In the Midst of Life

A LIFE SAVED

Mrs Ratski was taken to theatre within an hour of the ambulance arriving at Slavek’s house, and Mr Carter took the case himself, with the registrar and houseman assisting. The abdomen was incised, and a volvulus was found to be causing the obstruction. Volvulus is the term applied to the twisting of a loop of bowel on itself. The pelvic colon is most commonly involved, and the patients are usually elderly. Manual untwisting of the bowel was performed after deflation of the loop with an aspirating needle, then the gut was examined, and no other abnormality was detected. Gastric suction was continued throughout the operation, and a saline and glucose drip continued. To relieve the pressure on the pelvic colon, a left inguinal colostomy was undertaken, which was intended to be temporary. A colostomy is when a loop of colon is brought out through the abdominal wound on to the skin surface, and retained in position with sutures. An opening is then made into the bowel, and the contents will drain into a bag or bottle.

The operation itself was relatively straightforward, but difficulties arose because of the anaesthetic. The patient was old, undernourished, and in deep shock. Her blood pressure was very low, hardly sufficient to maintain circulation, so cardiac stimulants and oxygen were given. The patient did not have adequate respiratory drive to breathe, so a tracheotomy was performed. The anaesthetist made an artificial opening through the windpipe, and passed an endotracheal tube directly down the trachea for oxygen and gases to be delivered under positive pressure. The gas used was ether, and Mrs Ratski went into an ether convulsion, which is a serious complication. Antidote drugs had to be given intravenously, the gas was stopped, and a mixture of oxygen and carbon dioxide administered instead. The patient was in theatre for three hours, and for most of that time the anaesthetist was battling for her life. Several times the theatre staff thought she had died, but each time the anaesthetist resuscitated her successfully.

Mrs Ratski returned from theatre to the ward. Post-operative intensive care units did not exist in the 1950s, so the ward sister and her nurses took that responsibility. We had been alerted that the patient’s condition was grave, and a small side ward had been prepared. The ward sister received the patient and checked her condition, and a nurse was told to stay with her. There were no monitoring machines in those days. A patient’s post-operative condition was maintained entirely by nursing observation and assessment.

Slavek had been obliged to go to work. He had been told to ring the hospital at midday, and that he could visit in the evening. When he telephoned, he was told that the operation had been successful, but that his mother was still under the anaesthetic. He came to the hospital directly from work, but she still had not regained consciousness. The breathing tube in her throat frightened him, so he asked the sister about it, and she told him that it was only temporary and would be removed when his mother had enough strength to breathe normally. He asked about the blood transfusion entering her arm. What was wrong with her blood? The sister quietly explained that it was normal procedure after major surgery to give blood. An oxygen cylinder hissing away beside her bed alarmed him, but at the same time it reassured him – everything possible was being done for her. Everything would be all right. She was sleeping and looked comfortable, so he slipped away.

On the second evening, he was alarmed to find his mother’s hands tied to the side of the bed. The sister explained that it was necessary, because his mother had tried to pull the tube out of her throat. His mother turned her head and looked at Slavek, her eyes full of anguish, but she could not speak because of the tube in her windpipe. He stroked her hand and kissed her forehead, whispering, ‘You’ll be all right, mother. They know what they’re doing.’

On the third evening the oxygen cylinders had been removed, but the tube was still in her throat, and her hands were still tied. Slavek asked about the tube, and the sister said that there would be a ward round tomorrow, so a decision would be made then. He felt reassured, and told his mother that the surgeon would see her the next day, and that everything would be all right.

But everything was not all right, and we, the nursing staff, knew it.

In the first instance, our patient’s recovery from anaesthetic had been abnormally prolonged. She had not shown any signs of consciousness for more than twenty-four hours, and when she did recover, she seemed excessively agitated. She had attempted to throw herself out of bed, and had to be restrained by two nurses. She tried to shout, but could not make a sound, because of the tube in her trachea, so she tried to pull it out. We nurses had to prevent her from doing this, and we explained that it must stay in place for a few days. Only then did we realise that she neither spoke nor understood English, and it took us some days before we appreciated how difficult this was going to be. She watched us carefully, and when a nurse’s back was turned she tried to pull the tube out again, and had to be restrained. The naso-gastric tube, which was attached to a machine for continuous suction, was another focus of worry. Then Mrs Ratski discovered the blood drip entering her arm, and had a go at that, too. The night sister had ordered her hands to be tied to the sides of the bed, because during the night when fewer nurses were on duty she would have undoubtedly succeeded.

