Precipice of Death

Walking through the hospital hallways at 2am is an eerie feeling. Everything is so quiet and still, and it’s a site that I had not yet seen, like the back of the refrigerator that I’ve had for many years. Only the sole necessities exist at this time of the night in the hospital; the emergency department, the nurses’ stations and of course, the mobile late-night express café- keeping doctors caffeinated is a necessity!

Night shift for me feels like I just flew back from a 17-hour round-trip from the United States. I felt groggy and my stomach was letting me know about it. When you completely swap your sleep wake cycle, and now you are eating at and working the graveyard shifts, it’s a different kind of equilibrium your body must adjust to. Additionally, not only does it affect yourself, but it affects the people around you. There would be a sequence of days where my schedule and Prisca's schedule ceased to align. I would get home from work in the morning, and she would be heading off to work from the office. Hence, a period of 16+ hours without seeing each other…back to the days of our long-distance relationship. Beside the incompatibility of your schedules, there is a reduced time that you spend with them too. As I’m sleeping and getting rest from the night, she is up and about like a normal person at 1pm during the day. The converse happens at night as she catches the zzzz one by one, and I’m responding to pages, one by one, in the early AMs.

Night shift is just like a cover shift. I work from 8pm to 8.30am and cover the specific specialty I’ve been dealt (acute aged care, rehabilitation, aged psychiatry, and subacute medicine), with the main goal of reviewing patients for the home team and ensuring a safe transition back to them in the morning. So far, I’ve attended falls and reviews for all kinds of things in the morning and attended MET Calls resulting in unfortunate death.

An important skill during my night shift has been the implementation of the ultrasound machine to get venous access through a cannula. It’s been such a useful tool. Essentially, it’s using an ultrasound machine to look at veins in real-time and insert a cannula. Often times it is used for difficult veins. There’s a hierarchy of attempting a cannula. First of all, the nurses have an attempt to get a cannula in. If they cannot or if the veins are difficult, the junior doctors (me) are called to insert a cannula. Following this, the unit registrars, and then the anaesthetic registrars have a go- the experts of cannulas in the hospital. I didn’t want to be calling anaesthetics at 2am for a cannula, so I thought it would be worthwhile learning how to do it properly. It’s worked wonders and made life on the night shift, following a page to insert a difficult cannula, so much better.

One of the fortunate experiences during my internship was that I did not complete a death certificate for any patients. Most recently, it was the first time that I have seen, with my own eyes, a patient who was alive one second upon review and dead in a matter of minutes. I attended a MET Call for a woman with laboured and fast breathing. The rest of the team and I consisted of two registrars and another resident reviewed this patient. We went through the DRSABCDs of resuscitation. From the end of the bed she was huffing and puffing, using her extrinsic muscles of respiration to get some oxygen inside her. I was in-charge of getting important blood (for pertinent blood tests) from this woman, but as I struggled to get some blood, and as the rest of the team were focussed on their allocated parts of the review, the patient deteriorated. Her breathing slowed down, and so did her time on this earth. The other resident jumped to her airway and supported it as best she could. The nurse couldn’t get an ECG trace anymore. She was going…

She had the characteristic sign of someone who would not make it: Cheyne-Stokes breathing. In other words, irregular breathing, following by a period of not breathing, and then irregular breathing once more, in a continuous cycle. I thought she was still alive due to this breathing, but her desaturated oxygen levels, and decreasing pulse told otherwise. We started to confirm the death by listening for a heartbeat for two minutes – nothing; listening for breath sounds for two minutes – nothing; assessing the response to pain stimuli – nothing; assessing if the pupils constricted to light – nothing.

She was gone. Just like that. Her body lay there accumulating the coldness of her wardroom; her fingers beginning to turn cyanotic and cold. There was no life visible in her body and there was no life left in her breath. Rest in Peace.

This experience was daunting for me because it exemplified the quickness in a deteriorating patient. The line between life and death is so thin, that is life is constantly on the precipice of no longer existing. For some that is frightening, for others, exhilarating, leading to taking every chance you get in life. For me? Being an almost arbiter of this transition to death, brings about a level of responsibility in which your limits are often exposed. We can do everything for a patient to ensure they have a good quality of life, but sometimes, death has a stronger pull than a team of junior doctors attending a MET Call during a night shift.

Following her death, I overheard the family members saying that: “We thought we had more time with her”. An echo of emotions that shows that we do not know when our time is up with our loved ones, nor when the last good-bye or last precious moment will be. The only time we have with our loved ones is now. We can hope to have more time in the future, but that is no guarantee.

Rest in Peace.