Saturday, January 30, 2010

no

Thomas sr. sprawls on his side on the mattress that his wife and youngest son have dragged into the lounge, his lumpish head supported on a stack of pillows, and on the crook of an outstretched arm that overhangs the edge.
‘God. Oh God.’ His breathing sounds like sacks of gravel being delivered in a cellar.
‘Will you go to the hospital, Thomas? Thomas – will you go to the hospital? Your levels are low, Thomas. They need taking care of. Thomas? Thomas?’
‘What?’
‘Will you go to the hospital?’
No.’
He groans and pitches massively, a bronchitic walrus languishing on a daisy patterned ice flow, tusks and flippers tipped with blue.
We’ve been in the flat for an hour, trying every angle, every point of leverage to persuade Thomas to agree to the trip to hospital, but despite his extremity, his refusal is clear and unequivocal. He had a bad experience at the hospital last year. He won’t be going again.
The pulse ox clip on his finger is redundant. Any fool could read the insidious blue creep up the fingers, the leeching of vitality from the lips and nose and earlobes. He will not have the mask on his face. He will not be doing with the nebuliser. He wants us to go and leave him alone.
‘Thomas. Thomas. Will you go to the hospital? Will you? We’ve called out these good people and you wouldn’t want to be wasting their time now, would you? Thomas?’
‘What?’
‘Will you go to the hospital and get sorted out?’
No.’

His wife, a tidily impatient woman with a voice as bright as a band saw, paces backwards and forwards between the kitchenette and the hairy hollow of his ear. Their son, the focus of a dozen framed photographs on the wall – Liam with his guitar, on stage or in a studio, in jeans or a mortar and gown, his fingers and smile always in place – holds his father’s hand, slapping the back of his wrist for emphasis, tugging at the loose flesh of his upper arm as if his very next move will be to drag his father by main force down the stairs and into the ambulance.

‘Don’t be such a stubborn bastard,’ he says. ‘Come on now. If you won’t do it for yourself, do it for Margaret. Do it for Tommy and me. But for God’s sake, Dad, you’ve got to realise. Your oxygen is way down in your boots, your lungs are shot to hell. You’ve got to go with these people and see the doctors. They’ll sort you out no problem. You’ll be back before you know it. So will you go to the hospital, Dad? Dad? Are you listening to me?’
‘What?’
‘Will you go to the hospital?’
No.’
Margaret buzzes back to the mattress side.
‘Should I call Tommy, then? Should I get Tommy to the phone? Maybe you’ll listen to him if you won’t listen to us?’
‘What?’
‘Shall I call Tommy?’
Margaret turns to us and hooks her tangled grey and black hair away from her face.
‘Tommy’s the eldest. He’s on a skiing trip at the moment. Oh but by Christ Tommy’d give him hell.’
She turns back to her husband.
‘Thomas? Thomas? Have you heard a word I’ve said, Thomas?’
‘What?’
‘Thomas will you go to the hospital with these people and get your breathing sorted out?’
No.’
Liam tugs his father’s arm again.
‘You fucking better go,’ he says.
Margaret gives him a slap on the shoulder and nods in our direction.
‘There’s no call for that now, Liam.’
‘Sorry.’

Rae and I are sitting on the sofa, a stack of kit about our feet – lifting cushions, belts, the resus, drugs and obs bags. All we need is the smallest hesitation, the slightest uncertainty, and we’ll be calling in a second crew to help lift Thomas from the mattress and into a carry chair, down the two flights of stairs and into the back of the ambulance that’s been idling outside the block all this time. Control have made two welfare checks since we’ve been here. Nothing’s moving, nothing’s about to.

‘Thomas,’ says Rae, shifting forward on the sofa and tapping the aerial of the radio on the underside of her chin, as if she were somehow trying to draw exactly the right words to use from the body politic within its range, ‘Thomas – listen to me. You won’t be able to survive on this level of oxygen indefinitely. Something’s got to give, and I’m afraid it’s likely to be your heart.’
Margaret gives a little gasp and puts a hand out onto her son’s shoulder. Liam gives his father another tug on the arm.
‘Will you hear this?’ he says. ‘Will you hear it?’
‘What?’
‘If you don’t come to hospital now, you’re in some danger of having a heart attack. Your heart needs a good supply of oxygen. Without it, it gets tired, and might pack up altogether. You have to understand that by refusing to come with us to hospital you’re putting yourself in danger of a heart attack. Do you understand what I’m saying?’
‘What?’
‘Thomas listen to the paramedic. She knows her job. She says you’ll die of a heart attack if you don’t go to the hospital. Thomas?’
‘What?’
‘Thomas, will go to the hospital? Please? Will you go to the hospital and get your levels sorted out? Thomas?’
‘What?’
‘Will you go to the hospital?’
No.’
She stands up straight.
‘You’ve always been such a stubborn bastard.’
‘Mother.’
‘I know I know. But he has. He’s no different to how he’s always been. Are you, you big old fool.’
‘What?’
She paces back to the kitchenette.
‘Can’t you just take him?’ Liam says for the fifteenth time.
‘If he says no, then I’m afraid we can’t. It’s his decision. I mean – he can’t be thinking all that clearly with his levels this low, but still he seems to understand what’s going on.’
‘Oh he understands all right. Don’t you?’
‘What?’
Liam looks at us both.
‘What do we do now?’
‘We can’t stay here all night. But you can call us back the moment anything changes. And unfortunately, the way things look, that probably means when he goes unconscious and can’t refuse. Then we’ll have him out in no time and down the hospital.’
‘Thanks for coming. I’m really sorry it’s been so difficult.’
‘No worries.’
We stand to go. I start stacking our bags on to the carry chair.
Margaret comes back in.
‘Thomas,’ she says. ‘Thomas?’
‘What?’
‘Will you go to the hospital and have your levels sorted out? Thomas? Will you go to the hospital?’
No.’
Liam helps us with our stuff.

