Thursday, January 23, 2014

Thank You And Goodbye



The night Dr Amal Ziada died was a horrible one. We had been standing around the ICU all morning, afternoon and evening, crying and feeling helpless as she rapidly deteriorated, systems failing, and finally lost her battle with cancer. It was a little after Maghrib I think. I went down to the hospital cafeteria to get some juice for everyone, then passed by the ER to see what I could do about my night shift that I was supposed to show up for in less than 4 hours. I had been texting people all day trying to get someone to take my shift but (unsurprisingly) couldn’t. The hospital nursing coordinator running the evening shift was standing behind me, discussing some issues with the shift-in-charge when her pager called the code:
‘Cardiac arrest ICU.’
Before the message was repeated the second time I was already at the end of the corridor, bursting through the doors and up the back-stairs, running after the on-call medical specialist who happened to be standing around at the same time. When I reached the room door in front of which a crowd of people crying and screaming, I realized I was still holding the bag of juice bottles, and threw it onto a stack of carton boxes in front of the on-call anesthetist’s room. Half an hour later we were parking our cars in-front of the house that would now be called beit al-bika for the next few weeks.
At some point after that I went home and changed into my scrubs, went back and hung around for a while before heading off to work. The shift started at midnight and ended at 8 a.m., and it was a Wednesday. I was exhausted and depressed and had no idea how I would make it through the night. Getting some sleep wasn’t even an option: night shifts are just as busy as mornings and evenings, with half the number of doctors and nurses, and there wasn’t even a room for anyone to rest in. As we stood around the whiteboard receiving the hand-over, I looked at my team. There were 3 of us and the in-charge had swapped with someone else. I was the only girl which was always bad news: it meant I’ll be handling all OBGYN emergencies as well as the majority of female patients who generally refuse to be examined by male doctors. Although the new in-charge was nice, he definitely wouldn’t be cutting me any slack. I tested my luck by telling him what a horrible day it had been and that Dr Leena and Saria’s mother had passed away a few hours ago. He was sympathetic – with them – but ignored my hints that I wasn’t up for it. Oh well.
The patient came in a little after 1 a.m. I think; a fat, rosy-cheeked little lady who didn’t speak Arabic, and her husband who looked almost exactly the same as her except for the moustache. She had all the typical symptoms of an MI (heart attack), with a typical history of chest pain coming on and off for the past few months relieved by rest. She was diabetic, which complicated things: diabetics do not sense pain like everyone else; their senses are dulled not only at the tips of their fingers and toes, but everywhere else including the heart. So when a diabetic shows up with any degree of pain anywhere over the chest, upper abdomen or neck, it’s a heart attack until proven otherwise. My grandmother Allah yar7ama had had a mild heartburn for several hours which wouldn’t go away, and by the time she got to a hospital the damage was too great for anything to be done. Every diabetic with chest pain is my grandmother to me.
We ran the usual blood tests and gave her some mild painkillers because her ECG wasn’t very decisive, so she wasn’t a candidate for any drastic intervention at the moment. Since she looked comfortable, I went about seeing the rest of my patients, working with only half a brain as I grew steadily slower and sleepier. The woman’s results came out not too long after: completely normal. The one decisive test is an enzyme that is specific to heart damage but had one important limitation: it may not appear in the blood until a full 8 hours after the heart attack. So usually if its positive that’s it, but if its negative we have to look at the background. If the patient is low risk, doesn’t have very strong symptoms and nothing else suggests an MI or another diagnosis is found, we leave it alone. But if everything points to an MI then it needs to be repeated AFTER 8 hours. This patient had a typical history and presentation, and had indeed appeared in just about 2 hours after the chest pain had started. But now, she was completely fine. I looked at her suspiciously, sitting up and chit-chatting, eating her dinner, completely pain-free. Her husband kept telling me she’s fine, she’s fine, we go home now doctora khalas, no need for anything else. He wouldn’t listen to me as I tried to explain that she needs another test which wouldn’t be collected for another 3 hours and they would have to stay put, and the language barrier wasn’t helping. They wanted to go home and would even sign a Leave Against Medical Advice form.
I gave up. I had no energy and couldn’t think. All I wanted to do was crawl into a corner and cry. Amal Ziada was dead. Amal Ziada who had written a chapter in the most popular physiology textbook in Sudan. My close friends’ mother and my parents’ close friend. A woman who was strong, funny, beautiful, kick-ass and who didn’t take crap from anyone, especially when it came to her own kids. She had given so much and made her place in the world, and had fought cancer like hell and lost; and here I was faced with a woman who had given nothing and was taking her own life and health as lightly as if she had a spare sitting in drawer at home. I know it wasn't fair of me to compare, but since then these 2 women are forever linked together in my mind. I gave up.
I went back to the doctors room to tell the in-charge that I was discharging the patient in bay 3 because they didn’t want to wait for the repeat results, and that they promised to come back if she felt anything else. The doctor looked at me for a while, then got up and we went back to the bay. He spoke their language and it was easier for him to communicate, and after looking at the results and ECG and the smiling woman sitting in bed, he then asked what me what I want to do. I told him they want to go home, and they live close by anyway. He said yes, but what do YOU want to do?
