"Don't you ever get scared, working on your own at night?", asked Nina, the patient's de-facto carer. Fair question I thought. My initial instinct is to be a typical man and say that I'm never really scared. But that's a lie. I think that anyone in this job, whether working on their own or with a crew-mate, has at least one moment where the Fight or Flight mechanism kicks in. There's a fear of the unknown sometimes, there's fear when someone pulls out a weapon and threatens you with it, there's fear being in a situation where you just can't see your way out.
My biggest fear, at work at least, is none of these. It's a fear of doing the wrong thing. I can't help over-analysing my actions sometimes, just to make sure that if, given another chance, I would do things the same way, because in this line of work, there is, at least sometimes, no way back.
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Alan is at the end of his wits. He sits at home with his 80 year old mum, Eve. He's there, waiting for the inevitable. The monotony is broken only by scheduled visits from the district nurse who gives Eve her pain-relieving injections. There is nothing more that can be done for her, beyond palliative care, ensuring that her last days are at least spent in some degree of comfort. Somewhere, however, the system has let them both down. No nurse has been now for 24 hours, when there should be a 4 hourly visit. Eve is in pain, and Alan can do nothing about it. He's tried the GP's surgery, he's tried Social Services, he's tried phoning the nurse directly, but realised that she must be away as the ring tone sounded foreign. In sheer desperation, he calls for an ambulance.
When we arrive, Alan is on the verge of tears. "I know I shouldn't have called you. I know that this isn't what you're here for. But I just need her to have some pain relief. She doesn't want to go. She wants to die at home. She's been crying for hours and I just can't take it any more!" He crumples to the floor, ashamed at admitting defeat. He had promised himself that he would take care of his mum, whatever it took out of him, but couldn't cope anymore.
Eve lies in her bed, unable to care for herself, unable to sit up on her own, barely able to convey what it is she wants or needs. She's frail, grey, and has a look that is almost begging for the end to come. The expression on her face, along with the agonised moan, screams for mercy. It's heartbreaking.
Technically, administering prescribed drugs is out of our remit. Especially the drugs that Eve was on, so we phoned for advice. We spoke to one of the on-call doctors who allowed us to step outside of our normal rules, and slowly give Eve some pain relief. Under their guidance, we watched how the medication took effect. The look of relief in both faces was remarkable. We stayed a while longer, ensuring that the medication did what it was supposed to, and that Eve was settled. Eventually the expression changed from one of mercy to one of grateful thanks. Then we went outside and completed a pile of paperwork.
10 minutes later, I'm still writing. There's a knock on the ambulance window. Alan stands there with tears streaming down his face again.
In a barely audible whisper, he chokes on the words as he says them "I think she's gone".
We rush back in to see that the inevitable has indeed happened.
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This was a couple of years ago. To this day I wonder if I brought about Eve's death, or whether I just made a sad ending a little more comfortable. That's my biggest fear. No second chances.
6 comments:
Very interesting post Ben, and thank you for sharing.
I had a similar experience - in hospital. I was aware of the patient, having had a chat with her relatives the previous evening. At about 4am I was called to see her as she was agitated and in pain. The plan, clearly documented in the notes, was for palliation and symptom control only. As she had been given opiates in the previous 24h (and not for over 6h), I felt that a further dose as before would be adequate. She was given the opiate IV and, over the course of 10 minutes or so settled and then became apnoeic.
It was a difficult decision to do nothing, avoid naloxone and just let nature take its course. I've always wondered whether I inadvertantly helped her on her way, or whether I just ensured she was comfortable on her way to a better place.
We struggle with difficult decisions in our jobs. Decisions that others outside the medical profession often struggle to understand. The problem is we'll never know exactly what happened to either of our patients, but we acted in their best interests in order to make them as comfortable as possible.
Ben, my mother was in the same position. And I know that the drugs she was given shortened her life marginally, and I will always be grateful for it, as I'm very sure that she was.
When there's nothing left to do but pray - go for the drugs!
- now THERE's a new motto for the Macmillan Nurses!!
OK, I've just read that back, and it' looks much more flippant and uncaring than I meant it to. I apologise. I did not at all mean to imply that it's an easy decision, or one that should be taken lightly. I'm sure that paramedics, doctors and palliative nurses are constantly weighing up the best thing in every given situation. Just wanted to let you know that from where I sat, as grieving loved one, I knew that the right decision was made, and I never for a second wondered if it would have been better for her to suffer a little longer just to give me another day or two with her. Sincere apologies if that didn't come across in the earlier comment.
Wow, what a piece.
You guys have my utmost respect. I've often wondered how nurses, doctors, paramedics and pharmacists get through their first few years on the job, where sometimes there is really no second chance.
If the drugs did hasten her death why would that have been the wrong thing? Consider if you hadn't given them...maybe she would have lived a little longer? She would have an extra hour or two with her son, her in agony and he in agony too watching her pain. How would that have been better? I don't believe that life should be preserved at any cost, death does not equal failure. Your job is to care for your patient and you did, you obviously still do. You are the right person in the right job and if ever I find myself in that woman's position (or her son's) I hope there are people like you on hand.
During our training as paramedics we are not exposed to a great deal of, if any, information on palliative care.
We rely on our abilities to reassure and make comfortable, to advise and to guide. Any one can quote ver batim from a text book and do the basics required. Our job requires empathy and compassion combined with the the mindset to treat others as you would want your friends and family to be treated. Those qualities Ben, you obviously have in bucket loads...
Another moving entry, nice one.
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