In the Midst of Life

LAZARUS

The wound in Dr Hyem’s chest was sutured under local anaesthetic, the broken ribs realigned, and the chest bound, to keep them in place. We then raised him to a semi-recumbent position and changed the bed linen. Oxygen was directly entering his lungs, so his colour was good, and the cardiac machine maintained his heartbeat. Fluid was dripping into his circulation, and drugs were introduced to raise the blood pressure, to stimulate the heart muscles, and to thin the blood; antibiotics, a clot-buster and diuretics completed the cocktail.

The registrar and his team were exhilarated by their success. They had saved a life, and that’s what medicine is all about. Lazarus had been raised from the dead. It was a miracle of modern medicine.

The team prepared to leave, all of them exhausted. By then it was 3 a.m., but adrenalin had been pumping through their bodies and now they were worn out. The registrar apologised for his rudeness. ‘It’s the tension that gets me,’ he said. ‘I’m not aware of it. I snap at everyone, they tell me.’ He left with instructions about monitoring the cardiac, pulmonary and blood pressure responses to the machines, and the adjustments that should be made in the event of physical changes.

Dr Hyem breathed quietly all night. His pulse and blood pressure were steady. The drip dripped, the oxygen hissed, the cardiac machine hummed quietly, and the twenty or more men who had been awake during the commotion of the night fell asleep as dawn was breaking.

I had many other duties to attend to in the hospital, but stayed with Dr Hyem as much as possible, and, as I looked at him breathing quietly, I began to feel ashamed of myself. He was alive. Why should I have wished the old man dead? It was unworthy of me; wicked even. He was alive due to the miracles of modern medicine. Nearly twenty years had passed since I had started nursing and everything had changed, scientific advances in drugs, surgery, in technology. I was old-fashioned, I told myself, and must embrace these changes.

At 6 a.m. I started my morning round of the hospital. It was still dark, but the return of day could be felt in the air – sleepy sparrows began to chirp, an early morning milk delivery could be heard in the streets, the first kitchen workers were arriving. As I finished my round, light was returning, and the fears of the night, enshrined in all our fairy tales, were receding. Had the darkness played its part in exaggerating the terror I had felt for Dr Hyem, I wondered?

By about 7 o’clock I had finished the morning round and was able to return to Dr Hyem. The registrar was there before me, checking the dials and drips, listening carefully to his patient’s heartbeat and lungs, taking a sample of blood for path lab investigations.

‘I owe you an apology.’ I said, ‘I doubted you.’

‘No, no, not at all. It can be pretty scary, but as you can see, it can be successful.’ He held out his hand towards Dr Hyem, who looked peaceful. ‘Not every attempt turns out as good as this one. In fact, if I’m honest, most fail. But it’s worth having a go, just to get a result like this.’

He continued with his checks and adjustments, saying as he did so, ‘New techniques for resuscitation are being pioneered in America. Some of our teaching hospitals are using them. Statistically, they are more effective. I would like to try them myself, but we don’t have the equipment here in this backwater.’

He’s a good man, I thought, and a dedicated doctor. He can’t have had more than a couple of hours’ sleep, but still he felt the need to see his patient before starting the day’s routine.

He patted Dr Hyem’s hand. ‘Well, you’re doing nicely, Dad. I’m pleased with you. We’ll have you running around again in a few days. I’m off to get some breakfast now, and I’ll come in and see you later in the day.’

As he left he said, ‘I’ve got a morning in theatre. Tell Sister Tovey I’ll be here around lunchtime.’ Then to Dr Hyem, ‘Doing nicely. You’re doing well. Keep it up.’

Such energy, such confidence, is invigorating.

Sister Tovey, the ward sister, to whom I gave the night report, felt differently. She was a woman about twenty years my senior and was nearing retirement. She had been nursing throughout the war, with two years spent in Egypt, receiving casualties from the fighting in North Africa, a great many of whom died for want of adequate medical attention. She was a woman of vast experience and few words.

