Night

Published by The Missouri Review, runner-up for the Perkoff Prize, nominated for the Pushcart Prize, and recorded at the Harvard T.H. Chan School of Public Health. Descriptions have been changed to ensure that no patient is identifiable.

The sixty-year-old retired policeman with encephalitis is fidgety in his delirium. This is the fourth cannula he’s pulled out tonight. He speaks, but his words come forth from his infected brain at random. I explain that he needs to stay in hospital so we can treat his infection. He says he has to "kettle, back, ranch, knife." That’s not on the cards just now. I place another line. I’d better bandage that, or he’ll pick it out.

I squeeze out of his room to grab some gauze. I’m gone twenty seconds. When I come back, the narrow pink tube I’d slid into his vein has been plucked out and deposited into his drinking cup. There’s a small puddle of blood on the floor.

Next door, a woman has a bad leg. Widespread infection of her soft tissue, cellulitis. She’s also dehydrated, confused, and a tricky customer. Intravenous access attempts by four staff fail, and we persuade the anaesthetic registrar to put a bigger line into a vein in her neck. This goes in eventually, but we need a chest x-ray to make sure the line tip is in the right place. She’s refusing to go to the radiology department for her x-ray. Says she’s been through enough tonight and wants to have the x-ray in the morning. That’s all very well, but she’s tremendously ill and has already lost a lot of time because of the difficulties we’ve had siting the line. She may want to go to sleep, but we’re concerned she may not wake up if we don’t get on top of her infection. Doctors should keep in mind four principles at all times: beneficence, nonmaleficence, respect for autonomy, and justice. In our actions, we should do good, avoid harm, advance individual agency, and act fairly. I err to the view that individual autonomy is paramount. Perhaps I should let her wait until morning for her x-ray?

But you have to be competent to make particular judgments about yourself. To be able to understand, retain information, communicate, and weigh up alternatives to be said to have capacity to make a given decision. I spend five minutes discussing the x-ray with her and get nowhere. She isn’t weighing up the risks: ten minutes’ inconvenience versus progressive, potentially fatal sepsis. I’m not convinced she understands what’s going on. But persuasion is better than coercion. You take steps to avoid coercion where possible, but this conversation is going nowhere.

I ask the on-call radiographer to come to the ward to do a portable film instead of taking her six floors down to the x-ray department against her will. She says this isn’t necessary and would expose her to more radiation for a less interpretable image. My argument, that a mobile x-ray machine might be a pragmatic solution given the obstinacy of the patient and the severity of her illness, cuts no mustard.

Time to stop faffing; this needs to be done. I abandon the bedside and march off to find the paperwork to declare her an "Adult with Incapacity"—the legal framework that in Scotland allows for medical treatment to be administered to people unable to give consent.

Shona, the charge nurse overnight, notices my frustration, and I quickly explain what’s up.

"Right!" is all she says before stalking off into the patient’s room. Two minutes, later a porter comes and wheels her off for her scan.

"She had a change of heart," says Shona with a dash of menace.

I wonder about Shona’s definition of volition, but she’s kindly and a force of the earth, and perhaps her techniques are more persuasive to the fuddled mind than my own. Good job the patient got her x-ray: the central line’s advanced too far into her heart and has to be drawn back before starting the fluids and antibiotics. We get these going, and I scurry away.

I haven’t seen my registrar or the first-year doctor I’m on with for hours. The hospital is full, and there aren’t enough beds to bring everyone into medicine who needs to be there. So we’re admitting patients via the surgical receiving unit and accident and emergency as well as our own medical assessment ward.

I walk toward the kitchen for a mouthful of water and find a man trying to break into the staff cloakroom. He’s looking for the toilet. Thankfully, the door was locked. I show him the way to the lavatory.

