Monday, May 12, 2014

out of the rain

I park the ambulance as close to the EMI unit as possible so we don’t have far to walk in this downpour, but by the time we’ve pulled all the equipment we need out of the back of the truck and jumped across all the puddles in the driveway, we’re soaked.
‘God that’s awful!’
‘Bloody hell!’
We take what shelter we can from the little canopy over the door, until one of the care staff opens up for us.
‘Follow me,’ she says. ‘Stella has a DNAR.’
She leads us through a couple of security doors, then down a corridor with a carpeted floor that gives a little and creaks as we walk. Past closed doors with colour-copied pictures of each resident sellotaped below the number; past the nurses’ station, the sluice, the laundry. Past the games room, where a number of residents are sitting in small groups quietly playing cards or board games, or painting pictures. They don’t look up as we pass.
‘Here we are.’
The carer knocks and shows us in.

Stella is lying on her back on the bed, making feeble, agonal gasps. She’s terribly emaciated, her arms and legs drawn up, all the hollows of her body accentuated, the mortal structure of it, the iliac crest of her hip pushing up beneath a meagre covering of skin.
‘Could we see that DNAR please?’ says Rae. The manager – a small, powerfully-built man with the air of someone more used to receiving forms than handing them out – passes her the red-margined document.
‘Dated and signed,’ he says. ‘As you can see.’
‘Fine. Thank you.’
Stella’s gasps fade to nothing as the arrest proceeds.
‘Shall we sit her up?’ says one of the carers.
‘No. I don’t think so,’ says Rae.
She feels for Stella’s pulse, then takes out her stethoscope and listens to her chest. I stick on some ECG dots and watch the line run flat on the printout, clear and unequivocal.
After a moment or two, Rae says: ‘Stella has died now.’
I write the time down.

Rae questions the staff about the sequence of events whilst I tidy up the equipment and start filling in the ROLE form.
The room is stuffy and foul-smelling. Stella collapsed on the toilet, and the faecal smell, along with the heat from the radiators and the heavy, plaid curtains drawn across the windows, gives the room an unpleasantly closed-in feel.
‘Let’s finish this paperwork in the office,’ says Rae. We leave the carers to clean Stella up, and follow the manager out into the corridor.
He leads us back to the nurses’ station, where Rae rests on the counter to finish up.
‘Would you like a cup of coffee?’ says the manager.
‘That’s very kind, but we’re fine, thank you.’
‘You’re sure?’
‘Yep. Thanks. Almost done.’
The station is just a long, narrow recess with a series of windows along the back that look out onto an overgrown garden. Even though the rain is still coming down hard, there must be a break in the cloud, because the room is suddenly swept with a clear, hard light – so intense, that every detail in the office stands out, like a painting on a broad canvas: the browning tips of a potted dracaena, a black SuperDry jacket and black nylon satchel hanging on a hook; an old style fax machine with a note that says: Feed sheets separately; a drugs company calendar with a cute quote about doctors for May; a shelf above a low filing cabinet with a bag that says in big red letters: Emergency Bag, and underneath, taped to the front of the shelf, another sign, saying Emergency Bag, in blue, with an arrow pointing straight up.
The burst of sunlight passes, and the room becomes dim again.
Rae finishes the paperwork.
She hands him the forms.
‘Thank you. We’ll notify the doctor,’ says the manager. ‘I’ll show you out. You need the code.’
We follow him back along the corridor.

Everyone in the games room is sitting as before, the patients absorbed in their games, the staff encouraging them. One of them looks up from his hand of cards as we pass.
‘Thanks again for all you’ve done,’ says the manager, holding the front door open for us.
It’s pouring outside.
We move as fast as we can, but our gear slows us down. We stow the bags, slam the doors, squeal as we jump in the cab.
But we’re safely out of the rain now, the wonderful, tumultuous rain, roaring and rattling a few inches above our heads, on the roof.


Alan said...

Spence, how difficult are these? Must be awful to have to stand essentially idle as somebody dies next to you.

Wayne Conrad said...

Spence, Good writing here. I like the rain, and the cursing about it, as bookends to the story.

When someone has a DNAR and they arrest, are EMTs always called?

Spence Kennedy said...

Hi Alan.
It is difficult, but then again, Stella was so ill that death was an inevitable outcome. The DNAR is a humane and pragmatic response to that, and gave her a dignified death (rather than the trauma of a resus whose outcome was inevitable).

Wayne - Thanks! Yep - they always call an ambulance. Essentially the DNAR is specifically about cardiac arrest, not treatment, and it's not always clear to the staff at the time what stage the patient is at. It's also about recognising death and administrating the next stage.

It's a little confusing that this is a nursing home. You'd think there might be other ways of dealing - but I think that's probably it. And ultimately, it's protecting themselves against any accusations of neglect / legal action. Easier and safer to have some kind of buffer.

Cheers for the comments!

TomVee said...

Did someone hold her hand?

jacksofbuxton said...

It must go against all your training to just watch over someone dying,but I suppose a DNAR means at least everyone knows where they stand for all that follows.

Spence Kennedy said...

TV - That's a good question. And I really wish I could say that someone did. But for whatever reason, between us all - the carers hurrying around fetching folders and forms and such, the manager overseeing things, us collating the information and making the clinical observations - such a profoundly important, basic human action got overlooked. It's of small comfort that Stella was unconscious and wouldn't have known; spiritually, I think it's still a vital connection to make.

But of course, things don't always go as they should. Rae and I talked about it afterwards. We're both annoyed we let it happen like that, and we're both determined we won't make the same mistake again.

Jack - I think DNARs are a positive development. They avoid a lot of unnecessary intervention, and let people die when they need to. It's a difficult conversation for the clinician to have with a patient in advance, of course, but I'm glad it's happening more often.

Cheers for the comments!