It’s still early in the year, the night has been long and cold, but the sky is appreciably lighter now as the late hour segues into dawn. The stars are bright; a plane glides across the vault of it all like a band of tiny diamonds.

Our relief are in early. We get away on time.

Thomas dies of a heart attack mid-morning. The crew call it on scene.

16 comments:

rheumablog said...

How incredibly frustrating -- and sad -- for Thomas's poor family. It makes you wonder if perhaps he really did know that by not allowing you to take him to hospital he would surely die. Perhaps he wanted to.

Situations like this must be frustrating for you, too, Spence. You're there to help, to heal, to save lives when you can. To be send away knowing that the patient will likely die ... what a horror.

Wishing you serenity.
-Wren

Helen said...

shudder.

Spence Kennedy said...

Hi Wren
I think you're right. I think Thom. had given up and either consciously or unconsciously decided that he'd die at home. Terrible for his family, of course, but there really was nothing we could do with him being so clear in his refusal. x

Hi Helen
Absolutely!

It helped when we heard from the crew that went to him later that day that the wife and son were okay with how things had gone earlier. They didn't blame us at all - they were reconciled to the fact that Thom. had been responsible for how things went in the end. V difficult.

Ambulance Amateur said...

BH Spence. I suppose I'm lucky in that, as a CFR, I've never been to one of those. I've had reluctant patients but never one who has refused point blank.

I had the exact opposite yesterday. I was sent to an abdo pain. Why, I dunno, as I can't diagnose, give pain relief or transport. Still, the number of patients who don't know their chest from their abdomen (or their arse from their elbow!)...

As soon as I walked in the door a woman in PJs said "Please take me to hospital NOW". I had to explain that I can't do transport and had to listen to a diatribe about why the Health Service was not interested in an old lady.

This offended me slightly, as she was only 5 years older than me, and I don't consider myself anywhere near old. :-)

We had to wait 30+ minutes for a crew, but her behaviour told me that giving her a chance to vent at someone diminished her pain.

Once the crew arrived, I made my excuses and left!

Baglady said...

Oh Spence. What lovely writing for such a sad end. To think that one little word could have changed it all. If only that had been what he wanted.

Rach said...

It definitely makes you feel as if he somehow knew and preferred to die at home rather in a hospital bed wires all around him.

No less frustrating for you all the same!..xx

Spence Kennedy said...

Hi AA

That made me laugh! I've been to a few patients like that - ready at the door with a bag, keys in their hand. They always look so incredibly aggrieved when I ask them to go back inside and have a seat so we can see what's going on.

I think living on your own doesn't help sometimes. You can talk yourself up into a real state, without anyone else there to give a more balanced view.

Mind you, having said that, I've been to plenty where having lots of people around has def made things worse, so strike that!

Thanks for the comment. Well done for doing the CFR stuff. Not easy, but def worthwhile...

Hi Baglady & Rach,

I just wish he'd been able to talk to his family about how he felt, to spare them the trauma of that last minute refusal. I completely understand why someone would want to die at home rather than in a hospital resus room, but it needs properly talking through (if at all possible). Palliative care and end of life treatment is pretty good here (could be better, but that's another story - in the news today, btw). I'm sure his GP could've arranged the end so it wasn't quite so awful. But then I suppose life isn't always perfect.

Thanks v much for your comments! xx

Louise said...

Helpless and heartbreaking in the face of the rules on informed consent.

Katharine said...

Brilliant brilliant brilliant. The right handling of a hugely difficult situation and rendered into writing by your usual deft touch. Very moving.

Spence Kennedy said...

Hi Louise
It's difficult when a patient at home refuses to do something which you know is in their best interests. You try everything in the book to persuade them to come, but in the end you're stuck if they say no. I just wish Thom. had been in a clearer position where he could negotiate exactly how he wanted the end of his life to be played out.

Hey Katharine
It was interesting that yesterday night we had another straight refusal: a neighbour called 999 because the guy downstairs had c/o chest pain after a few drinks, then said goodnight and gone to bed. When we got there he wouldn't let us in the house. We had to shout through the letterbox, but no matter what we said, he refused to let us in or have any kind of treatment at all. Nothing we could do - but the neighbour was unimpressed. He seemed to think we'd be able to kick the door in and drag the guy out. (The neighbour was pretty drunk, btw, which didn't help things). Again - v frustrating. But if someone's in their own home, it's a big legal operation to have them taken out (which is reassuring in a way)

Thanks for the comments! Hope you're both well x

lulu's missives said...

Hello Spence,
Gosh, finding it hard to read anything other than text books!
Love the bit "a bronchitic walrus languishing on a daisy patterned ice flow". Beautifully written.
Sorry about the inevitable sad ending.
Hope all is well.
xx jo

Spence Kennedy said...

Hey Jo
I can just see you behind that big stack of text books (reading a magazine) ;)
I must admit that I was shocked to hear our prediction come true just the day after. If only he'd been able to make better arrrangements. Still - a lovely family, so what more can you ask for?
Good luck with the studies. I quite fancy doing something (but what?) There's nothing like a bout of exams to get you fired up!
xx

Anonymous said...

nice post. thanks.

Spence Kennedy said...

Cheers, Anon!

Liz Jones said...

He died at home which was what he wanted, to stay at home. I doubt going to hospital would have changed anything, but maybe his family could have been better prepared .

Spence Kennedy said...

Hi Liz
You're right. But it's like you say - it would've been so much better for everyone if they'd been more preparation. It was terribly traumatic for the family.

Thanks for the comment.