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“I’m just going to pop in a drip and take some blood tests.”

To me, my voice sounded hollow and nervous, but Lisa, my patient, nodded and even seemed impressed. But then, she didn’t know I had only been a doctor for 3 days, and today was my first day on-call. She didn’t know that, if I did put a drip in her arm, it would be only the third time I had performed this procedure successfully.

It took me five minutes to find someone who was free to show me where all the supplies were kept, and another five minutes to pick out all the bits and pieces I needed. I carried my little tray back to Lisa and put a tourniquet around one of her arms. I watched happily as her veins began to swell. This looked quite easy after all. I selected a vein and wiped it with a sterile alcohol wipe. I opened a drip and gripped it with my right hand. The tip of the cannula seemed to be oscillating, and I realised my hand was shaking. Without waiting to think about it any further, I stabbed the needle into her arm. Lisa winced but said nothing. Rather to my amazement, I saw a flash of blood in the shaft of the cannula. I was in a vein. Sweating slightly, but elated with my unexpected success, I eased the needle back towards me, sliding the plastic tube surrounding the needle forwards into the vein. I’m a pro.

BEEP BEEP! BEEP BEEP!

I had only been carrying my pager for 3 days, but already I was aware of its peculiar ability to go off whenever it was most inconvenient. It seemed to know when I was sitting down to eat lunch, or using the toilet, or performing a sterile procedure. I could see the flashing light on the display, but the screen of the pager was obscured by my trouser pocket. This call would just have to wait. I hoped it was nothing urgent.

The next stage was to remove the needle and plug a syringe onto the drip, which I could use to take the blood test. The syringe I needed was sitting on my tray, still in its sterile plastic wrapper. Not good.

“Um…hold still, very still” I told Lisa. Letting go of the cannula with the needle hanging precariously out of the back, I used both hands to open the syringe. Lisa did as she was told, and the needle stayed in place. Having opened my syringe, I pulled the needle out. Immediately blood began to stream out of the hole onto the bed sheet. Fumbling and panicking, I plugged the hole with the syringe. A 4 inch blood stain on the sheet was evidence of my incompetence. Lisa looked at it with polite interest. “Was that meant to happen?” she asked me.

“Oh, yes, actually that’s a good sign.” I told her, improvising. “It means we’re definitely in a vein.”

“Oh, that’s good” said Lisa, apparently reassured. I wondered if she was on drugs.

BEEP BEEP! BEEP BEEP!

I glanced down again at my flashing pager. By contorting my body I managed to catch a glimpse of the screen and recognised the number – one of the surgical wards. Then I looked at my hands in their blood-stained latex gloves, then at Lisa’s arm with the drip and syringe hanging off it. I would just have to finish quickly and answer.

I withdrew a blood sample and swapped the syringe for a plastic cap, in the process leaking even more blood onto the sheet, which Lisa now accepted as normal.

Finally, I picked up the adherent dressing for the cannula and peeled off the cover.

BEEP BEEP! BEEP BEEP!

I didn’t even look at my pager this time. The dressing had stuck to my latex gloves, and I couldn’t get it unstuck. I excused myself and found a nurse to stick the cannula down while I answered my pager.

 

“Hello, it’s the on-call doctor”

“mmm…doctor” said a voice I didn’t recognize. “mmm…can you come up to ward 20?”

I waited for the voice to continue but it did not.

“What for?” I asked.

There was a pause. “Can you come up to ward 20?” repeated the voice.

I was getting a little irritated. “I’m actually quite busy at the moment. I’m just in the middle of seeing a patient in A+E. I’ll get to the ward as soon as I can manage.”

I was going to put down the phone, but the voice stopped me.

“Mmmmm. Doctor, you need to come to the ward now” it told me.

“What’s the problem?” I asked again.

“It’s about Mrs Stevenson” replied the voice pointedly, as if this would make everything clear to me.

“What’s wrong with Mrs Stevenson?”

“Mmmmmmm…” said the voice, in a slightly lowered tone, as if it was about to tell me piece of highly secret information. “I can’t say” it continued. And she put the phone down.

Naturally, the ward in question was at the opposite end of the hospital to A+E. Hospitals are odd places out of hours. My shoes squeaked on the plastic floor as I walked across the empty entrance hall under the modern windmill sculpture hanging from the ceiling, which was slowly rotating for only my benefit. The only sign of life I could detect was the waxing and waning of an electric mop, somewhere out of sight. It seemed oddly peaceful, but I had a presentiment that would soon change.

I cast my mind back to the patients on the ward. I had been there recently, and none of my patients had seemed likely to suddenly deteriorate. A couple of hours earlier, my colleague Hector had handed over his patients to me before leaving the hospital. He had seemed troubled by something, but he told me everything was fine.