‘Dr Hyem told me he wanted no resuscitation,’ she said.

‘He told me that also.’

‘And he told the cardiologist. I know, because I was there at the time.’

‘It must be recorded on his notes, then.’

Together we looked, and there, written quite clearly on about the fourth or fifth page, were the words, ‘In the event of cardiac arrest, do not resuscitate.’

‘I suppose they didn’t see that,’ I muttered.

‘More likely didn’t look! These resuscitations have to be carried out at lightning speed. There’s no time even to think. Just get on with it, that’s the message. I don’t like it. Not a bit.’

‘Well, he’s alive,’ I said.

‘What for?’ she demanded.

The question seemed callous. But was it? Or was it realistic? My first doubts, momentarily dispelled by the registrar’s breezy confidence, returned. I did not reply.

‘What for, I say? Congestive heart failure? Renal failure? Liver failure? I must speak to the cardiologist about this. I don’t like it.’

‘Well, he seems to have recovered and his condition is stable. There is nothing more I can say or do. I’m worn out. I must go home and get the children off to school. Then I must go to bed.’

We parted, and my mind was in turmoil as I drove home. The events of the night were screaming in my poor tired brain. Had it been a triumph, or a tragedy? The registrar’s confidence and Sister Tovey’s doubts were struggling with each other. That dreadful cry, like all the ghosts and ghouls of Hell, kept sounding in my ears. But it was probably not a conscious cry, I told myself, just the involuntary emission of residual air in the lower lungs escaping through slack vocal cords. He was alive, and his condition stable, that was the main thing. One should not drive after a night like that, when the mind is in such a state. It was surprising I did not have an accident.

The children restored my equilibrium. I defy anyone to get too serious when there are children around. Their laughter, their squabbles, their endless questions, their intense passion if a crayon or a book is lost, flying around the house to get a pair of gym shoes – all these little things brought me back to normal. We ate breakfast together, and I found, to my surprise, that I was hungry. Then there was a knock at the door, and a little friend arrived, then another, and the girls raced off together to the primary school down the road. I went to bed and slept, reflections on life and death eclipsed by the vitality of children.

Dr Hyem did not die, but he did not live, either. His heart had been in failure for a long time, and now all his vital organs began to fail too. The slow gradations of decay set in.

Failing circulation, caused by a congested heart, creates ‘back pressure’, affecting all the organs of the body. In Dr Hyem’s case it caused congestion of the lungs, so he had great difficulty in breathing. Fluid collected in his lower lungs, creating a bubbly, rasping sound with each breath. The fluid became infected and pneumonia developed, which was treated with antibiotics.

The back-pressure from inadequate cardiac output puts added strain on the kidneys, which were struggling to excrete the body’s waste products. Uraemia, or blood poisoning from renal failure, was kept at bay by intensified doses of diuretics.

Back-pressure put new strain on the liver, already grossly distended and striving to cope with the rising acidosis caused by diabetes. The pancreas, the gall bladder, the intestinal tract – all of them were congested.

Back-pressure forces fluid to leak out of the arterioles, the smallest blood vessels, into the surrounding tissues. They become waterlogged, a fluid swelling known as oedema. Ascites developed in the abdomen. Dr Hyem was totally bedridden. He sat there, day after day, with his legs, thighs, buttocks, scrotum, and belly swollen with oedema and ascites. However hard we tried, bedsores could not be prevented.

Had back-pressure affected his brain, or was it something else? Dr Hyem hardly spoke during the last weeks of his life. When he did attempt to mumble a few words, they were slurred and barely audible. His eyes were usually closed, but when open the pupils were dilated and fixed. The resuscitation, although quick, may not have been quick enough. Small areas of the brain may have been starved of oxygen and died during the minutes that had ticked by during resuscitation.

