We accepted the patient at five in the morning. He was blue-lighted thirty miles up the motorway from the hospital in his home town. It was a chest infection that had caused him to be admitted to a hospital ward, one like hospital wards everywhere: too busy, understaffed, caring in a haphazard institutional way. Easy for an elderly man, not wanting to bother people, to stand and trip and fall onto the floor. Easy for the old, less resilient blood vessels under the membrane enclosing his brain to rupture and bleed on impact. Easy for a clot to form, swell, exert life-threatening pressure on his brain resulting in symptoms of neurological deficit, confusion and limb weakness: restricting his ability to move, cough, swallow, exacerbating his chest infection. These were symptoms that, in an elderly patient, on a busy, understaffed, haphazardly caring ward, were easy to miss. But by the night shift they must have noticed. Their doctors spoke to ours, and at five in the morning we accepted him for emergency surgery.
I got home around half past eight that morning, into bed for nine, five hours sleep, waking at two, the familiar pre-nightshift anxiety kicking in. When I came back onto the ward at seven there he still was. The morning ward round had seen him and decided he wasn’t fit for surgery. He wouldn’t, they considered, survive general anaesthetic. They had a full list of people waiting for life-saving surgery who could take his place. The plotting on his chart suggested that he was progressing more rapidly towards death than the time axis alone would account for. An x-ray showed consolidation on his chest (what a good, descriptive, medical word that is: consolidated. Fortified. Entrenched.)
‘What’s the plan, then?’ I asked the nurse who handed him over.
She told me hourly observations and ‘full escalation’, an extravagant term meaning theoretically anything under the sun, everything except for surgery to remove the haematoma.
I tried the doctors. ‘What’s, um, the plan with him?’
A prescription, I was told, of different antibiotics and blood products that weren’t stocked on the ward.
I rang on-call pharmacy to try and source these items. For context, I was the nurse for nine other patients, too – nine patients who each had to be given their medications, to be observed and have those observations recorded, their tracheostomies cleaned and suctioned, to be turned and checked for bedsores and incontinence – and I had to complete a mountain of paperwork to prove that all of this had actually happened.
I contacted the Critical Care Outreach Team, specialist nurses with an Intensive Care background who support regular wards to manage critically ill patients.
‘But we must have a definite plan in place!’ they said, and went to talk to the doctors. A plan was formed: Intensive Care had been liaised with, and should be liaised with further in the event of his condition deteriorating further. Then their shift finished and they went home.
Further than what? I wondered.
The phone rang for me. ‘It’s his son.’
I approached the phone trying to rehearse a coherent picture to present: ‘New antibiotics, close monitoring, recent review, perhaps for surgery tomorrow…’
‘Just let him go, love,’ said the voice on the phone, working class, rough with emotion. ‘We don’t want him to suffer. He’s been through enough.’
There was here, I felt, an essential misconception regarding the ethics and remit of nurses.
Well, on the whole I rather agree with you. I’m completely flabbergasted that we’ve taken your father away from his family, apparently without consulting you, in order that we do nothing and watch him die.
I didn’t say this of course. I tried to radiate warmth and protection down the phone line with the tone of my voice while I lied with hopeful words.
‘We’re not quite at that stage yet.’ Then I wavered back towards truthfulness. ‘Would you like me to ring you during the night if anything changes?’ If, for example, he starts dying at a more accelerated pace.
‘Yes please, love.’
I felt I had communicated and been understood at some level.
Night shifts, like many things, are often worse in anticipation than the reality, but conversely, when the experience is worse than you had braced yourself for, it feels particularly debilitating. I gamely launched myself into the plan but every task I completed generated more until I was overwhelmed by an Augean stable of shit. In order to support the man’s sagging airway we had inserted an nasopharyngeal tube, a large soft rubber tube that we’d shoved through a nostril and down the back of his throat. Periodically mucus obstructed his windpipe and stayed there because he was too weak or unconscious to cough. This meant that the oxygen carried around his body was insufficient to supply his vital organs and his monitor would beep to let me know. This would prompt me to stop whatever I was doing, get a thinner flexible catheter attached to suction, slide it down the tube, and try and suction up some of the swamp. I have no personal experience of this but I can only assume that having a plastic straw pushed through your nose into your trachea, triggering a reflex that causes you to violently cough, is unpleasant. I did this so many times to him, jabbering words of comforting explanatory nonsense into nowhere as I made this barely conscious man splutter and heave beside me.