Mrs Ratski lay immobile, hands restrained, in terrified silence. Soundless sobs racked her body, and tears streamed from her eyes. She could not swallow, because of the pain in her throat. Her mouth became completely dry and crusted, and had to be moistened and cleaned every hour, but even so her tongue was ulcerated and cracked. She did not pass any urine, so a nurse had to catheterise her, but she held her body completely rigid, to prevent anyone from parting her legs. Did she think she was being raped? I wondered. Maybe she had been, in a prison camp? A muscle relaxant was injected, which she could not prevent, and the catheter inserted.

The house surgeon, registrar and anaesthetist visited frequently to check her condition. On the fourth day Mr Carter did his ward round. These were always elaborate affairs – the consultant, accompanied by the ward sister, followed by his team of doctors, and another team of nurses who were there to do or get things. It was highly ritualistic, like a visit from royalty. The consultant would go round the beds of his patients, asking questions of the sister, checking notes, ordering another test or another path lab analysis, changing a drug, or the dosage of a drug.

Mr Carter approached Mrs Ratski’s bed. She lay still, her lips compressed, only her eyes moving, as they flickered from one white coat to another. Mr Carter read through the notes. ‘I hear you have had trouble with her, Sister.’

‘Yes, sir. She keeps trying to interfere with the dressings.’

‘That is why you have tied her hands, I suppose?’

‘Yes, sir. It was the only way.’

‘Hmm. Well, we can discontinue gastric suction and start fluids by mouth. The blood drip can be removed after this bottle. That will help you, won’t it, Sister? I can’t give any instructions about the endotracheal tube. That’s a matter for the anaesthetist. Everything else satisfactory, Sister? Urine, faecal discharge?’

Yes, sir. Do you want to see the wound, sir?’

Yes. Get a nurse to remove the dressings.’

I was at the back of the entourage, so I came forward and removed the dressing. Mr Carter looked at it.

‘Hmm. Satisfactory. You can remove one of the drainage tubes, Sister. We’ll take the other one out when we remove the sutures – we’ll have to take her back to theatre when we close the colostomy. You can do that, Ryder,’ he said to the registrar.

Yes, sir.’

‘Well, everything satisfactory, wouldn’t you agree?’

‘Yes, sir, very satisfactory.’ said the registrar.

And they moved on to the next bed. As they went, the tension in Mrs Ratski’s body visibly relaxed.

After the round had finished, Staff nurse told me to assist her in the removal of the naso-gastric tube. The blood had very nearly run out from the bottle, so she removed that also. With the removal of the suction machine and the drip stand Mrs Ratski looked more like a human being.

The anaesthetist came and said that he would remove the endotracheal tube under local anaesthetic. Staff nurse assisted him, and I was told to accompany her. The young house surgeon also came to watch, because he wanted to know how it was done. At the sight of another surgical trolley and several doctors and nurses, Mrs Ratski became visibly distressed. She could not make any sound, and her hands were still tied, but all her body language was that of panic. The anaesthetist took up a syringe of local anaesthetic, and, as she saw the needle approach her neck, Mrs Ratski’s skin lost all colour, and sweat poured from her brow. The anaesthetist retreated. He took her pulse rate.

‘It’s gone up to one hundred and twenty. I can’t proceed like this. She will have to have a general.’

So, for a second time, Mrs Ratski was prepared for theatre and given a pre-med and muscle relaxant. Removal of the tube and suturing of the trachea and outer muscle and skin only took a few minutes, and then the patient was back in her bed.