In the adjacent bed, a man is lying in the scud. Stark naked, he grins at me. I cover his lower half with a sheet and ask him how he is. He tells me it’s 1967 and he’s on tour with the band. I check his temperature: 38.9°C. Listen to his chest: right-sided crepitations. We’ve dipped his urine already: nothing abnormal. Probably delirium secondary to a chest infection. I check his bloods, scrawl a starting dose of doxycycline, and wish him a pleasant evening.

Back to the triage area. Bloody hell, that man doesn’t look well at all.

He’s groaning and puffing like a wounded bear. I walk over, wash my hands, introduce myself, and lay a hand on his belly. It’s not rigid, but the lightest pressure is exquisitely painful. His muscles clench on contact with my hand. His temperature is high, and he’s not passed wind today or opened his bowels for four. This could be many things: constipation, trapped wind, a perforated or obstructed bowel, an infected gallbladder. He’s coughing a little, and his breath is laboured. I reckon it’s mostly pain that’s restricting his breathing. I ask for morphine to settle him and request an erect chest and abdominal film. A 10-mg dose of morphine barely touches the sides. We give him a little more and hook him up to some fluids. The x-rays are helpful: there’s no air under the diaphragm, so a perforated gut is unlikely. There’s no sign of the bowel being abnormally dilated, which is somewhat reassuring. He’s probably not obstructed. There’s a lot of stool there. Maybe it’s all constipation? What about the temperature, though? His bloods are just back from the lab: liver function all over the shop, and his markers of inflammation are high. The pattern of dysfunction in his liver enzymes suggests an obstructive jaundice. Right enough; maybe he is a little yellow about the eyes. There we have it: obstructive jaundice with sepsis. He’s got an infection running up the ducts connecting his gallbladder to the start of his small intestine: ascending cholangitis. The guy shouldn’t be with the medical team at all. Let’s get him across to the surgeons. I sort his antibiotics and page the surgical registrar on call. He calls me back, and I recognize his voice. Oh, no. It’s the American guy who never helps the medics out. Here we go.

The situation is plain. He agrees with the pathology and has at least a decade more experience than I. He says he won’t come and review the patient. Whatever. At least we’ve got him on the right initial management. We both know this man has been brought to medicine by mistake and will need to be cared for by the surgeons. But the surgeon won’t agree to take over his care without his consultant’s in-person review. Sometimes this sort of practice is fair enough, but here the diagnosis is patent. I suggest that since the surgical firm has fewer patients than medicine and our man needs their care anyway, we should cut out the waiting and get him to a surgical bed now. I get a characteristic response: he’s not in charge of beds and won’t take responsibility for the care of this man overnight. If we move him, we have to manage him remotely. The guy’s pretty sick, so that’s a bad option. This registrar is wasting time. Fine. We’ll keep him in medicine overnight and let the surgical ward fill up with medical patients. It’s not in the interest of the patient, the medical department, or the surgical service to have this bloke in the wrong place, but sometimes if people can’t be persuaded to pull in the right direction, you have to cut your losses.

"All right, we’ll keep him in triage. I’ll see you first thing in the morning, and we’ll anticipate your taking over this man’s care from then. Good night."

I put down the phone hard.

I wonder if things are getting away from us. Lot of spinning plates tonight. I check my list. Better get going. The man with lung cancer has been coughing up blood all day in small volumes. His cancer has started to erode into one of the main vessels in his lungs. Eventually it will wear into the lumen of the artery, and he will exsanguinate: his death will occur by a catastrophic loss of blood into his lungs. There is nothing that can be done to stop it now. He knows it. When it happens, we need to be ready. I write up a single massive dose of a sedative drug called midazolam for use when required. He’s already got that running in slowly to minimise his agitation, but when the horror comes, we’ll enter the room and fill him with it. We’ll cover the floor in dark towels. He will die messily and fast, but if we act quickly enough, he shouldn’t be conscious for more than a few seconds of his final nightmare. I take a few seconds to imagine his fear. Close my eyes and take a breath. Go to the next patient.