I headed for the ward, walking fast but carefully, trying not to break into an undignified trot. Nothing creates panic like the sight of a running doctor. What kind of unspeakable problem was waiting for me? In my head, I rehearsed the list of medical emergencies I had learned for finals. Anaphylaxis, cardiac arrest, respiratory arrest, status epilepticus. But it was a surgical ward, so I should expect a surgical emergency. Pancreatitis? Necrotising fasciitis? An acute abdomen? Whatever it was, how was I going to cope with it? I’d been working as a doctor for less than 3 days. I checked my notebook for the reassuring contact details for my senior colleagues. I would find out what the problem was and then ask them what to do.

I arrived, panting slightly, at the ward in question. I could smell the familiar aroma of faeces and disinfectant, but I could also detect the scent of overcooked hospital food, reminding me that the patients were eating their dinner. I looked around for the urgent problem that couldn’t be communicated over the phone. All the patients I could see seemed well. Drips beeped gently. Hospital knives and forks tapped on hospital plates. A television was blaring out the theme tune to a quiz show. Someone was snoring with impressive proficiency.  An elderly man with a dirty white beard, nicotine stained around the mouth, wearing anti-thrombosis stockings and a hospital gown that gaped indecently at the back, shuffled past me towards the bathroom, wheeling a squeaky drip stand.

Where was the emergency? Where were the nurses? I caught sight of a nursing assistant disappearing into the sluice room and called out. She clearly had urgent business with a bedpan and didn’t stop, but yelled “Constance” at a volume that was impossibly loud, given her petite figure.

Constance was the largest woman I had ever seen. As I tried not to gape in astonishment, she waddled down the ward towards me in what must have been several nursing uniforms attached together.

“mmmm.mmmm… doctor?” I recognized the voice and also the economy of words from my telephone conversation.

“What’s the problem?” I asked, trying to sound irritated rather than scared.

Constance glanced around the ward as if searching for eavesdroppers. A couple of non-descript people were sitting outside one of the side rooms, but no one seemed to be paying attention. Constance was clearly not satisfied.

“Follow me” she instructed, and she set off down the corridor almost touching both sides simultaneously. I followed her involuntarily, pulled along by her gravitational field. She stopped outside a door labelled “store-room” and I followed her in. There was only just room for both of us, along with several boxes of cardboard bedpans, a couple of broken wheelchairs and a portable hoist. I was still thinking about the patient waiting in A+E, and was really starting to lose patience.

“What’s going on?”

“It’s Mrs Stevenson” said Constance, in a hushed voice, indicating the room opposite with the two visitors sitting outside.

“What about her?”

Constance paused. “She’s dead.”

I replayed in my mind the peaceful scenes on the ward when I arrived and compared them with what ought to happen when a patient was found dead. Why was no-one trying to resuscitate Mrs Stevenson? Where were the real doctors?

“Have you called the cardiac arrest team?” I asked.

“Oh, no.” answered Constance.

I started to go out of the room to call them myself.

“No, she was expected to die, and she was not for resuscitation. She was admitted with an ischaemic bowel, and she and her family refused surgery. We were keeping her comfortable. We just need you to certify her dead.”

As she continued talking, my mind drifted off. This was the unspeakable emergency? I thought of the patient waiting in A+E. She was alive (at the moment) and probably in pain. I wanted to be looking after her. And anyway, how was I supposed to certify someone dead? I knew the theory, but I had never even seen a dead person before, aside from the formaldehyde-preserved cadaver I had cut up in medical school.

As my mind drifted back to Constance, she seemed to be concluding her speech by telling me about a different patient who was suffering with diarrhoea. With some effort, I made the mental connection that this other patient needed to be looked after in a side-room to avoid her diarrhoea spreading, and therefore there was some urgency in liberating the side-room being occupied by Mrs Stevenson, who was hovering in legal no man’s land between the alive and dead state and could not be moved to the morgue until I certified her death.

Constance directed me to the room opposite. The two relatives seemed to have left. I put my hand out to knock on the door, but suddenly realized there was no point. Mrs Stevenson presumably was not going to answer. Then again, presumably there was some chance that she wasn’t dead. I knocked gently.

“Come in” said a voice. I jumped. When I entered the room I found a sombre scene. Four or five family members were grouped around the bedside. Some had clearly been crying, others were grieving in a more understated way.

“I’m one of the medical stu…doctors” I stuttered. “I…” I wasn’t sure what to say next.

I’ve come to certify her dead wasn’t right, as it implied there was no doubt.

