James Castles

Doctor, Doctor

Novel extract

Prologue

November rains had been lashing London for a week, washing the city’s rubbish into the Thames. On the ward, there’d been a general resignation among staff and patients that the half-hearted autumn was finished. Good. I was ready for this crap year to be over. And I liked the cold.

I’d worked all week, and had picked-up an extra weekend shift—wanting the money, needing to keep busy. Arriving at the hospital on Saturday morning, I discovered I’d also been allocated to the arrest team, so I had emergency responsibilities on top of ward cover. By 5pm I’d responded to about two dozen non-urgent pages, plus four peri-arrest calls (sepsis, internal bleeding, chest pain, and a fruitless search for whoever’d triggered an “assistance required” in the basement outside Pathology). Most of the team were still at another peri-arrest, while I was heading to review a patient who’d had a fall. 

Mee-mee-mee.

My jaw clenched at the pitiless tones.

Mee-mee-mee.

I pulled the pager from the waistband of my scrubs, holding it up to hear the message. The recorded voice of the switchboard operator was grainy and metallic. “Peri-arrest,” it said. “Camden ward, B-Two.” Nausea spiked in my gut. The message repeated three times while I did a one-eighty, hurrying, without running, down the corridor towards the stairwell. An adrenaline surge tried to drown my fatigue.

Entering the bay, I pulled on gloves and took in the scene: a young guy sitting in a wheelchair with an oxygen mask strapped to his face; a nurse crouched next to him; a woman in civvies standing behind them; another nurse going through the drawers of a crash cart. The only other member of the arrest team present was the F1—Jack or Jake or something like that—standing on the far side of the empty bed with a patient file in his hands. He looked up from the notes and actually smiled when he saw me. Naked relief, I assumed, that he was no longer the only doctor in the room.

“What’s the story?” I asked, crouching in front of the wheelchair. The patient’s skin was light brown, freckles standing out on his cheeks.

“He’s asthmatic,” replied the nearest nurse. “He was in the day room and started having problems. We got him in the chair and brought him back, started a nebuliser.”

“When?” I asked, looking up at her.

“I don’t know. Ten minutes ago, maybe.”

“It was almost fifteen,” said the woman in civvies. She was wearing a surgical mask and had one hand on the man’s shoulder.

“Name?” I asked.

“Gabriel,” said both women.

“Hi Gabriel,” I said, eyes flicking back to him. “I’m Isaac, one of the doctors. Tell me, how are you feeling?”

Sweat shone on his forehead, and his wheezing was audible over the sucking hiss of the nebuliser.

“Finding it…”

Wheeze.

“Really hard …”

Wheeze.

“To breathe.”

He was also tripoding, bent forward with his elbows on his knees, hands clasped out front. Bad sign of respiratory distress. My own chest felt tight, like there was a fist around my heart.

“Ok. It’s about to get a lot busier in here,” I said. “But don’t worry about anyone else. Just focus on your breathing. Nice and deep for me, ok?” I gave his hands a squeeze. His eyes met mine before dropping back to the floor.

“Can I have some vitals on this man?” I asked, standing.

It should have been done already. The ward team was in a flap. The nurse next to me sprung up, going for the pulse oximeter, while the one behind me unbundled the blood pressure cuff. Gabriel’s wrists were bare apart from a single small bandage.

“Why doesn’t he have a line in?” I asked.

“It was blocked. We took it out this afternoon,” said the nurse who’d been nearest. Navy smock with white piping—probably the ward sister.

“You,” I said, looking at the F1. “Cannulate him.”

Jack or Jake opened his mouth but didn’t seem to know what to ask. I pointed at the boxy red crash cart and turned back to Gabriel. He was wearing a dark hoodie over a grey t-shirt. I helped the nurse move his arms and get the hoodie off. Her movements were jerky and rushed.

A rip of velcro, then the blood pressure cuff burred and huffed.

