Month: September 2013

Fade to green


I fainted half a dozen times during my training. It’s a problem that worries quite a few people, so here are some of my fainting tales. They may make you feel better.

I should have known it would be a problem because during GCSE biology I was asked to dissect a cow’s eye. It slipped and rolled under my scalpel, glancing at me as it turned. My teacher asked me if I was alright. Apparently I had gone green. As soon as he said that I began to feel green. I lay my head down on the cool workbench and soon recovered. It was close one.

Then, before applying to med school, I spent a night in the local Casualty department. I watched a junior doctor try to prise a splinter from the hand of a young lady. It was hurting her, and she kept yelping. The doctor got irritated and said the anaesthetic ‘should be working’. He kept digging into her hand, she started to cry, I felt lightheaded, moved my legs to keep the blood flowing…and I was out. It wasn’t the gore, it was the negative emotion – I think. Anyway, they put me on a trolley, checked my blood glucose, and the same doctor told me the only explanation for such low levels was an insulinoma. I got home, looked it up, and for some months assumed there was something unpleasant growing within me.

So to med school, and the post-mortem. I had been really looking forward to this. The Professor of pathology lifted out a series of pre-mobilised organs and held them up for those of us in the viewing gallery to see. I glanced past his gloved hands at the cadaver, glimpsed the head, saw the juices drip off the liver…and down I went. As usual I came around immediately, to be told that when the Professor heard the thump he looked up and called out, ‘Will someone see if she’s alright?’

Then came venesection practise. My partner shakily inserted a needle into one side of my elbow vein and out the other, causing a ‘sixer’ sized haematoma. As it swelled I began to sweat, the edges of my visual field closed in and I immediately sat on the floor with my head between my knees. Another close one. However, come the first day of my third year as a medical student, entering the wards at last after two years of lectures, I did less well. We met the house officer (she seemed so grown up) and were told that it was our job to do the phlebotomy rounds each morning. She assembled a vacutainer set and asked me to roll my sleeve up. Pretending to take blood, she held the needle a centimetre from my skin. My brain said NO WAY, the sweat came on and clunk, I was down. The clunk was the sound of my forehead connecting with the edge of a sink. The rest of the day went fine, but the bruise took a week to settle.

I entered the operating theatre as a student on a vascular surgical firm with great trepidation. For some reason the blood and gore did not affect me as it did some others. I watched a consultant repair a ruptured abdominal aneurysm, observed the blood as it pour off the table into his white rubber boots, saw him curse as he nicked the spleen and was forced to remove it…but the fascination allowed no room for vasovagal syncope.

But I was not cured. For my elective I travelled to Nepal via Delhi.  In a busy Indian market square I asked a cobbler to repair the soles of my shoes. He stuck strips of orange rubber onto them with stringy glue that he applied with a stick. His friend tried to clean out my ears with a cotton bud while I waited, but I pushed him away. I was pleased with the job on the shoes though. Anyway, come the first day on the wards in Kathmandu I was feeling a bit rough, having accidentally swallowed some tap water while shaving two days before. I stood in the breeze of an inadequate fan, watched a cat slink between the legs of a hospital bed and lick some organic fluid from the edge of bucket containing sharps…and there we go! I came to on a bed with ECG stickers on my chest. The Professor, a very serious man, asked me if I had a heart problem. I said no. What really upset me was the group of students and doctors at the foot of the bed peering at the soles of my shoes.

After that there were no more uncontrolled total faints. I came close during a stressful central line insertion as a senior house officer, but I think a hangover predisposed me to it. I slipped to the floor, put my cheek to the plastic tiles, sweating, the wire still sticking out of the patient’s neck, and fought it until a nurse brought a cup of ice cold water. Within minutes I was back on my feet, hands clean, fresh gloves on, ready to finish the job. I don’t think the patient ever knew what was going on.

Since then I have found myself in many faint-prone situations, but I am glad to report that it is no longer a problem. Blood, stress, chaos, suffering…none of it hits my pulse rate or blood pressure. Rest assured, if you are a fainter, it gets better.

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Don’t tell me the odds

I survived the war…the odds were long for prisoners like me, but I managed it. Luck played a part, but so did resilience, and, though it I can’t prove it, my ‘survival gene’. I won’t tell you exactly what I went through but I was in Singapore when it fell in 1942, I was captured and imprisoned, and I was starved. I saw friends and fellow soldiers swell with malnutrition, vitamin deficiencies and heart failure, and a good number fell to the ground on the building works. There was cruelty. The chances were that I would not survive, but I did.

Since that time I have dodged a few bullets: a car accident on the M1 in 1975 (‘a miracle you survived’ said the intensive care nurse when I came back to thank them for all they had done), and the bad bout of influenza in ’92 nearly did for me. I was on a ventilator for two weeks, and developed kidney failure as well. The family were brought in, and they heard that I was ‘very, very unlikely’ to survive. But I did. I’m a survivor.