In the evening, when Slavek called, he was relieved to find his mother’s hands free, and all the machines gone. Her throat was bandaged, however, and she still could not speak; this was due to throat ulceration, which is very painful, but ultimately not damaging.

After a few days she could speak, but we did not know what she was saying. We were able to sit her up in bed, and she could look around at the other patients. Fear and distrust were always in her eyes, and she reacted with dread whenever a doctor came near. We nurses tried to feed her, but she refused; we could not persuade her even to drink.

‘If this goes on, she will have to have another saline drip. She cannot go without fluids,’ Sister said. In the evening when Slavek visited she asked him to try to persuade his mother to drink. But even he could not. He told us that she thought we were trying to poison her, and he could not convince her otherwise. If he brought her drinks and food from outside, she would perhaps take it. So he did, and she drank and ate a little for a few days.

On the seventh day her sutures and drainage tube were removed, and her condition appeared to be stable. On his ward round, Mr Carter said that if all went well the colostomy could be closed on the tenth post-operative day. He was confident of a complete recovery.

In the early hours of the ninth day, the night nurse reported extreme restlessness, and signs of pain and distress. The night sister went to the ward and found Mrs Ratski doubled up in pain and moaning piteously. Her pulse was rapid and her temperature high. The abdomen was examined; it had become rigid again. Whilst the night sister was present Mrs Ratski vomited copiously and effortlessly, without retching. Sister was alarmed and called the house surgeon. The time was 5 a.m., and when he arrived only ten minutes later, symptoms of shock were very apparent, and her temperature and pulse had risen again. It all happened very quickly. The patient vomited once more, a green, bile-stained fluid, in a projectile fashion.

The registrar was called and a quick examination was all that he needed.

‘This is another obstruction. Acute abdominal dilation with fluid and gas could be due to a paralytic ileus. We’ll have to get her to theatre at once. I’ll speak to Carter – and Sister, you alert theatre for an emergency abdominal.’ He turned and spoke to the houseman. ‘Give her a good shot of morphine and get naso-gastric suction going straight away. We will probably need more blood, but have some serum ready until we can get into the blood bank.’

The registrar was at his best in an emergency – quick, confident, decisive, and, above all, commanding. He performed the operation himself. Part of the intestine was found to be paralysed and dilated with gas, and the area of the original volvulus had adhered to coils of the large intestine and showed signs of gangrene. The sigmoid colon and the rectum were removed, and the rectal orifice closed. The colostomy, which was intended to be temporary, was now permanent.

When Slavek visited in the evening he found his mother in the same position as she had been nine days before. The only difference was that she did not have a tracheotomy and endotracheal tube. He was deeply distressed. What had happened? He was simply told that his mother had had to go to theatre for further surgery.

Nothing went right after that. The old lady was in a pitiable state. Two major operations and anaesthetics at her age took their toll. For two weeks she barely clung to life, but we kept her going. The gastric suction was continued for three or four days, and the drip for about a fortnight. Drugs were given by injection, because she would not swallow them. Her abdomen again filled with gas, and a trocar and cannula was thrust into the peritoneal cavity to release the gas. This was done under local anaesthetic and she was too weak to resist. Her mouth, tongue and throat were massively ulcerated long after the naso-gastric tube was removed. The self-retaining catheter had to be changed for cleansing, and she tried to resist, but was too weak to do so effectively. A urinary infection developed, so drugs were given to combat it.

Then she developed a chest infection, so more drugs were ordered – all of which were injected. Her cough reflex was inadequate, so a physiotherapist was called in to stimulate coughing by use of exercises, palpation and postural drainage. Her heart was compromised by her weakened condition, so cardiac stimulants were given. She had been in bed for so long that she developed bedsores, which we treated two-hourly but could not prevent. The abdominal wound, after the second operation, looked as if it was never going to heal and, together with the colostomy, exuded such a foul smell that it was sometimes difficult to go near her.

Doctors came and went. They tapped her abdomen, listened for abdominal sounds, and conferred over their findings and differing opinions. They took samples of blood for path lab reports on haemoglobin levels and white cell counts; took more blood to measure the electrolyte balance; ordered sputum and urinary analysis; probed orifices; and discussed erythrocyte sedimentation rates.