Patients with head injuries need to have their consciousness levels monitored. If they’re speaking, it’s relatively easy. You can ask questions to determine if they know who, where, and when they are. It’s less straightforward if they can’t speak. You know they’re unwell but you want to know if they’re getting worse or better. You can see whether they can obey commands. Can they stick their tongue out when you tell them to? You want them to do this. You shake them, you shout in their ear, you generously interpret twitches of the hands or spasmodic yawns as evidence of comprehension – so that you don’t have to try and coerce the fully stretched doctors to come and review them; so that you can promise yourself you’ll check again in an hour when maybe you’ll have more time and they’ll show a more honestly identifiable result, so that you don’t have to consider the possibility that you least want to consider, that the patient is nosediving on your shift.
The last level before total unresponsiveness is response to painful stimulus. You squeeze the trapezeoid muscle by their shoulder until you deliver enough pain up the nerves to their blood-clouded brains and back out again, hoping they’ll open their eyes, or reach up to stop you, or move their limbs in uncoordinated distress, or growl ‘Whathefuckareyoudoing’, and try and punch you and, believe me, if you get the last one it floors you with relief and happiness.
By midnight it was clearly going badly. His blood pressure was dropping, his breathing was fast and laboured, his temperature high. I called the doctor. She prescribed intravenous fluids, a tricky line to draw. In weakened patients, the heart is already struggling to manage the load, and it compensates by pushing less. If you add fluids, it can increase the risk of heart attack, or flooding his already swamped lungs.
In areas like intensive care, fluids are carefully calculated. Whether this can turn back the tide of a failing body, I’m not qualified to say. But that was definitively not what we were doing. We were guessing, gambling. All of the input/output figures I’d diligently recorded were a theoretical show of information that might end up in a coroner’s report. What had happened to the plan?
His blood sugar dropped dangerously low, and the doctor recommended oral dextrose gel. It comes in a tube like toothpaste and you rub it into your gums.
‘Is this how we manage critically ill patients with no swallow now? By squirting gel into their lungs?’ The gap between what I was thinking and what I was saying was narrowing to non-existence. My colleagues, who’d taken a break from their own workloads to mediate this discussion, looked on interestedly. The doctor said nothing.
‘What about a senior review? How about I stop checking on him altogether if you’re not going to do anything?’
‘You can’t do that.’ She was a junior doctor, able, hard working by definition. She spoke at least three languages and had overcome who knows what obstacles to train and work in the UK. ‘I’ll speak to my registrar,’ she said.
I went guiltily back to my patient with the dextrose gel. Slopped it into his cheek cavity, massaged the loose folds of skin at the jaw. He gurgled. His blood sugar came up.
I suctioned, shouted at, shook, pinched this man, shone lights in his eyes to check his pupils. On and on it went, frantically bailing water from a wrecked boat. The doctor came to speak to me. She might have put her hand on my arm.
‘I know it’s very stressful. You’ve got so much work to do.’
I appreciated it: it was a nice gesture, to come and say that to me when I’d been angry with her. But I also thought, no, I’m not going to let us escape from this immoral, dishonest thing we’re doing, just with some nice words.
‘I’m not stressed because of the work,’ I said. ‘I’m stressed because he’s dying. He’s dying, and he’s been dying since he came in here, and someone needs to make the decision whether we’re going to let him die or try and save his life, but not this half-arsed full escalation where we pretend we’re doing something but we’re not managing anything, nothing at all. I think he’s going to die.’
At around three in the morning things reached a lull. I was sitting at the foot of his bed with a pile of notes, optimistically hoping to make a start on my paperwork while I kept an eye on him. I wrote by the light of his bedside lamp. I looked up and saw the numbers on his oxygen monitor drop, not slightly and variably like they had been doing all night, but definitely and sharply. I got up, shouted for the others, grabbed at the suction on the wall. The others arrived, saw the numbers on the monitor, didn’t believe them.
‘Is it reading right, is it on his fingers?’
‘Yes, yes, it definitely is, he’s not well enough to shake it off.’
I was trying to put gloves on, jam a catheter into the suction. My hands were shaking. One of my colleagues said, ‘I’ll do that,’ and took it from me. I became aware of the anger that had been following me round all night as I’d scurried round putting up fluids, mixing up antibiotics. I couldn’t look at the man in the bed, and then I did and felt utter disbelief. I started to cry, shielding my eyes with my hands, hissing expletives. They told me to go off the ward, that they’d take care of it, and went back to looking after him. I walked to the door, paused to see if I could get myself under control, couldn’t, and walked out.
I let myself into the staffroom and wept and rubbed my face and ran my fingers through my hair and laughed and cursed. Anger subsided and I felt hollow and cold. I noticed my surroundings again, the white walls stained with food, infection control and anti-fraud posters blu-tacked onto them, the battered lockers taking half the room’s space. I realised there was nowhere for my emotion to go. I stretched, blew my nose, wiped my face. Tears started again. I wiped them away. I felt detached and resigned, away from that small area of floorspace where drama reigned. I realised I might benefit from something to eat and drink after eight hours of frantic work. I made a cup of tea and stole a packet of biscuits (theoretically a sackable offence) and ate looking out of the window at the exterior of the huge hospital in the dark, alone with the fridges and generators humming through the walls.