So now I come to this week. I’ve not been right for months, but 5 days ago I got properly sick. It looks like the heart is catching up with me because suddenly, just like the chaps in the prison camp with wet beriberi, my legs started swelling and I got desperately short of breath. Apparently my chest x-ray shows that my heart is hugely enlarged, and after the echo test I overheard someone say that it was pumping like an old carrier bag. I get the meaning. I’ve got bad heart failure, from the fags I’m sure, and two of the valves are shot. But I’m what…born in ’24…I’m just shy of 90, I’ve done pretty well.

So one of the random doctors came along this morning and did the usual checks, crossed some things off the drug chart and added some more, then looked at me, all sensitive in the eyes, and sat on the bed. He said,

“Eric, I’d like to ask you something that you may not have thought about before.”


“It’s about what we should do if your heart were to suddenly stop. If you were to have a heart attack, a cardiac arrest.”

“I know what you mean. But I haven’t thought about it.”

“As you might know, we often call the emergency team to try to restart hearts with chest compressions or electric shocks, but we have to be sure that there is a good chance that it will work. Sometimes, if the heart is already very weak, the chance of it working is very small indeed, and the damage that those attempts can do is quite significant.”

“So what are you saying?”

“Well, in your case, I don’t think it would be a good idea. We know your heart has become very weak over the last few years, without you knowing it, and if it were to stop – and I’m not anticipating that it will, you’re quite stable – the chance of getting it going again, strongly enough for you wake up and be close to how you are now, is unlikely.”

“How unlikely?”

“I can’t give you a definite number.”

“Don’t they know?”

“Well, I did read a study that found for every 30 people in their nineties who were resuscitated only 1 left the hospital. But everyone is different, it’s a decision that needs to be made on an individual basis.”

“But from where you’re standing the odds are bad.”


I really hadn’t considered all this before. Perhaps I should have. You see, I enjoy my life, and I have confidence in my ability to survive. I’ve proven it, after all, time and again. But yes, I am older now, the floppy bag in my chest is on its last set of batteries, so I suppose I need to listen. But I wasn’t prepared to say – ‘OK, mark me down for no resuscitation.’ I’m sure it’s awful, being compressed and shocked, I’m sure the machines you have to go on are uncomfortable, but I’ve had worse. They way he spoke, I’m not sure he’ll agree to put me down for resuscitation anyway, it sounds like it’s his decision. But he did ask me. Didn’t he? Or did he tell me. I don’t know. So I’ve left it for now. I want to think about it.


The doctor sits in the canteen with his team. His junior colleague asks,

“So, the old chap with the bad heart. Do I do a DNAR form?”

The senior doctor replies,

“Tricky, tricky. In my opinion he has next to zero chance of surviving a crash call. I made that pretty clear didn’t I, within the bounds of compassion.”

“I think so.”

“Would you give chemotherapy to a cancer patient if there was, say, a 2% chance of it working?”

“No, of course not.”

“In fact, you wouldn’t even discuss it. It wouldn’t be on the agenda. So you could argue, why are we even discussing resuscitation with this man? Statistically, medically, it’s an irrelevance. It won’t work.”

“You don’t know that. And you’re talking about the end of his life. The moment of death. He’s bound to have an opinion. You didn’t say it was guaranteed not to work.”

“Trust me, it won’t. He might get a pulse back but he wouldn’t get off inotropes afterwards. And his kidneys are already working at 20% capacity. They will fail too. And will intensive care take him? No. If he stays for resus we’re holding out a false hope. It’s dishonest.”

“So I should do the form shouldn’t I? It’s the weekend, we can’t leave it.”

“I’ll need to go back to him, see if he agrees. He wanted more time, so be it.”


Back on the ward.

“Hello again Eric.”


“I wondered if you had thought any more about our conversation.”

He sat down again, carefully addressed the subject. He made a good case. And you know what I said? Well, I didn’t say much. I didn’t have the energy. I couldn’t be bothered to tell this doctor about my scrapes with death, about the commitment I made to myself back in ’42 never to give in, never to accept fate without a fight…because that’s what got me through it, and that’s what got me off the ventilator in ’92. It was survivability. I’m still the same man, mentally, if not physically. Call me stubborn, but his statistics don’t apply to me. I’ve proved that. I’m going for it.


The doctors’ mess

“Did he agree?” asks the junior.


“What do we do?”

“Respect it.”

“It’s crazy…it’s not the right decision?”

“Well I’m not signing it.”

“I’ll talk to him some more. Do you mind if I try?”

“And coerce him?”

“Persuade him.”

