Intersection

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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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