They came and went, and, as the weeks passed, they came less and went more quickly. In my experience, consultants, and particularly surgeons, kept an invisible barrier between themselves and their patients. Before and during the operation their professionalism could not be faulted. But once the post-operative stage was reached they became more remote. The house surgeon, the most junior of the doctors, was the only one who spent any time with our patient.

But, in fairness, there was nothing more that they could have done. They had twice, by emergency operation, rescued Mrs Ratski from certain death. After that, it was up to the nursing staff to help maintain life. And this is what we did, day by day, hour by hour.

One of the most distressing things to witness was her fear of us. Nurses do not usually inspire fear. We asked Slavek if he knew why she was afraid, and he told us that she thought she was in a prison camp where the Nazi doctors carried out forcible experiments on human beings. He tried to reassure her that she was in an English hospital because she had become very ill, and that we were making her better, but it made no difference. She was convinced that we were conducting experiments on her and pointed to her stomach.

‘Look what they have done to me. They have cut me up and pulled my insides out (she pointed to her colostomy). They have interfered with my private parts; it is too terrible to say what they have done. You wouldn’t believe it if I told you. They cut my throat – you saw it. No, my son, this is a medical experiment, the work of the devil. They have no heart, no pity, no soul. They are machines doing the work of the devil.’

Mrs Ratski was tough, both physically and morally. She had lost almost all her menfolk in wars and insurrections. Political conflict had been her only experience of life, and she had kept going through it all to keep the nucleus of her family alive. During the Second World War she had been in one of the many prison camps, where she must have endured cold, starvation and cruelty. She had been surrounded by death, but somehow survived.

In hospital, she lived through two operations and began to recover; but with increased strength she became more resistant to our efforts to nurse her. She fought us whenever we came near her, even for benign things like bed making. We tried to give her drugs by mouth, but she hit us and spat at us and knocked them to the floor, so the doctors ordered that drugs be given by injection. This required three nurses – two to hold her down, one to inject. She screamed and shouted what was probably abuse at us, then hit us as soon as she could. She tore off her abdominal dressing, and the colostomy bag; she even managed to pull out the self-retaining catheter. We were at our wits end to know what to do, so paraldehyde was ordered. This was a colourless fluid with a distinctive and revolting smell, which emanated from the patient, and could be smelled for a wide area around. We nurses hated having to inject it, because such a large quantity had to be given with a wide bore needle, thrust deep into the muscle. It certainly sedated the patient, but seemed to have peculiar properties, and I wondered if it was hallucinogenic. When the effect of the drug wore off, after about six hours, patients were often wildly excitable and disorientated.

Mrs Ratski had been in hospital for five weeks, and during that time I became increasingly troubled. When the paraldehyde started, I could not contain myself any longer. I blurted out to the staff nurse, ‘Why are we giving her this stuff?’

‘Because we have to be able to control her.’

‘But it’s mind-bending! People aren’t the same after they have had it.’

‘I know, but we have to give it.’

‘Why?’

‘You are not here to ask questions, Nurse. You had better speak to Sister, if you are worried.’

‘I am worried, and it’s not just the paraldehyde that is worrying me. It’s everything.’

It took a lot of courage to speak to Sister. The nursing hierarchy in those days was such that a junior student nurse couldn’t speak to a ward sister unless spoken to first, so I asked Staff if she would intercede for me.

A couple of days later, as I was going off duty, Sister called me back.

‘I understand you are worried about giving paraldehyde to Mrs Ratski, Nurse?’

‘Yes, Sister, and lots of other things, too.’

‘What sort of things?’

‘Everything, I suppose. Her treatment, the operations, the drugs, like cardiac stimulants, antibiotics –just everything…’

The severe aspect of Sister made me so nervous that I could not continue.

‘You are not criticising the treatment Mrs Ratski has received in this hospital, I trust?’ The words were delivered in such a way that they sounded more like a threat than a question.

‘Oh no, Sister,’ I said hastily, feeling foolish.