They keep coming. Three women with chest pain, one of whom has had a heart attack; the other two have not. An eighty-three-year-old moved down from a small hospital farther north to be investigated for suspected motor neurone disease. The muscles in his tongue fasciculate, he can’t swallow his food properly, his tendon reflexes are brisk. Doesn’t look good for him. Then a man with an asthma attack already stabilised by the team in A&E. Easy. There’s a woman who has been vomiting for the past week, who discharged herself from hospital because her upper gastrointestinal endoscopy wasn’t happening as fast as she wanted. The problem persisted, and she regretted her decision to leave hospital, so we take her back.

By 7am, I’ve not sat to rest for nine hours. We’re almost up to speed. I bleep our medical student and ask for a hand to polish off the morning blood round before the consultant arrives. Outside, it’s snowing. I walk into the one quiet bay where all the patients are still sleeping in the darkness. I press my forehead against the window and feel the coldness of the glass.

The arrest page goes off on my belt. I shove my stethoscope into my pocket and start running. The voice through the pager announces, "Cardiac arrest, ward 7C … cardiac arrest, ward 7C." Up one floor. I thump through the doors into the stairwell and join the medical registrar, who’s running too. A few flights below, I can see the intensive care registrar carrying a big bag of airway kit. We enter the ward, breathing heavily, and grab blue gloves from a dispenser on the wall.

You can tell where the action is by the direction in which people are scuttling. They’re in a bay at the far end of the ward. The curtains have been drawn round the other beds, and a column of bodies is trooping to the bedside in the middle with stethoscopes, a resuscitation trolley, saturation monitors, bits and bobs for putting in lines, worried expressions, and a sense of drama. I join the tail of the line up on the balls of my feet with raised eyebrows—What’s going on?

This woman looks all right, actually. She’s on her back, high-flow oxygen mask on, huddled round by nurses and the daytime medical team, who’ve come into work early. Practically anyone can be made to look unwell with these contraptions of malady around them, but she’s conscious, her vital signs look fine, she’s got a nonknackered medical team with her already, and she certainly doesn’t need resuscitating now.

"Looks like a vasovagal. Nothing to see here, folks. Thanks for coming by."

Fiona, one of the middle-grade doctors on the ward, seems happy to take things forward. Dr Vernon, one of the high-dependency unit consultants, arrives in time for the good news.

"Our pleasure, Fiona. Nice to see you!"

A reprieve. For the wee lady, of course. But also for us. We head back to receiving.

The same consultant who’d hurried to the resuscitation call corners me while I’m trying to arrange for a long line to be inserted for the fidgety policeman. We need a route to give his antibiotics that he can’t pull straight out, and my crafty plan to place a tube out of reach in his foot failed because I couldn’t find a usable vein. If I just get this last thing sorted, I can get away.

"Why does a CT head not help make the diagnosis for this gentleman?"

I look at her blankly through a fog of fatigue and misgiving. What is she talking about? Oh, she’s asking about the guy I’m getting the line for. I fire back. "I think it’s useful. The guy presented with confusion and new word-finding difficulties. We want to make sure he’s not got a bleed, a tumour, an infective focus, or a big stroke."

I wait for the backlash.

"Stroke is a clinical diagnosis. You can’t see anything on most people’s brains on CT so soon after a stroke unless there’s a bleed. Anyway, it’s just his speech which is shot, so the affected area will be tiny." She’s looking at the initial impression of the admitting consultant.

"Yes, but he came in with a high fever as well. We’ve started treatment for encephalitis, and the CT I think was done partly so they could proceed with a lumbar puncture."

"Oh, I see. Well, in that case, maybe it’s fair enough."

The interrogation ends, and she realises I’m from the night team rather than one of the day staff fresh onto the ward. Perhaps it’s the gauntness of my face or the fact that I’m slurring the end of my sentences. Her expression mellows, and she shoos me out of the ward. I congratulate my colleagues on surviving the night and thank the medical student for sticking with us to the end.

I get a high five from Shona on my way out of the ward. I sling my satchel over my shoulder and walk outside, blinking mole-like in the morning.