Breaking Bad

11.30 in the morning, things are starting to hot up in the Emergency Department.  The ‘crash box’ sings out, and one of our staff nurses takes the pre-alert message from the ambulance paramedic. 

"42 yr old female, collapsed at work, ETA three minutes."

This doesn't sound good, but could be all manner of conditions. We follow our routine of diverting a team of staff to our resuscitation room to receive this patient, the ambulance crew and to prepare thoughts, equipment, task allocations and medications.

Soon enough, the crew arrive with the lady, and we transfer her to our trolley then hear a formal summary of information from the paramedics: "This is Eilidh, 42 year old lady, normally fit and well, complained of a sudden headache at work today, then collapsed at her desk.  No past medical history. No meds.  Friends at work have called her husband - he's on his way up to the ED."

Our team do a rapid assessment of Eilidh and things do not look good. She has clear signs that her brain has suffered some sort of catastrophe, likely a sudden bleed, and the pressure inside her skull is compromising her most basic functions of survival - alertness, pulse, blood pressure and breathing.

We induce a coma to alleviate her distress and protect her brain as much as possible, and take over her breathing with a ventilator while we organise a CT scan of her brain.  We are just preparing to move through to the scanner, when a receptionist pops her head round the curtain.

"Is this Eilidh?  Her husband's just arrived.  He's in relative's room 1."

The most miserable of all tasks now needs to begin - breaking the news to her family that she is unlikely to survive this and that their lives are about to change forever.  There are some furtive looks round the room.  The senior staff nurse and I decide to go and start what is often a multi-staged process.

I knock on the door of the relative's room and we head in.

During the next five seconds, I am doing what many of us do when we meet patients for the first time.  I am trying to soak up as many visual clues as possible to ensure the pitch of the subsequent conversation complements the parties involved as closely as possible - their pre-existing understanding of events, their ability to take in medical information, their expectations of the interaction and their resilience. 

This is a very inexact process and relies heavily on assumption, judging on appearances and reactions. This evolves as we learn more about our patients and their loved ones.

"Hello, are you Eilidh's husband?"

"Yes, I’m Bill. Gill from her work called me to say she had fainted or something.  I've come from work and I've got a meeting at 1pm - can I pop down and see her quickly before heading back?"

Oh boy - this is going to be difficult.

"My name is Dave, I'm one of the Consultants here in the Emergency Department.  I'm afraid I have some bad news."

I start to paint the bleak picture, no euphemisms, straight talking and no room for misunderstanding.  All with some empathy – a tough task.

Bill’s face is now solemn and his mind must be churning at what might be coming next.

"I'm really sorry, but Eilidh has had a collapse today, and it looks like she has had some serious bleeding into her brain."

The air is now thick with tension, a good 20 seconds of silence hangs in the room.

"Will she be alright though? We're going on holiday with the kids next week."

Children too.  Life is rarely fair.

"Well, she is very unwell at the moment.  We have induced a coma to allow us to support her as much as possible and she is just getting a CT scan of her brain at the moment.  We'll know a lot more after that."

"But she'll be alright?"

“We'll know more after the scan, which will be back in the next 15 minutes or so.  I will come back and speak to you then,” I pause. “There is a chance that Eilidh may not survive this."

Bang - we let the news sink in for a few seconds. We then try our best to support a man whose life has been blown apart in an instant.

"Can we call anyone for you, Bill? Get you a cup of tea or anything else?”

He is speechless and just sits shaking his head, trying to understand the incomprehensible.

The nurse sits with Bill whilst I excuse myself to check on Eilidh's situation, and check the CT.  She is showing more signs that the brain is becoming more compromised and the CT confirms a huge area of bleeding.  This is a terminal event.

I head back along to the room. Bill’s still in the dazed state of unmanageable grief. His ability to take much more information in will be very limited, but he needs to know that he is in the process of losing his wife. 

We walk him through the salient points, repeating as necessary, and the start of his new life has begun.

Seize the day.