I’ve come to check whether she’s dead didn’t sound very compassionate.

Had they even been told that she was dead? I glanced towards the bed, with the shrivelled pale figure that only seemed to take up a fraction of the space. People seem to shrink when they die. I glanced back to the relatives. Several sets of red eyes gazed back at me. The silence stretched on until I felt I had to break it.

Suddenly, I had a moment of inspiration.

“Would you be able to wait outside for just a few minutes?”

To my relief, nobody argued, and the group of mourners filed silently out. The last man, as he disappeared out into the corridor, said to me over his shoulder “I hope you do better than the last doctor”. Then, before I could ask him what he meant, the door closed and Mrs Stevenson and I were alone. The last doctor?

The main lights were off, and Mrs Stevenson was illuminated only by the reading light above the bed, which was set on the dimmest setting. It felt like a vigil. The dark, still atmosphere made me shiver, and I reached across and switched on the main lights. For a moment nothing happened, but then the fluorescent tubes gradually flickered and hummed into life, changing the atmosphere from chapel into morgue. At my first glance, I could see that she was dead. There was no colour in her face, and not a flicker of movement. I called her name and reached out to shake her shoulder. She was cold, and I found myself withdrawing my hand as if I had been burnt. Telling myself off, I put my hand back on her shoulder and gave her another gentle shake. Then I felt for a pulse in her neck, forcing myself to wait a full ten seconds before taking my hand away again. I listened to her chest and noted there were no breath sounds and no heart sounds. Finally, I wanted to check whether her pupils would respond to light. Her eyes were closed. Fighting my sense of revulsion, I lifted up her left eyelid. Her eye stared up at the ceiling. She had startlingly bright blue eyes that might have belonged to a child, but they looked somehow cloudy, like a fish eye on the fishmonger’s slab. The pupil did not react to my torchlight. I released the eyelid, and watched it slide slowly down to cover the eye again. It didn’t close completely, and I had to help it closed. The silent room and the cold skin were getting to me, and I couldn’t bring myself to check the second eye. I almost ran out of the room, remembering to switch off the main light again, and ignored the clustered family as I headed back to the nursing station to write in the notes.

When I opened the notes to write my entry, the cryptic comment about the “last doctor” was explained. In slightly shaky handwriting that I recognized as Hector’s, an entry was written at 5pm, a couple of hours before I was called. Asked to certify death. No breath sounds. Silent chest. I can feel a pulse. There was a gap. Unsure if patient dead. Please ask on-call doctor to review later. I remembered Hector’s sweaty and worried face as he told me that he had nothing to hand over and dashed from the hospital, having felt a pulse in a patient with no heart sounds and asked the nurses to call me to review a patient who, deep down, he knew was already dead. I toyed with the idea of photocopying the entry to blackmail Hector when he became a famous cardiologist, but I decided it would contravene patient confidentiality. Anyway, I had living patients to see. I wrote my entry and headed back to A+E.

At 8pm I passed the pager to the doctor who was covering the night shift. She looked smart, and she smelt of freshly washed hair. I was gently self-conscious about my sweaty wrinkled shirt. I handed over the things I hadn’t managed to finish with a pang of guilt, and she was gone with the pager. I sat still for a moment to savour the guaranteed peace, then I gathered my strength and headed towards the door. The main hospital entrance was shut, and I had to leave through the emergency department. As I passed through, I could hear familiar hospital sounds. There was the urgent bleeping of pagers and the routine hum and beep of blood pressure machines and drip machines. I could detect a loud asthmatic wheeze nearby and the more distant sound of retching. A high pitched voice, perhaps a child, cried out in pain.

I walked past these noises, reminding myself that, until tomorrow at least, they were not my responsibility. The sun was just disappearing behind the doctors’ accommodation block. A thin crisp crescent of moon stood out in the faded violet-blue sky and a few scattered clouds were highlighted with disappearing traces of pink. It was a beautiful summer evening and I felt refreshed by the light breeze. I breathed the cool air deeply into my lungs and enjoyed the sensation of stale sweat evaporating coldly from my skin. It was nearly 9pm. I knew that the sensible thing to do would be to head back to my room, grab some food, and get some sleep – I had to be back at work in 11 hours’ time. But my mind was racing, and somehow I knew that sleep would not come easily after the day I had just finished. I headed to the local pub, a regular haunt for hospital staff, where I thought I might find some friends.

Hector was there, with Amy, another medic I knew. I settled in the vacant chair with my pint and a packet of crisps that would be my dinner, Amy had what might have been water, but might have been a gin and tonic, and Hector had whisky. They hardly looked up when I arrived.

“I didn’t know you drank whisky” I said to Hector.

