She lay mostly silent and still, the occasional grimace the only indication of moments of intense pain and maybe fear. The freshly pressed, stark white bed sheet allowed little contrast against her cold skin; all colour had drained from her face and her arm lying on top of the sheet felt of ice. Yet she knew he was there. Sitting calmly and purposefully by her side, holding her hand, watching her face, listening to her every breath, noticing and acting on any indication that she may be in pain.
She had only arrived in the department a short hour ago, rushed in as an emergency to the brightly lit, busy, noisy resuscitation room in the Emergency Department in which I was a junior doctor. I had watched on as the ready assembled team had listened to the handover from the ambulance crew; 89 year old lady living alone, known abdominal aortic aneurysm, 7cm on her last scan, surgical treatment not possible, one daughter living over 100 miles away. She knew she had been living with a ticking time bomb gradually expanding within her for years, but until this night it hadn’t really caused her any problem. Yes, there had been the initial fear and discussion of possible surgery, but once that was ruled out, and over time she had come to accept, and at times even forget, the diagnosis within her.
Tonight the pain had been sudden and severe. She’d managed to press her lifeline and summon help, but by the time she arrived with us she was hypotensive, and even to my inexperienced, junior eyes it was obvious that life was slipping away as the aneurysm continue to bleed. Not the sudden, rapid death within minutes that I had thought might happen in such patients, but a slower ebbing of colour, and warmth, and life. The pain persisted, gnawing, uninvited and unwelcome.
As quickly as they had arrived, the team of specialists drifted away from the room. Emergency surgery was not an option for this patient. I stood at the end of the trolley. She was my patient now.
I was working with Adam, one of the experienced charge nurses in the department. Adam was one of the handful of people who to this day I am convinced really shaped my career. He was confident, yet compassionate, the life and soul of the team. Adam would be the one pulling practical jokes on poor unsuspecting juniors doctors and nurses, but the one who as a junior you totally knew had your back. If I had been a patient, Adam would be the sort of nurse I would want looking after me. I trusted him. In an emergency when multiple tasks needed completing seemingly simultaneously Adam was there, generally ready with whatever was needed before it was asked for. Years of experience under his belt, Adam could easily have done my job as a junior SHO; I didn’t think I would ever have the skills needed to do his.
Together we worked to care for our patient. Priorities had changed from resuscitation to care of the dying. We talked with our patient, making her comfort and peace our priority. Pain relief was rapidly administered and a small team assembled to move her on to a comfortable bed from the austere hospital trolley, and from behind the curtain a pillow was passed; a generally illusive item in most A&Es.
I watched on as Adam pulled up a chair and sat next to the bed on which our patient lay, holding her hand, watching her face and listening to her every breath. If he noted any indication of pain or distress he carefully titrated further pain relief, adjusted a pillow, or spoke calmly with words of kindness, almost love. And he sat. Undistracted, unhurried, peaceful.
I don’t know how long it took; maybe twenty minutes, maybe over an hour. As time passed her grip on his hand loosened until it was no longer and as her shallow breaths faded and disappeared, Adam waited a few minutes longer before standing from his chair, tucking her arm under the sheet, gently touching her forehead and turning away.
This event happened at the stage in my career when I was making decisions about which specialty I wanted to train in. This was my second A&E post, and I was pretty sure this was the job for me; I enjoyed the variety, the fast pace, the procedures, the team camaraderie. What I witnessed that shift endorsed my decision and gave me a role model to aspire to. In Adam I had witnessed first hand the humanity and humility needed to work in an acute environment. The switch of pace from the recognition and processing of a ruptured aortic aneurysm, fast, urgent and terrifying, to the sanctuary afforded this patient by my colleague, enabling a dignified and humane death, was quite spectacular. At that moment I knew I wanted to do it all.
I often wonder how many people, both inside and outside of medicine, believe that A&E is either all drunks and plaster casts or, at the other end of the spectrum, is like an episode of ER; heroic, speedy and dangerous? The reality is, it’s both, and it is neither. Each day brings a new collection of people, each with a story to tell, a need to be heard, a desire to protect and be protected, with fears to acknowledge and anxieties to quell. Most importantly, each day brings another opportunity to learn new skills, and role model those we have to others.
Adam taught me skills that no text book or lecture ever could. There was no powerpoint or podcast, no list of objectives or competency assessment. Simply time to observe and work alongside a fellow professional who knew what was important to his patient at that time, and demonstrated compassion and care with the upmost humility.
Adam sadly died a few years ago, but I was reminded of him only recently when working in the department I am now a consultant in. I had been involved in a particularly traumatic case, the death of a young person. Having spent time with the family of my patient, kneeling on the floor beside two grief ridden parents, I had retreated to the staff room for a few moments of solitude. A young newly qualified nurse followed me into the room and her words surprised me. “I’ll never forget seeing you in there” she said, “how you cared for that family, seeing you kneeling down beside them, how kind you were.”
Adam, thank you for everything you taught me. I hope I’ve done you proud.