When I walked back onto the ward things were relatively calm. My colleagues had suctioned pints of fluid off his chest and he had rallied. They had presented a united front to the doctors. An doctor from Intensive Care was on the ward pretending to consider putting a ninety-year-old on a ventilator. The ‘plan’ was back on.
One of the support workers had been dispatched to the coffee chain that opportunistically infected our hospital corridors to buy me a large, hot, sweet, milky, profit-driven coffee and cake. I was on the other side. Two hours to go. Dawn was coming, the relief shift in sight. I sat shoving cake into my mouth with one hand, writing my notes with the other. I checked on my ten patients, feeling a weary incapacity to deal with any more drama. They remained obligingly stable. I stayed thirty minutes late, writing a careful chronology of everything that had happened. He remained in bed, alive but unconscious, stable but with no obvious medical solution in sight. I managed to cycle home without crashing. I went to bed.
My theory of post-nightshift sleep is that there is a competing demand of adrenaline versus fatigue. Fatigue wins initially, but once it has been satisfied to a certain level, the over-active brain demands attention. When I woke I cried again. That afternoon I was supposed to be catching the train to see my family. It was December, not long before Christmas. The yellow light and people and bags squeezed together, the trickles of dirty water on the floor, made the carriage alternately cosy and squalid. I turned towards the window and tried to hide the tears that I couldn’t stop spilling from my eyes from the commuters sitting next to me. It was as if I was still trapped next to the man’s bed in the dark, unable to find a way to escape.
I once had to sit through a simulated video where a patient has a slightly raised blood pressure, which prompts the nurse actor to have a conversation with a very affable consultant actor who reviews this alarming development within five minutes of its discovery. In another mandatory training session we were told that moving a heavy patient in bed should be carried out by no fewer than six people. I worked on a ward with thirty male patients, a decent proportion of whom needed some assistance to move. In the morning we might have seven or eight members of staff. Having six people to move a patient was theoretically possible, in the same way as getting a consultant review of a patient within five minutes might be. Our professional duty requires us not to walk away. We can’t arrive in the morning to a ward full of sick patients needing care and refuse to deliver it because it’s unsafe for us to move people.
When a patient is critically ill a plan is supposed to be decided by senior doctors, ideally in consultation with the patient and their family. The plan could be stopping intervention and supporting the patient and family in the end of life. It could be ‘ward-based care’, where the patient is treated according to the resources of a normal hospital ward, with the understanding that if treatment isn’t successful they won’t be transferred up to intensive care and supported by ventilator. These difficult decisions are considered according to different factors: the likelihood of success, quality of life, the preferences of the patient, the invasiveness and unpleasantness of the treatment, availability of resources. My patient had lived through the night. If he hadn’t, the junior doctor or I might have been questioned on our inability to escalate the issues to more senior doctors, but other than that, probably nothing would have happened. The problem wasn’t the decisions, which weren’t mine to make or question, but the fact that these decisions were made on the basis of factors that didn’t exist in reality. We accepted him and treated him intensively, painfully, dangerously, and justified it on the basis that there was no treatment that we would withhold.
Sometimes in job interviews I’m asked, ‘Tell us about a difficult situation and how you dealt with it,’ and my mind flicks automatically to that night. Then I think, No, and pick some more manageable narrative. It was a bad shift, one of the worst that I worked – but it wasn’t exceptionally bad, in the life of the ward, or in the lives of hospitals generally.
A couple of weeks afterwards I saw one of the critical care nurses. She asked how the night had gone once she’d left and I told her. She listened, then said, ‘You can claim that one,’ and I said, ‘Yes, yes, we bloody can.’ We saved a man’s life. But it will be a long time before I forget sitting in the dark, listening to an old man’s breathing falter, the moment when the numbers on his monitor dropped before the alarm had time to catch up with them, and reality threatened to come pouring in.
Afterword: There are currently 43,000 vacant nursing posts in the NHS, equating to around 12% of the workforce (figures from Nursing Times & The Guardian.) Contributing factors to this shortage include the loss of the nursing bursary (it now costs a minimum of £27,000 just to train to be a nurse) and the loss of EU staff, who have left the UK in droves since 2016. It is estimated that up to 5,000 EU nurses have left the UK and the NHS since the Brexit vote, according to a recent Freedom of Information request, as reported by The Guardian.
The Conservative Party have presided over unprecedented cuts to the NHS and have created a situation that has led to a huge shortage of NHS staff, lengthy waiting times to see a GP or specialist, and the worst crisis in A&E in decades.
Please use your vote wisely this election.