‘Good. You may go off duty, Nurse.’

A few days later, in the middle of a morning’s work, when all hands were needed to cope with the volume of duties we had to finish before lunchtime, Staff came up to me and said, ‘You are to report to Matron’s office at once. I will take over your work here.’

In those days, the matron of a hospital was a very powerful and influential figure, and most of them were quite outstanding women with remarkable minds, and great character and moral standing. A good matron knew everything that was going on in her hospital, and had her finger on every pulse. She had a prestige and authority that is quite unknown in nursing today. Many a consultant surgeon had been known to quake in his shoes if he received a message requiring him to report to Matron’s office – a junior student nurse might collapse on the spot. Miss W Aldwinkle, OBE was in the top rank.

But I was not afraid. In fact, I was relieved. I had been called to account for myself once before, in an altercation with a consultant who had pushed me, and I had gained the impression she was a wise and understanding woman. I felt I could talk to her in a way that I could not talk to the ward sister.

I approached her door and knocked. ‘Please enter,’ a voice called.

It was a large and beautiful room, in a fine Victorian building that overlooked a spacious courtyard.

‘Sit down, Nurse Lee. I understand that you are worried about the treatment given to Mrs Ratski?’

‘Yes, Matron.’

‘What exactly worries you?’

‘It is hard to put into words. What concerns me is the amount of mental and physical suffering we have put her through. But I think it’s more than that, really.’

‘We always meet suffering in hospitals.’

‘Yes, but this has been inflicted by us.’

‘She would have died if she had not come to hospital.’

‘But what is so wrong with that, Matron? My grandma died a few years ago, and no one thought it was wrong. She had a heart attack and just died. My grandad and my mother were with her. She didn’t have to go through the weeks of suffering Mrs Ratski has endured.’

Matron looked steadily at me in a way that encouraged me to continue.

‘Mrs Ratski knew that she was going to die, and she travelled all the way across Europe in order to see her son.’

‘Yes, I know the story.’

‘So why couldn’t she be left to die in peace, like my grandma did?’

I was only eighteen, and my mind was in turmoil. Vague and disconnected thoughts I barely understood myself came tumbling out.

‘What’s wrong with dying, anyway? We’re all going to die. If we are born, we must die. The road always goes in one direction. There are no alternative routes.’

Still Matron said nothing. I was getting so worked up I had to stand and walk around.

‘You don’t know what that poor old lady has been through, Matron. I do. I have been there day, after day and her suffering has been awful. Simply awful.’

‘I know the extent of her suffering.’

‘And it is all so futile. What has been the purpose?’

‘Mrs Ratski is alive.’

‘But what sort of life is this? We have turned a vigorous, healthy old lady into a pathetic invalid. She will never recover properly. And it may be that her mind has been damaged. She knew what she was doing before she came to us. Now she doesn’t.’

‘Sit down, Nurse.’

Matron rang a bell and a maid entered.

‘Would you fetch a pot of tea and two cups, please, and some biscuits?’

‘Yes, Matron.’

Matron looked at me and sighed.

‘I can see you are upset, Nurse, and you raise questions I cannot answer. Nobody can. When I was your age, I was a young nurse in the war working in France. Death was all around us. Millions of young men died in that war. Millions. Yet I remember one who came to us with his face blown apart by an explosion. Where his nose, mouth and chin should have been there was just a great, bloody hole. Still, he was alive, and his eyes moved, and his mind obviously worked, though he could not speak because he had no mouth or tongue. The surgeons patched him up; they grafted skin over the shrapnel wound, and he recovered. But he had been a handsome young man, and was now left with two eyes and a ghastly-looking hollow with a hole in it, and a tube in the hole, so that liquid foods could be passed into his stomach.’

It was now my turn to gaze at her without speaking.

‘I was about eighteen, and like you I thought: “Why have they done this? Surely life with such a face, if you could call it a face, is worse than death.”’

I did not know what to say. There was a knock at the door and the maid entered with a tray.

‘Thank you, Bertha. Put it here, please.’

Matron poured tea.