“He’s made up his mind. It’s not a rational thing. It’s about not letting go of 90 years of life without an argument. I understand it. I don’t agree, but I understand.”

“And if he arrests, we’ll look pretty silly, leaving a 90 year old with severe heart disease for resuscitation.”

“So be it.”


fall of singapore painting


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This is a brief tale of two patients who never met, but whose lives became briefly entwined with huge consequences.  Until the day that saw both became ill their life lines had not intersected before. Suddenly those lines veered from their usual course and dived across the city towards a bland, anonymous nexus…the hospital. They arrived within an hour of each other but were too preoccupied with their own symptoms and fears to become aware of one another in adjacent cubicles. Their relatives passed in the corridor, and may have stood in line together at the coffee machine. The patients, an elderly man and a thirty-five year old woman, were seen by different doctors. His angina settled with morphine, oxygen and nitrates; her asthma attack eased with nebulisers and infusions. She was transferred to the medical high dependency ward for monitoring, he to the coronary care unit. Their lives diverged once again as they were transported to different ends of the hospital.

At 2am his angina leapt back up for attention. The nurse looking after him turned up the nitrate infusion, but bleeped the doctor on call as the pain score rose from 7 to 9. The doctor responded and began to make his way to the ward. He knew that the ECG was essentially unchanged – the nurse had told him so, and he trusted her interpretation. She had seen a hundred times more ischaemic  ECGs in her career than he had. But he had a plan – intravenous beta blockers, to slow the heart and make the myocardium less hungry for oxygen.

As he turned the penultimate corner his bleep went off again. He spotted a phone hanging from the wall and called the number. It was HDU. A young woman with new onset asthma was deteriorating. Oxygen saturations were dropping, she was confused, peak flows were unrecordable…every red flag he could think of was being waved.

The coronary care nurse knew what needed to be done. Her patient’s pulse was 95 beats per minute, but a simple injection could bring it down to 65 and ease the pain. He was clutching his chest, pressing on the sternum as though to reach into the cavity and tear the source from his body. And now, on the cardiac monitor, she saw definite signs of ischaemia. Where was that doctor?

The doctor turned the final corner…and entered the high dependency unit. The asthma patient was close to collapse. He laid her down, began to assist her breathing with a bag and mask, and calmly ordered the nearest nurse to summon the entire medical emergency team.

On the cardiac ward the nurse had gone so far as to draw up the beta blocker in readiness. She was quite prepared to tell the doctor what to do if necessary. Then she would phone the on-call cardiologist herself to discuss emergency angioplasty. Nervous now, she walked from the bed space to the desk, in order to bleep him again. He had said he was on his way, and, though she couldn’t be sure, she thought she had heard his footsteps approach up the corridor five minutes ago. He must have got distracted.

‘Good call,’ said the anaesthetist on the emergency team, ‘…she needed intubating. I’m glad you didn’t hang about.’ The junior doctor felt good for what he done. He had recognised the red flags and had responded to them efficiently. As he left this scene of minor glory (he had qualified only 18 months ago after all) the crash bleep sounded. He and the rest of the crash team ran to coronary care, leaving behind only the anaesthetist who continued to ventilate the asthma patient.

They worked on the elderly angina patient for 25 minutes, but his heart could not be coaxed back into life. The many injuries it had accumulated before and since the bypass operation 18 years ago meant, for reasons we don’t fully understand, that once its lifelong habit of beating had been interrupted it would not be restarted.

His family were shocked, but not surprised, if that combination of reactions makes sense. They knew nothing of the junior doctor’s genuine intention to see their father, nor of the badly timed phone call that caused him to turn around and walk away from the coronary care unit. There is no way of knowing if his arrival would have made a difference…but it might have. So here we see how the life lines of two patients eventually crossed, the exact point of intersection being in that corridor, where the beige plastic phone hung on the wall, when the doctor on call decided to prioritise the needs of one before the needs of another.

A hospital represents a huge exchange in which hundreds and thousands of life lines touch each other every minute, altering in subtle ways the medical decisions, therapeutic actions and clinical outcomes of complete strangers. This sounds strange…and not a little wrong. A patient’s outcome should depend on several things, but not on the nature of their neighbour’s competing condition! On any given day the care a patient receives will be influenced not only by the vagaries of their own illness, the expertise of the doctor they encounter and the compassion of the staff they meet, but by numerous factors beyond the essential medical dynamic. The concentration and character of life lines running through the great nexus will also determine what happens. This fanciful representation may reveal a degree of caprice that we would rather not admit to, but we witness caprice every day, in nature and disease, in human response, in physiological or pharmacological idiosyncrasy. It is unavoidable. While we marshal these random factors into a logical, safe and personal management plan to the best of our ability, it does no harm to remind ourselves that the job of picking apart those life lines and prioritising their needs can never be an exact science.


[The cases are fictional]

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