“I don’t” he said. “I’m going to the bathroom”. And he abruptly got up, and walked away unsteadily. It occurred to me that he and Amy had finished work three hours ago, and these might not be their first drinks.

I looked around the pub. I could make out clusters of nurses, some still in uniform. I could see a few people that looked like civilians. Relatives, I thought. Maybe a few patients getting a sneaky pint. Inwardly, I wished them well. Finally, I could see some groups of doctors. These were the seasoned pros. The old hands. The veterans. They didn’t care that they had just seen a dead old lady. They were not fazed by the wounds they had stitched, the vomit they had neatly sidestepped and the urine puddles they had trodden in. They looked relaxed and happy.

Amy brought me back to reality. “You look terrible” she told me. “What happened. Did you kill someone?”

“No.” I paused. “I don’t think so, anyway. It was just a tough day. Non-stop.”

“Don’t worry” said Amy. “Just 362 more days to go”.

My feelings must have been quite apparent, because Amy almost smiled. “I’m on-call tomorrow, so I guess I’m about to find out what it’s like” she told me. “I think it’s time to call it a night”. She got up to leave.

I still had half of my pint. I wasn’t quite ready to leave, so I sat alone watching the others in the pub, and drinking. One of the veterans detached himself from the gaggle and swaggered over to me. As he got close, I recognized my direct boss in the surgical team. For the first time since I’d met him, he looked freshly shaven. His tired and stained tie had gone, and instead he was wearing a fashionable shirt open at the collar to reveal a thick matted mane of chest-hair. A cigarette dangled between the fingers of his left hand.

“How are you doing!?” he almost shouted. “Good work today! Come on over and meet some of the guys.”

I looked over at his group of happy relaxed doctors, and I knew I wasn’t one of them yet. My head was throbbing gently, and I wasn’t ready to pretend.

“Thanks. I’m shattered, and I’m about to head home and sleep. Next time it would be great. Sorry.”

He shrugged. “Sure thing. See you.” And he swaggered away.

I put down my pint glass with the last inch of beer, and went to use the gents. As the pressure of the beer faded away, I heard a familiar sound that reminded me of the wards. Someone was retching in one of the cubicles. I smiled faintly. This time I didn’t need to get involved – it wasn’t my responsibility. As I washed my hands, the retching stopped, and I heard a sound that could be best described as a whimper. I swung the door open to leave and stepped back out into the pub. Suddenly something clicked in my brain. I hadn’t recognized the retching, but the whimper sounded very familiar. And Hector had never returned from his trip to the gents.

I poked my head back into the gents. A gentle groaning was audible.

“Hector?”

The groaning stopped abruptly, and there was silence in the cubicle for a while as Hector considered how to respond.

“Uh – yeah” he said. “Uh – I’ve just been a bit sick. But I’m ok. I just…I’m just…I can’t seem to get up.”

I swung open the cubicle door. Hector was sitting on the ground next to the toilet, with his head at the same level as the bowl. He looked pale green, but he smiled weakly at me. I considered the irony in surviving my first day on call with unstained clothing, and being vomited on by a colleague in the pub after work. Then I put this thought to one side, helped him up, and we staggered back to our accommodation.

“Ian”  he said with drunken sincerity after I had deposited him on his bed. “I’m not sure I can do this whole doctor thing.”

“Why not?” I asked

“You know, I have always been pretty good at exams. In fact, I quite enjoy them. But the worst thing that can happen in an exam is that you don’t pass. But suddenly, we are looking after real people. And the worst thing that can happen if we get it wrong is… When I was asked to certify that woman dead this afternoon I couldn’t do it. I mean, she seemed dead, but I couldn’t get out of my head the idea that I would certify her and she would wake up. Or be buried alive.” He paused. “In the end I just ran away and left you to deal with it.”

“Don’t worry” I told him, with as much authority as I could muster. “You’ll be fine”.

I left Hector lying fully clothed on top of his bed and walked across to my own room in the next block. It seemed difficult to believe that I could feel so physically tired from just one day of work. I stood under the shower for 15 minutes, cleaning off the sweat, the smell of disposable gloves, disinfectant and plastic aprons but most of all cleaning off the cold and shocking touch of death.

After my shower, before going to bed, I stood by the window of my room and breathed in some cool summer air. The sky was now a deep purple colour and some stars were visible. To my left, I could see the entrance to the emergency department. A solitary ambulance was unloading a patient, and I wondered if she would be coming my way in the morning. In the strange illumination from the blue flashing lights, I caught just a glimpse of a pale and wrinkled face with grey hair. It looked suspiciously like Mrs Stevenson.

———-

This is a work of fiction

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