I asked the woman in civvies to give us space as I moved behind Gabriel, telling him I needed to listen to his breathing. My stethoscope prodded my ears, background noises muffling and distorting. I pulled up his t-shirt and placed the stethoscope’s diaphragm at a sequence of points on his back, working down, tracing a step-ladder pattern across his spine. I also placed it over his lateral ribs, although I already knew what I was hearing: wheezing at every point and reduced air entry. Not good.

I moved around, pushing on Gabriel’s sternum, guiding him into an upright position in the chair. I listened to his chest: he was tachy, his heart racing to push oxygen around his body. His skin was clammy.

“Other side,” I snapped. Jack or Jake had been trying to nudge past me to reach Gabriel’s left arm for the cannula; the side nearest to the bed. He bumped me as he scooted back. I eased the nebuliser mask off Gabriel’s face, catching a scent of the bitter vapour. His lips were dry and chapped, but I didn’t think there was the purpling that would suggest hypoxia. Not yet. He was getting ten litres of oxygen per minute, along with the asthma medication. I glanced up at the monitor, seeing his oxygen saturation was only ninety-one percent: low, on ten litres.

Gabriel returned to the tripod position—an instinctive pose the body took as it tried to optimise the mechanics of breathing. His notes were on the bed; I picked them up, skimming for headlines. Tones beeped and the blood pressure cuff continued its huffing, burring cycle. Jack or Jake swore under his breath as he tried to cannulate Gabriel. The back of his neck was sunburn-red. I decided to call him Jack.

“What’s he on?” I asked the sister, interrupting whatever she’d been saying to her colleague.

“Paracetamol,” she said, frowning. “And he has a regular inhaler. I can’t remember the—”

“No, the nebuliser. What have you given him now?”

She flushed, and said it was salbutamol.

“And ipratropium?” I asked.

“No.”

“Get it. He needs both.”

She hurried out of the room, passing another nurse who’d just arrived. There was still no-one else from the arrest team.

“How do you know Gabriel?” I asked the woman in civvies. She’d moved to Jack’s original place on the far side of the bed, and was hugging herself.

“He’s my son. Is he going to be ok?” Her voice shook.

“Has he been hospitalised with asthma before?”

“Yes. Many times, as a child.”

“Did he ever need intensive care?”

She nodded. “Two times.”

Shit.

I turned to the nearest nurse. “How long since you put out the peri-arrest?”

He shook his head and said, “I’m not— It wasn’t me.”

“Put out another one. Now.”

I crouched down again, looking at Gabriel’s colour. I thought his freckles were starker than when I’d arrived. The pressure in my chest was increasing. Keep your shit together. This isn’t the same as her. It isn’t.

“Is he going to be ok?” his mum asked me again.

“Can we move you onto the bed?” I asked Gabriel.

He shook his head, eyes down, shoulders rising and falling.

The sister returned, and detached the now-empty salbutamol reservoir from the front of the mask, refilling it with ipatropium solution. The nebuliser kept hissing. Jack, finally done with the cannula, looked at me for new instructions. In baggy scrubs, he looked even younger than he probably was.

“I need an ABG. And rush the results.”

His hands moved towards the venous line he’d just inserted.

“Arterial Blood Gas. New vial. New puncture. In an artery.”

He scrambled up, and started opening drawers on the crash cart.

I told the sister to increase Gabriel’s oxygen to fifteen litres, maxing out the rate. I listened to his lungs again. They were quieter than before: less wheezing, less airflow. Very bad.

“How do I rush this?” asked Jack, holding up a cherry-red vial.

“Do it yourself,” I said. “Go now. Put it the machine. Don’t wait for someone else.”

He left, almost running.

On the monitor, Gabriel’s oxygen saturation hadn’t shifted. In my head, I tried to run through escalatory protocols for asthma, but the situation was hitting the ceiling of my knowledge. A line of tension dragged across my jaw and into my neck.

I bent down again, looking into Gabriel’s face, his eyes wide and scared.

“We’ve got you,” I said. “You’re ok.”

One of the ITU registrars walked into the bay, and I felt my chest loosen, just a bit.