‘These are deep and terrible subjects, Nurse, to which there can be no answers. I know you are upset, and I understand.’

‘That is a terrible story, Matron. I would not want to live with a face like that. What happened to him?’

‘He lives in an ex-servicemen’s home. He cannot live in the community, because everyone stares and points at him.’

‘So he is still alive! Is he happy?’

‘I do not know. He seems content – he is a gardener, and gardeners are always happy people. And he has a dog. When I was your age I thought as you do. You have just said: “I would not want to live with a face like that.” But I very much doubt if that man would say that he would rather be dead.’

‘But he was young, and he had a whole future in front of him, even with such an affliction. Mrs Ratski is old, she has come to the end of her life. She said she was going to die; she achieved what she wanted to do, and then said she was content to die. The obstruction in her intestines would have meant her suffering would have lasted only a few hours, and she would very likely have died in her son’s arms, like my granny died in my grandad’s arms.’

‘But the medical and nursing professions cannot allow anyone to die, if it can be prevented.’

‘But who are we doing it for? For the benefit of the patient, or the benefit of the medical profession? We say that the welfare of the patient comes first, but I am not so sure. The practice of medical skills and techniques seems to come first.’

‘I am certain that Mrs Ratski has been treated for the best of motives – to preserve life.’

‘But for the rest of her days she will be a decrepit old invalid who will be a burden to everyone!’

‘Human life is precious.’

‘And human death is sacred. Or at least it should be – and would be, if we allowed it to be. In the short experience I have had, sitting with the dying, I can say that the last few hours are always peaceful, almost spiritual. Wouldn’t you call that a sacred time?’

‘Yes, I agree, Nurse, and I have had thirty-five years of nursing experience. I don’t really know what is meant by the term “death agony” because I have never seen it.’ She paused and thought, then added, ‘Perhaps, in a few people, I have seen what can be described as a struggle with death, and it can be distressing to behold. But for the vast majority of people death is gentle, tender.’

‘Well, it’s not like that for Mrs Ratski. The agony has been going on for five or six weeks, and it will continue. She has been deprived of a gentle death.’

Matron said nothing, but I blundered on.

‘She thinks she is in a concentration camp, you know, and that we are using her as a guinea pig. She can’t understand what we are doing, or why. She is terrified all the time, terrified of us.’

‘Yes, I know. That is something no one could have anticipated.’

‘But she has lived in fear, Matron, for weeks. It is tragic, terrible. I can’t bear to see it.’

I was getting tearful, and had to stand up and walk about again. ‘And there’s another thing. All these injections she’s having. Dozens of them, daily. And now we’ve started paraldehyde. It’s mind-bending, Matron. It replaces one madness with another, different sort of madness.’

I walked the length of the room and back, then sat down.

And there is another thing that worries me, Matron. All this business about “she must have”. It is written in her notes. “If drugs are refused, to be injected.” And we, the nurses, have to inject them. It seems wrong.’

A nurse must obey medical orders.’

‘She does refuse drugs, all the time, so we hold her down and inject them. Isn’t that assault? And who commits the assault? The doctor who orders it, or the nurse who does it?’

‘I cannot answer these questions. Perhaps a lawyer could, but I doubt it. If life-saving drugs are to be given, they must be given, and any court of law would uphold the medical necessity to save life.’

‘Well, I don’t agree with the law!’

‘Nurse, you are young and passionate. You are trying to understand a subject too deep for understanding. Death used to be as you have described it – your grandmother had a heart attack and just died in her husband’s arms. That is how it used to be for the vast majority, but not any more. Medical science has found hundreds of death-defying tactics, and, as this century unfolds, thousands more will be available to us. We do not know where it will end. Perhaps we will come to a point when human beings are unable to die.’

‘That is a frightening thought, Matron.’

‘Yes, it is.’ Matron stood up, all four feet eleven inches of her, indicating that the interview was over.

‘I advise you, Nurse, not to talk too freely with other people on this subject. You will not be understood. In fact you may be positively misunderstood. All sorts of sinister interpretations could be drawn from your remarks. It is a dangerous subject.’