Stephen Bridger

I am not meant to start until Monday but Reuben, my new boss, invites me to cover the weekend. I can not refuse.

I don’t articulate any reluctance on my part but I have misgivings. I have never worked here before. I have had no induction. I don’t know where things are or should be. I’m as frightened as the poor sod who fate decrees will be my first patient. He’s in the Surgical Admissions Ward – SAW for short – an acronym as bizarre as it is apposite.

“I’m Dr B,” I say. “And you are?”

“Peter Elroy.”

“Can you tell me what happened?”

“Woke up, felt sick as if I’d eaten something dodgy. Sat up, and then my head went... swimmy, you know. Made it to the bathroom. Threw up and there was blood in the pan. Loads of it.”

“And this happened at what time, exactly?”

“Half seven. Quarter to eight’ish maybe.”

“Have you been sick since?”

“No, but I feel a bit.”

“Anything like this happen to you before?”

“Never.”

“Are you taking painkillers – Aspirin, Brufen, anything like that?”

“No.”

“Any other medicines?”

“Inderal, a beta blocker, for blood pressure.”

Mr Elroy’s systolic hovers around the hundred mark. His pulse is eighty but that could be down to his Inderal. He isn’t shocked – well at least not in terms of current physiology – but he looks dreadful. When I reach across to check his pulse, his hands are cold and clammy. Peripherally shut down is the medical term. Fine beads of perspiration pepper his pale forehead. His eyes dart towards the door as if looking for a means of escape or a friendly face.

SAW is only a six bedded unit. Mr Elroy is the first patient to arrive. It is Saturday the thirtieth of July; it is officially two days before the killing season is meant to start.

I pretend to know what I’m doing as much for Mr Elroy’s sake as my own. And of course for Karen too. She’s the staff nurse here. She wheels a stainless-steel tray towards me. The tray contains the paraphernalia necessary for venepuncture.

Karen is in her forties. She has peroxide pixie hair with darker roots. Her eyes are tired, her skin sallow. A pack of Marlboro Lights pokes out from one of the waist pockets from her rather scruffy uniform.

I’ve never used this type of vacutainer set-up for taking bloods. Karen assures me nothing could be simpler.

She places an inco-pad as a bib across Mr Elroy’s chest and then hands him a cardboard bowl to hold. “Just in case,” she says.

“Peter,” I say. “I need to pop one of these in.” I hold up a green Venflon.

“They’ve already tried,” he replies.

And failed. He has multiple bruises over hands and forearms. The Paramedics have blown half a dozen veins already. I tighten the torniquet above his right elbow, straighten his arm and hunt for anything which looks halfway decent. There’s nothing, not even the houseman’s friend which is the vein at the base of the thumb at the level of the wrist. I try to wake his veins by sharp slaps with the back of my fingers like I’ve seen more competent doctors do, but they’re either hiding or plain not there.

I try the other side. Nothing obvious but with percussion (a gentle tapping with the middle finger of my right hand) I sense something at his left elbow; it’s possibly the antecubital but I can’t be sure. I advance the needle, relieved to see dark blood welling in the reservoir at the back of the cannula. Once anchored, I withdraw twenty mls and hand the blood-filled syringe to Karen.

“Full blood count, U’s and E’s, clotting and a cross match. Four units, please.”

“I can’t do that,” she replies. “Only doctors can. And you’ll have to call the labs and the porters too. The numbers are by the phone.” She nods in the direction of the desk by the window. She hands me back the syringe.

“Ok, can you set up a unit of Gelofusine? Or Haemacell. Whatever you’ve got. Stat. Please.”

“Only if you write it up.”

“Of course.”

I need to transfer the blood to the vacutainer tubes before it coagulates. Karen has provided me with a selection with different coloured tops but I don’t know which are the right ones. It’s stupid. It’s the sort of stuff I should know.

I sit at the desk while Karen connects the drip.

“Which is the blood count one?” I yell.

“Purple, I think,” she replies. “There’s a chart in the Treatment Room.”

My bleep chirrups (insistent, annoying, distracting) and a four-digit number rolls across the tiny orange LED strip on its top.

I’ll call them later.

By the time I’ve packaged the bloods ready for collection, my bleep chirrups again. It’s the same number.

“Hi,” I say (trying to sound cool and collected). “Reuben’s Houseman. You bleeped me.”

“A few drug charts need rewriting, and Mrs Andrews needs reviewing. She’s in a lot of pain.” A female voice. Shrill. Harsh.

“Is there anyone else you can call? I’m kind of busy at the moment.”

“You’re the surgical house officer?”

“Yes.”

“Well, you’re meant to cover us.”

I sigh. “I’ll get there as soon as I can.”

When I phone the haematology number, the phone rings about a dozen times before a young-sounding woman answers, her voice clipped and glacial. “How can I help you?”

“Full blood count…”

She cuts me off. “You don’t need to call for counts on a Saturday morning. All bloods are processed…”

“It’s urgent,” I interrupt. “And a four-unit cross match. Mr Elroy, Surgical Admissions, haematemesis, shocked.”