“Whoa, two calls,” she said. “What’s going on?”

She wore neon blue crocs which squeaked against the grey floor as she crouched in front of Gabriel. I tried to remember her name from morning handover, but I’d been tired and not paying attention; I thought maybe it started with D.

“This is Gabriel,” I said, trying not to sound too relieved. “He’s a twenty-four year-old man, admitted with a lower respiratory tract infection. RSV positive on swabs.” She peered at Gabriel’s face. “Twenty minutes ago, he became dyspneic in the family room and was brought here. Given back-to-back nebs—salbutamol and ipratropium—but he’s not responding.” She lifted her stethoscope from around her neck, wincing as it snagged her ponytail. “I think he’s fatiguing. I’m worried he’s developing a silent chest.”

“Why?” she asked, glancing up at me.

“His resp rates have dropped, but he still can’t speak in full sentences. Reduced air entry bilaterally.”

She stood, going to Gabriel’s back to listen to his lungs. Jack returned, asking me where the nearest blood analyser was. We were a long way from A&E.

“This is a resp ward. They’ll have one here. Ask a nurse,” I told him. He left again, almost collecting the med reg, Jelena, as she strode in. D continued her assessment while I answered Jelena’s questions, delivered in one of the Eastern European accents I couldn’t differentiate.

“His lips are cyanosed,” said D. “Were they like this before?”

I bent down, seeing the purpling. “No,” I said. Gabriel’s eyes followed me, and I tried to keep the worry from my face.

“How are you doing now?” asked D.

The word “not” wheezed out, and Gabriel shook his head.

“Can you tell me what you’re feeling?” asked D, her voice taut.

Gabriel shook his head again, bringing his arms up and waving his hands in horizontal chopping motions.

“He wasn’t this bad when I arrived,” I said.

D pushed herself up and moved to the crash cart.

Jack had returned, and he thrust the blood gas print-out at me. I handed it to Jelena. Her expression was neutral as she scanned it. She looked up and asked, “You mother?”

The woman in civvies nodded.

“A lot is going to happen,” said Jelena. “I need you to move.”

Gabriel’s mum took a step back, huddling into the curtain at the head of the bed. A nurse hurried forward, tugged on her elbow, and led her to the middle of the bay.

“I will explain when I have moment,” Jelena said. “Later. Now, stay behind team, please.”

“We need to get him on the bed. Can you?” D asked me as she hunted through the cart’s drawers.

I nodded.

“You, and you.” I said, pointing at Jack and the two largest nurses in the room. “Let’s go.”

The four of us took positions around Gabriel. I lifted him at his shoulders, Jack and one nurse under the knees and buttocks, and the second nurse on the other side of the bed, ready to pull him across. In one tangled heave, we got him onto the bed, as another nurse lunged forward, unsnagging the nebuliser’s line. We brought the bed’s incliner up to its maximum angle, supporting Gabriel’s back as he continued to tripod. I checked the seal around his mask and tried to give him a smile. His breathing was slower and shallower.

As med reg, Jelena was in charge of running the peri-arrest. She led a differential, making sure we hadn’t missed anything else that could have been causing Gabriel’s symptoms. His presentation appeared clear-cut, but it was dangerous to run with the obvious—Jelena’s methodical calm was just what we needed at a time like this. As we spoke, D placed an additional, wide-bore, cannula and administered magnesium sulphate to relax and widen Gabriel’s airways. I squeezed his calves to check for signs of a DVT. The differential discussion took under a minute, discounting a PE, anaphylaxis, or a panic attack and bringing us back to asthma.

“But his PCO2 was normal,” said Jack, referring to one of the ABG results.

“Because he’s fatiguing,” said D. I felt a sick satisfaction—my earlier assessment had been right. Gabriel’s respiratory muscles, fighting for every breath for almost half an hour, were approaching complete exhaustion.