The thing about working in an ER is that you are put in situations where the decision you make could mean everything to a patient: you could save their life or kill them. Even the smallest decisions matter. But it’s not just that. There are a combination of things, some of which you don’t have control over. I tell myself that I don’t have control over everything because it sometimes makes losing patients easier, but it never really does. How busy the shift is, what time of day or night, if you’re feeling particularly stupid that day, who the nurses on the floor are and (especially) the nurse in charge, the radiologist on-call and how (un)cooperative he/she is, and most importantly, who your senior is. This particular doctor was easy going, nice, and very cautious, meaning he would always take the ‘cover your back’ approach to managing patients and would happily over-treat or over-investigate than miss something. He also trusted my judgment and often asked my advice about treating patients even though he was several years my senior and had much more experience. And so, he genuinely wanted to know what I thought about this case so that he could support me as appropriate. I heard myself saying that I wanted her to stay for another 3 hours so that we could repeat her blood test. Even though they were irritating me and she looked perfectly fine, there was still that small possibility that something was going on. So, he turned to the husband and barked at him in Urdu, and whatever he said apparently terrified the couple because they quickly agreed to stay. I was too tired to even be grateful at that point, and all I could do was order the tests and instruct the nurses and then walk back to the doctors’ room and plunk down into a chair. At that point I think I was talking outside my head, because the doctor in-charge told me to go take a nap. In the entire 5 years I had been working at that hospital, and the 3.5 years in the ER, the only time I had taken a nap during a night shift was when there was a cyclone outside and no one could reach the hospital anyway so there were basically no patients at all. I didn’t even make him tell me twice, and I locked myself in the suturing room and was asleep in less than 3 minutes: fully dressed including my labcoat and shoes. I woke up an hour later for Fajr, prayed and went back into the doctors’s room. I hadn’t seen my face in the mirror but apparently I looked so bad both doctors quickly told me I could go back to sleep if I wanted. Which I did. And woke up a couple of hours later so the sound of someone trying to break the door down, as the nursing morning shift had arrived and were going about their hand-over rounds of patients and equipment. I suddenly remembered my diabetic patient, so got out of bed (on which we usually cast broken bones, suture wounds, drain abscesses, remove fish hooks from fingers and pry off tight rings), unlocked the door and looked out to my left towards the high-dependency bay. The first thing I saw was Dr Johnston sitting at a computer in the station facing the bay. He was a senior cardiology consultant, and his being anywhere near the ER especially so early in the morning didn’t make sense. Senior consultants don’t come to emergency rooms to see patients; they have about 6 people in different ranks under them to do that. Yet here he was, surrounded by the entire on-call medical team. As if to answer my question, the woman appeared in my sight, still sitting upright in bed, but instead of smiling and happily eating her dinner, she was crying her eyes out and tears were running down her chubby rosy cheeks as she was rushed down the corridor by several nurses and doctors towards the door. I caught a passing nurse and asked her what in God’s name is going on, where was my patient being taken??
‘Cath lab doctoraa, then to ICU!’
Cath lab? ICU?? She was going for a rescue PCI?? I detached myself from the doorway and went to the doctors’ room to find my in-charge. He and the other doctor were sitting typing their notes, each one holding several patient’s clipboards. My senior saw me and informed me that the repeated blood test we had almost missed had come back positive. Not only positive, but it was 10 TIMES higher than normal. I couldn’t believe it. Before I could process this information, I suddenly remembered that the shift was almost over, and that I had slept through almost half of it. The 2 doctors had redistributed the workload as well as my own patients and completed the rest of the shift on their own to let me sleep. That was only the second time I or anyone else had slept on the job. I knew certain shift-in-charges would sooner see me drop dead than let me rest for 5 minutes. If someone else had been on the shift… that thought led me back to the diabetic patient. If it hadn’t been that particular doctor, we would have let the patient have her way and she would have gone home and died in her sleep. In fact, the doctor who was originally on the shift would have most likely let her go. I never found out what made the 2 doctors swap shifts, but I guess Allah had plans for that woman to live through my shift and die some other time.
As I walked home that morning, several fuzzy thoughts floated around in my head that I was unable to process. The only 2 things that were clear were: thank you Dr Mubashir for helping me save a patient and letting me sleep. And goodbye Dr Amal Ziada, until we meet again.
أجمعين. انشاالله ربنا يجمعنا بيك في الفردوس الأعلى



3 comments:

  1. إنا لله وأنا إليه راجعون
    Really It was a horrible day full of events, master-tragedy and pain
    It was an honer for my poor personnel to administer Chemotherapy injection once, but it was a whole beautiful lecture i had from her that night.
    RIP Dr. Amal Ziada

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  2. RIP Dr. Amal.
    The only thing I can say about this post is that your diabetic patient is destined to live. Sobhan Allah maybe Allah made you sleep because she and her husband may have tried again to convince you to discharge them, and maybe you would have said yes.
    Anyhow, my advice to you is always stick to your protocol no matter how naggy a patient is.

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  3. This is a very moving piece. Just came across it. Shows how things fall into place. My mom calls it "Handasa Rabbaniya" how everything 'went down' that fateful night.

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