“Who are you?”

“Dr B., Reuben’s new House Officer.”

“Have you signed the transfusion register?”

“Errr…”

“You can’t request a cross match until you’ve done your induction.”

“This is my first day.”

“No exceptions.”

“I’ve got a shocked patient who needs blood. Are you…”

“Ring the Consultant. Or get someone to ring on your behalf.”

“The Consultant?”

“Yes, the Haem Consultant on call. You can contact him via switch.”

While I’m talking to Haematology, I’m watching Mr Elroy half propped up on the trolley, vomit bowl balanced precariously on his lap, monitor bleeping, systolic ninety-five, heart rate eighty-seven. Karen fiddles with the giving set. “Just need to put this here,” she says as she straps adhesive dressing over the plastic tubing, sticking it to Mr Elroy’s hairy forearm. She unlocks the spigot. “It’s working fine,” she says. “How are you feeling? Better? We can always give you something for the sickness,” she adds.

I open my Pocket Oxford Handbook and glance at the relevant pages. I confirm what’s needed. Another Venflon (two are mandatory for a gastrointestinal bleed), a urethral catheter (to measure output), and a prescription for intravenous acid suppression, fluids, and antiemetics.

Simples.

Except I can’t find another sodding vein. I stab Mr Elroy a further five times before giving up. “Sorry,” I say each time I miss. He winces but remains mute and uncomplaining.

“Can you please set up a catheter kit for me, Karen?”

“Have you called someone?” she says, the doubt in her voice obvious.

“Mr Shah’s not answering,” I reply. “I think he’s in Theatres.”

Mr Shah is the Surgical Registrar. Well actually, not quite a registrar, he’s a Staff Grade. I don’t know whether this is better or worse. I met him briefly at the start of my shift. He smiled and introduced himself, expressing relief I’d turned up. “If you hadn’t, it would have been tricky,” he said. He handed me the bleep. “Any problems call me. I’ll be scrubbed for a couple of hours but should be out of theatres by midday at the latest. We’ll catch up then and go around the wards, shall we?”

“Yes,” I agreed.

Shah was dressed in green scrubs. His white boots heavily stained with iodine and spots of dried blood and bile and other unidentifiable bodily fluids. A stethoscope dangled from his neck. He looked relaxed. Confident. “Don’t worry. You’ll be fine. If you’re not sure then ask one of the nurses,” he said. He turned towards Karen who was sitting at the desk. “You’ll show him the ropes, won’t you?”

“Story of my life,” she replied. “Telling house dogs what to do.”

Shah half snorted, half laughed. “Most of the nurses are fairly decent but there are a few honourable exceptions.”

“It’s worth giving the Anaesthetists a call,” Karen shouts from the other side of the room. “They can be really helpful when it comes to venous access,” she adds. “Switch will have their number.”

It’s a good idea but I’m a failure before I’ve even started. An imposter in a white coat. I don’t need medical training to tell me Elroy’s in trouble. But I don’t want to look a complete no-hoper; there are things I can do before calling for help. First off, I must get his bloods to the labs, then catheterise, then write up his notes and prescription chart.

I phone Switch – a single zero – ask them to put me through to the on-call Consultant Haematologist.

“And you are?” an older male voice snaps back at me.

“Dr B, Surgical House Officer.”

“Micro, Haem and Radiology Consultants only accept calls from Registrars or above.”

“It’s urgent,” I plead. “I need four units cross matched and the Lab tech won’t sanction my request until I’ve confirmed it with the Consultant.”

“I’m under strict instructions…”

I want to scream but Mr Elroy is looking at me. He can hear every word I’m saying. It doesn’t matter how frustrated I am at this unexpected impasse, I must remain professional.

“Uh!” I interrupt. “I understand.”

But I don’t.

“Well then, can you please call the Anaesthetist on call?”

“SHO or Registrar. O and G, or ITU?”

“SHO. Not the O and G one.”

“Fast or ordinary?”

“What?”

“Fast bleep or ordinary bleep?”

“Fast…I think.”

“To SAW.”

“Yes,” I agree. “To Surgical Admissions.”

The line goes dead.

The bottles of blood remain within their plastic specimen bags lying (accusingly) on the desk awaiting collection. I’m about to bleep the porters for the second time when I see Elroy waving at me, beckoning me with his bruised right hand.

I glance at the monitor – systolic ninety, heart rate 103. Not good. I check that fluid is still flowing into his Venflon. The Bag attached to his metal drip-stand is half empty. He’s deteriorating despite this. Shit!

Elroy flaps at me more wildly.

I hurry towards him.

“What’s wrong?” I ask.

It’s a stupid question.

“Need the loo,” he says.

“Number one or two?”

But it’s too late; the smell gives me the answer before he can reply. I lift the sheet and gaze at the crap between his legs. It’s purpled with clots as big as my hand.