I looked back at Gabriel. Propped up, legs splayed, his skinny frame bony and fragile. I heard a sucked-in sob and turned. His mum had been moved into the vacated wheelchair, which had been pulled away from the bed. Her face mask puffed in and out. Her eyes didn’t leave her son. Curtains hid the bed opposite Gabriel’s; behind them would be another patient, unseen and unheard, but not unhearing. Be grateful, I thought. It’s worse to see it.

Jelena made an announcement, her voice hard and clear. “This is life-threatening asthma. With his history, our threshold to intubate is low. We need to bag him. Agree?”

I nodded, feeling another adrenaline surge. Jelena had sounded even calmer than when she’d arrived. It scared me.

“Agreed,” said D.

Jack didn’t move. He was pale and sweaty.

The new plan was to take over Gabriel’s breathing before he suffered respiratory failure. Intubation equipment wasn’t kept in standard crash carts, so we’d have to wait for a specialist nurse to bring an airway trolley from theatre. The team’s ITU nurse had arrived during the differential, and he now stepped out to call theatre. Still at the bedside, I caught the scent of mashed potato and tomato sauce, which must’ve been the dinner trolley passing in the corridor.

“Do you want me to do the pads?” I asked Jelena, who’d remained at the foot of the bed, overseeing and directing. D was behind her, phone to here ear, as she pre-alerted ITU and asked for more staff. I couldn’t see Gabriel’s mum anymore. I assumed she’d been ushered out.

“Now please, yes,” Jelena said to me.

One nurse cut Gabriel’s t-shirt off, while another repeated obs.

The defibrillator pads were rubbery palm-sized rectangles with wires dangling out of them. I peeled off the backing strips, placed one sticky pad on Gabriel’s right pec, the other, left-side, lateral, lower-rib. Once connected to the crash cart’s monitor they would display the electrical activity of his heart, and could deliver shocks for certain categories of cardiac arrest. I turned to find a nurse ready with the leads from the crash cart. Gabriel had lain back, too tired to hold himself up. I plugged the leads into the pads’ dongles and glanced up.

I went still. His eyes were open, but empty.

“Gabriel?” I asked.

“Gabriel?” repeated D, who’d just returned to the bedside. “Gabriel? Can you hear me?” She squeezed his shoulder.

“Check for pulse.” Jelena’s imperative voice.

D went for the carotid artery, finger to the side of Gabriel’s neck. I went for his femoral. A nurse helped me yank down Gabriel’s tracksuit pants and I put two fingers high on his inner thigh, just below the line of his banana-patterned undies. I pressed, willing there to be a beat.

“No pulse,” called D.

“No pulse,” I echoed, looking at Jelena. Her lips gave a twitch that could’ve been displeasure.

“Sinus rhythm on monitor. This is PEA arrest,” Jelena declared. “Isaac, on the chest.”

I moved.

D pulled the bed’s emergency release and the recliner snapped down with a bang. Gabriel’s body jerked. The whole bed sank to knee-height.

Gabriel’s skin was warm beneath my interlaced fingers. I leaned over him, my shoulders above his chest.

“I’ll get the adrenaline,” called D.

 Elbows locked, bringing my bodyweight to bear, I pushed—a five centimetre depression—then released, allowing the spring-back. Again. Started the count in my head. Again.

“Scribing,” called Jack.

The lyrics of Staying Alive ran perversely in my mind. I used the song to sync my movements to one-hundred and twenty beats per minute, one-hundred and twenty compressions per minute—two per second. Again, again, again, again, again.

Around me, team members vocalised more actions, findings, and instructions. The details didn’t register, my focus tunnelled.

The count, and the rhythmic, brutal motions became my world. It was simple. It was relief.

“Twenty-eight,” I called out, verbalising the near-end of the first set.

Push, release.

“Twenty-nine.”

Push, release.

“Thirty.”

I stopped, but held my position, breathing hard. To my left, the ITU nurse held the bag-valve mask against Gabriel’s face, his hand splayed in an awkward claw to ensure a good seal. With his other hand he gave the soft bag a squeeze. He repeated it once more. Two puffs of air, that was all.

“Compressions,” called Jelena.

I started again.