to get the IV in, she seemed to have no veins, her blood pressure was so low thatI couldn't get a radial blood sample and had to take one from her femoral artery.

I caught sight of a child's drawing 'Get Well Soon Mummy' . I checked her date of birth as I labeled her blood sample. She was 34, she looked a lot older. We got her blood pressure up a bit.

Her family arrived whilst Susie was on the phone to Intensive Care. A young well dressed husband, holding a sleeping blonde toddler'.

'Sorry, there's no one else to babysit'.

The night sister sat him down in the relatives room, and made tea with the full china tea service. The tea set that only gets used when things aren't going well.

Carrie, the ITU reg came up to help try and get her stable enough to go to ITU. We rang our consultant, and we tried to stablise her enough for him to take her to theatre to try and stop the bleeding.

At one point I rang a haemologist for advice on how to stop the bleeding, could we give any blood products. This one had a reputation for never giving up, we used to joke that we had to nail down the coffin lids to stop him trying just one more thingI recounted the whole stor to him.

'What are you doing?

', Getting in a second femoral line'.

'No I mean what are you doing, she's dying, but if you still want to treat her give her...'

We managed to get her stable enough for the first procedure. Half an hour later we were back to square one, the consultant hadn't been able to stop the bleeding. We organised a scan to get more information, the radiographer was wearing a hand knitted Reindeer jumper. The consultant decided to take her back to theatre for another procedure, this one might stop the bleeding. Susie prepared to go to theatre, I breathed a sign of relief as I'd left the house officer alone with the new admissions for far too long. I was looking forward a breather from the tensions on the ward.

About 3/4 of an hour later Susie came down to the admissions ward, looking exhausted, and puffy eyed. Doctors don't cry.

'How is she'?
'She died 10 minutes ago'
'Crap - coffee?'

She told me the full story over coffee, how she died during the second procedure. how they had been in such a rush her husband hadn't had the chance to say goodbye.



The next morning we told the story to the day team at handover.

'What the were you on? That woman was dying, and you took her to theatre! that's awful palliative care!"

I shrugged 'Dr Jones took her for the endoscopy'.

It wasn't true, it wasn't just Dr Jones' decision. We all lost our sense of perpective that Christmas Eve. There was something about the unopened presents, hansom husband, the blond toddler, about it being Christmas, that made us all loose our rationality. None of us could possibly face the prospect of a young mother dying at Christmas. And because of that we look away her husband's last chance of a goodbye.

Years later I still feel guilty when I think about it.

*not her real name

If I get cancer, I'm never going to get treatment. I so don't want to end my life like that.

Mind you, I gave birth in exactly the way I didn't want to, flat on my back taking drugs, and I've managed to live with that.

Mina - I don't think anyone does.

The reason this haunts me years later is that this isn't how death from cancer is for the vast vast majority of people who have it. What was different here is that this was someone who had a good chance of recovery from cancer who suddenly had a massive bleed.

If she'd decided against treatment she'd have been at home when she started bleeding, and I expect her family may have panicked and called an ambulance.

If I get cancer, I *do* want treatment.

My mother's now survived about 13 or 14 batches of the stuff. She's had growths removed here there and everywhere, and she's still fighting strong.

Well said.

There are some decisions where there is no right answer, only The Best Awful.

A Nice Death is the best we can hope for. Sometimes it even happens. But mostly we expect doctors to pull off gargantuan efforts on our behalf to prevent even that. It's a tricky line we are asking to be trodden. That time...you got it wrong. But you shouldn't feel too guilty about that.

My guess about what's causing a lot of your guilt is the exactly same factors that caused you to do at overzealously to save a life: the little blonde girl; the father; Christmas; no chance to say goodbye. Well - death sucks and I'd lay money that this Christmas there'll be someone who dies on a road somewhere without their family having had a chance to say goodbye. It doesn't always go to plan.

I'm also guessing that there'll be a doctor on duty in a Scottish hospital around that time who'll have learned from his entirely forgiveable mistake.

I am SO glad you don't tell me your crap-day stories when they happen.

B

Hindsight is a wonderful thing. I wonder if the husband took the same view as you?

But even so.

We have a saying 'The retrospectoscope is always 100% diagnostically accurate'.

Humm. Seriously. Given that this is semi fictional, a complication of several real incidents, it's hard to tell how how it would have felt.

I believe he would have said, 'Thank you for doing everything doctor', but how we would feel years later, I don't know.

I've got a sense of foreboding about this Chritmas. I'm sure one of my ailing relatives is going to be rushed into hospital. I take comfort from knowing that (at least some) doctors do care if they get it right.

We recently struggled to keep a relative out of hospital. That was no reflection on doctors, It's just that he was dying.

Christmas is an awful time to lose a loved one. A reminder of your loss pops up annually and hangs around for the three months following September. My mother died on February 29th.

- you could have warned us how heart-rending this would be. A "not suitable for work warning" or something. Well written, Z.

Are you allowed to show your feelings in such a situation? I would like to know if doctors are allowed to show regret, or if there is some insurance clause which makes remain absolutely neutral when talking to the relatives, even when they haven't quite done the right thing.

I hope you only have happy experiences this Christmas. And I look forward to the next instalments.

There were many, many aspects of Dad's care (not necessarily the medical care but the looking after him aspects) that I was not happy with, but the medical treatment on the day he died was right I think, in that they did what they could to make him comfortable, but ultimately decided not to cart him off to theatre for something that would likely kill him anyway. Instead they kept him calm and comfortable as they could for just long enough for mum to get there.

The only thing I was unhappy about is that when the catastrophic event happened they left an initial message on mum's answer phone at home when she was at work, and then didn't try her at work until two hours later, or try any of the rest of us at all (as would have happened if he had still been in ITU rather than the high dependency ward they moved him out to) so as a result mum got there for his final breath, and my brother and I missed him.

But for the medics, you can only do what you think is right at the time - and use the hindsight to inform you next time. That is what you have done and that is all anyone can ask.

There's no hard and fast written rule of the hospital policy that says 'Doctors must not cry'. But it is considered a bit unprofessional to cry when you're talking to the relatives of the deceased, they're the ones who are more affected, not you.

You can, if you want to, cry in the Clean Ultility cupboard / staffroom / your office, as Susie did here.

You do have to put up a few emotional barriers just to get your job done. If you work in an area where people can die 3 or 4 times a week, then you can't be spending half an hour crying after every death. You'd never get any work done! I know that in areas where patients on't die very often (pediatrics, rheumatology for instance) the doctors do get much more upset when they do die, they can afford to cry there.

Also you have to think of your family. They deserve to have you home from work as a functional wife / father / girlfriend / etc. Doing a job where you come home from work in tears 3 times a week is not fair on them. It wouldn't have been fair on Ben if I'd ruined her Christmas by bringing my tears home with me.

When my father-in-law died recently.my sister-in law asked 'Why didn't you tell me he was so ill!!!'

Well - we'd she'd seen him three days before, as had my wife. One sibling had been able to work it out and had organised her life around that. What was she supposed to tell the other?

'You go away and do what you have to do while I sit with him. Departure time is 7am Sunday. I'll give you a call so you can show up for the grand finale.'

What she *wouldn't* say is 'Honestly? I don't think he'd have wanted you around.'



, Z. Thread annexation.

for Kelli.

Sorry a Smipost there.

Is it too trite to suggest that the necessary bottling up is why doctors are said to drink disproportionately? Or is that an urban myth?

I'm impressed, Z - I don't think I could do that kind of job.