“Help me,” he whispers. His eyes are wide open, bulging, white sclera surrounds the entirety of his grubby brown irises. Breathing quick, shallow and untempered. Sweating. Whimpering.

“Help me!” he repeats.

“Karen!” I shout.

He vomits fresh blood. It erupts from his mouth like a volcanic spume of molten red, pours down his Inco-pad, splatters the metal rails of his trolley. Great heaves wrack his body.

I lift the cardboard bowl in a vain attempt to capture the liquid cascading from him. My whitecoat’s sleeve is now covered in the stuff. I’m babbling. “It’ll be fine,” I say. “The Anaesthetist is on his way. We’ll sort you out.”

An aproned Karen rushes towards the trolley clutching a new vomit bowl and a handful of fresh inco-pads.

“Oh fuck,” she says.

I’m on my knees while Karen holds the patient’s extended arm as I hunt for a second vein. I cannot express the depth of my relief when the Anaesthetic SHO arrives. He’s barely older than me but he’s been working at the sharp end for at least a year longer. Maybe more. He takes charge. I am no longer responsible. Every decision his and his alone.

He stands on the patient’s right, grips Mr Elroy’s wrist, fingers pressed against the radial pulse, while his eyes flit from the patient to the monitor, finally settling back on me.

I take my cue: “63-year-old,” I say. “No previous history of bleeds. Large volume haematemesis just before eight this morning. No history of NSAIDs. Hypertension for which he’s on Inderal. History of triple A repair seven years ago.”

I follow the Anaesthetist’s eyes to the long linear scar which extends from below Elroy’s sternum to his pubic bone.

“Is this the only fluid he’s had so far?” the Anaesthetist asks.

“Been here for fifteen minutes.”

In reality, it’s closer to twenty-five.

“The paramedics couldn’t gain access,” I explain.

It’s not meant to be an apology but it sounds lame.

The Anaesthetist presses his right hand into Elroy’s belly, digging deep into either side of his abdominal scar. “Any pain?” he asks.

Mr Elroy shakes his head.

“Bloods?”

“Not yet,” I reply. “Cross matched for four units, but the Porters haven’t collected.” I nod towards the desk. “And the Haem Consultant hasn’t sanctioned. Switch says only Registrars or above can call them direct.”

“That’s crap. Anyway, don’t think we have time for that, do we?”

It’s obvious he doesn’t expect a response. “Staff, can you please fetch four units of O Neg from Theatres. You know where to go?”

Karen nods, rips off her apron and heads to the door.

“You’re going to be fine.” The Registrar rests a hand on the Elroy’s shoulder. “Just need to get a bit of blood back into you.”

I almost believe him.

The patient’s eyes flick between us, short saccadic movements, jerky and uncertain. He looks like a frightened rabbit. There’s a smear of dried blood at the angle of his mouth. In the kerfuffle I’ve missed his gold wedding band on Elroy’s left ring finger.

“Is there anyone I can call?” I ask him.

Mr Elroy opens his mouth as if to reply but instead lurches forward. Blood streams from him. Torrents of the stuff. Even more than last time. It overflows the cardboard bowl, spills down the fresh inco-pad onto the sheets. There’s eight pints inside of us, but this seems incalculably more; it floods his lap. It pools at my feet.

“Crash!” the Anaesthetist shouts. He struggles to lower the bed while yanking the sheet in an awkward attempt to swivel Elroy onto his side. It’s only later I work out he was trying to prevent aspiration. I race to the desk. I don’t know the cardiac arrest number. Just press zero. Switch. Wait two or three rings before the operator answers.

The wait is interminable.

The puddle of red extends towards me. Glossy bright. Fresh. Arterial.

I stand on a footstall, fingers entwined, the heel of my hand on his lower sternum, shoulders rocking back and forth. The Anaesthetist squeezes the Ambu bag connecting the piped oxygen to the endotracheal tube. This is a token effort. Mr Elroy is dead long before the Arrest Team arrive. Asystolic. He exsanguinated before our eyes.

“Must have been an aorto-enteric fistula,” the Medical Registrar explains. “The graft from an aortic aneurysm repair sometimes erodes into the gut.” He shrugs. “Of course, it’ll need a postmortem to confirm this.” He looks at me. “You’ll have to call the Coroner first thing Monday, ok?”

I am conscious of so many people milling about - the Medical Registrar and SHO, a couple of additional nurses, a porter, a tattooed ODP. They all look as if they belong. Things are tidied away and repackaged, idle chitter chatter, comments about other patients compete with gossip and local news. The Anaesthetic SHO writes out a side of notes. I realise I don’t even know his name. He never introduced himself. Karen cleans up. And I am excused to return to my room where I empty the pockets of my soiled white coat and exchange it for a freshly starched one.

I still have forty-seven hours before I officially begin my first shift. My bleep bleeps. It’s another outside call. Another admission.

There’s no time to reflect.

By the time I return to the Surgical Admissions Ward, all signs of Mr Elroy have been removed. His trolley is covered in fresh while linen. The metal side bars sparkle as if he was never there.