All the medical staff in the hospital took a great deal of interest in Dr Hyem, for open-heart resuscitation was a sufficient novelty in a small suburban hospital in the 1960s to attract attention. The registrar who had led the team became something of a celebrity. The staff all crowded around the bed, studied the notes, and regarded the machines and dials and drips with scientific interest. The cardiologist spoke to the lung specialist, the urologist to the gastro-enterologist, and the diabetic specialist to the dietician. They took brain scans (EEGs), heart scans (ECGs), recorded blood count and electrolyte balance (electrolytes were all the rage at the time), took X-rays of his chest, aspirated his lungs, measured his insulin levels and the mounting acidosis in his blood, changed his drugs, increased the changes, tried new drugs, changed them again and increased them again. They held special meetings to discuss the case; they could not have done more.

But, as the days stretched into weeks, the doctors visited less frequently and departed more quickly. Did they just lose interest, or had the passion for progress spent itself? Was there no more scientific or biochemical excitement to be gleaned from Dr Hyem? Doctors tend to regard a dying patient as a personal failure, and frequently withdraw if the process goes on for too long. Dr Hyem was dragging on and on. Perhaps the reality of a slow, lingering death was more than they could stomach.

The doctors made all the decisions affecting the physical condition of Dr Hyem, but they did not see the details of what this would entail: the reality and the humiliations endured by Dr Hyem were witnessed only by the nursing staff.

Daily hourly we treated bedsores that developed quickly because of immobility oedema and a watery diarrhoea that poured from him in the early days. The sores quickly became great, stinking holes, which we packed with flavine but which became black around the edges from lack of blood supply. The diarrhoea cleared up, and chronic constipation replaced it, which aperients and enemas could not shift, so a nurse had to remove, manually, lumps of impacted faeces from his rectum. When I read that in the day report, I hoped fervently that Dr Hyem’s sensitive mind had been so damaged that he was not aware of what a young nurse was doing to him.

Spoon-feeding a little semi-solid food was always difficult, and was frequently regurgitated, trickling out of the corners of his mouth, over which he had no control. The amount of food and fluids and the quantity of glucose in the drip had to be monitored all the time, and balanced against his insulin injections to control his diabetes.

His breathing was always laboured and painful to see. His cough reflex was seriously depressed and he could not bring up the sputum that collected in his lungs. A frothy exudate bubbled from his mouth sometimes. A physiotherapist came in to try to help him to cough by palpating his chest, but this caused so much pain to his broken ribs that the idea was abandoned. With stagnant, infected fluid in his lungs, his breath became foul smelling. Pleural aspiration was ordered to drain off some of the fluid and a cannula was inserted into his lower lungs, and a little watery stuff drained away. This relieved the pressure for a while, but it did not halt the accumulation. It seemed that Dr Hyem would drown in his own bodily fluids.

A catheter was in place all the time, and this avoided incontinence of urine, which would have made the bedsores worse, but it had to be changed every few days, and kept clean, which was unpleasant and possibly embarrassing for Dr Hyem. Unless we cleaned his mouth every two hours with glycerine, his tongue became so dry that the skin peeled off, and ribbons of grey, stringy stuff could be pulled from his throat.

The doctors saw none of this. Junior doctors sometimes get an idea of the suffering and humiliation that patients endure, and what nurses do, but a consultant seldom does. The more senior a doctor, the less he knows of the unpleasant details. None of this will appear in medical textbooks, which are written by academic and scientific medical experts, who spend much of their time in laboratories and libraries. Only nurses are at the bedside. And nurses don’t tell.

The end came for Dr Hyem because his renal failure and longstanding diabetes could no longer be controlled, and acidosis developed over a few days, first with abdominal pain, and a decreased volume of urine. Then his blood pressure dropped and his pulse became thin and rapid, his ocular tension was low and his skin became very dry. The doctors decided not to attempt treatment, and he drifted into a diabetic coma from which he could not be roused.

Dr Hyem died peacefully, five weeks after a successful resuscitation from cardiac failure.