The Tear That Never Falls

This was the prequel to Misadventure.

I still get the flashbacks, the PTSD.  I haven’t worked in the department for over twenty years, though periodically I visit, twice in the last year, like a felon drawn back to the scene of the crime.  Sometimes I dream about the place; I grapple all night, amid a zone of chaos, with an intractable problem.  I remember hundreds of these nights.  We used to think that there must be a better way of doing this.  We joined forces with our colleagues across the Tasman, in the college in Melbourne, and organised.  We had a plan, and a vision, and I think that is why there was a period in the 90s when despite the pandemonium I used to wake with buoyancy and hope.

Shortly after midnight on Sunday, December 21st., 1991, an invisible swirl of wind darted between the Manukau Heads, flashed across the Manukau Harbour, thundered briefly through South Auckland and vanished out into the Hauraki Gulf.  In its brief and violent passage across the built-up area east of the airport, tongues of the wind flicked down avenues with the venturi effect of tremendous acceleration between tall buildings, resulting in short-lived and chaotic street-tornadoes that cut a swathe of devastation almost before people had realised that the wind had picked up.  I worked on in the bowels of the emergency department, completely oblivious to this little local natural disturbance.

It was only a forearm flesh wound requiring a few sutures, but the patient had been kind enough to inform me that he was HIV positive, and I had taken him, not into one of the main theatres, but into Room 9, a small treatment room towards the back of the department, where I had set up a suture tray, then carefully gowned, and masked, and put on the heavy Perspex visor, then the sterile gloves.  A staff nurse looked in.  No, I didn’t need any help, but could she put screens over the door, and, no interruptions please.  I sat down and, carefully and methodically, cleaned and closed the wound, then applied tulle, an outer dressing and, finally, a sling.  I had closed out all the extraneous noises coming from the rest of the department, but I had heard the snarl of the ambulance siren, and was aware that something was taking place in Resus.  I carefully disposed of all sharps, then delivered the used suture tray and all the protective clothing into a large marked laundry bag which I closed up and deposited in its place at the back of the sluice.  I competed the paper-work, handed a copy to the patient, and bade him good evening.  I walked into Resus.

“Clear!”  Yolande applied the defibrillator paddles.  The patient gave an indifferent shrug, a 360 Joule shrug.

“Back in sinus!  Have we got an output?  Yes!”

I said accusingly, “You have resuscitated Mr Proudfoot.”

Mary Heenan said, “You haven’t resuscitated Mr Proudfoot?”

Mr Proudfoot, who was in the end stages of a severe cardiorespiratory illness, had requested that the next time he was admitted in cardiac arrest, he should be left in peace.  His cardiac consultant Dr Finlayson had even taken the trouble to come down to ED.  “The next time Mr Proudfoot dies,” he had said, “(and I choose my words carefully) – the next time Mr Proudfoot dies, he should not be resurrected.”

What had we done?  He had set his lands in order, made his will, paid all his bills, said goodbye to all his friends, kissed his family and told them he loved them, and made peace with his maker.  There was nothing to fear.  This was merely part of the progression of things – birth, childhood, education, career, marriage, children, domesticity, patriarchy, the twilight years and now, another physiological entity in its due place, demise.  Yet indeed there was something to fear.  The Health Service.

The Resus door opened and a trolley was pushed in.  An agitated, fit-looking young man.  “We need to double up,” said the staff nurse.  “Push Mr Proudfoot over there.”  The doors closed then immediately opened again.  Another trolley, bearing a screaming toddler, accompanied by two desperate parents.  “Near drowning.”  We were getting crowded.  I was looking at the agitated man.  He was dressed in Lycra, with the knee-length shorts of the cyclist, and a colourful top.  He stared wide-eyed at the ceiling.  Bizarrely, he was still cycling, still on his bike, peddling furiously.  I turned to the child.  Pink, well-perfused, alert, screaming robustly.  I asked the distraught parents what had happened, and at the same time I could hear the nurses trying to deal with Mr Proudfoot.  “There’s no room for him in resus.  We can’t monitor him in the corridor.”

I said, “Take him off the monitor.  No more shocks.”

“Right.”

The near-drowning child was in good condition.  It was a classic story.  They had moved house that evening.  The parents paused for a rest during the unpacking, and noticed the child was missing.  They found him, face down in the pool.  They must have found him immediately after he’d fallen in.  No hypoxia, no aspiration, no neurological damage.  Another minute and the story would have been very different.  The mother cried tears of vexation, anger, guilt, and overwhelming relief.  I knew they would never forget this night.  Twenty five years from now, at his son’s wedding, the father would make a light-hearted and witty speech about his son, embarrassing him with a few anecdotes of childhood.  He would touch with wistful levity on this fateful night.  There would be laughter from the wedding guests, and his bride would smile fondly over the notion that she had nearly been widowed a quarter century ago.  The best man would make a lewd and raucous speech.  Dave taking a header into the family pool when he was two.  What a joke.

But amid the laughter, the mother and father of the groom would cast a glance at one another, and hold one another’s gaze fractionally, and utter a silent prayer of gratitude that fate had looked down upon them, albeit indifferently, yet chosen to let the coin fall one way.

The cyclist was still peddling.  I laid a hand on his shoulder.  “Come on mate.  Off your bike.  Was there a triathlon today?”

Karen Jones nodded.  “Pukekohe.  2.4 km swim.  180 km bike ride.  And a marathon.”

“But it’s past midnight!”

“Yes.  There are still a few runners out.”

“What’s his temperature?”

“38.”

“Good enough.  Give him some intravenous fluids and see how he goes.  Come on, pal.  Climb down.  You’re in hospital.”

He grinned.  “Hospital.”  But he kept peddling.

The ambulance R/T squawked away.  A fight, in a hotel.  Gang-related.  There were knives, and somebody had a firearm.  The Armed Offenders Squad were in attendance.

Yolande tapped me on the shoulder.  “How do you reduce a dislocated jaw?”

“Glove up, put your thumbs on the lower molars, and your fingers behind the angles of the mandible.  Pull down, then rotate the jaw forward, then push it back.”

She rehearsed it in mid-air.  “Down, forwards, back.  Okay!  Got it!”  It is sometimes said that there is no such thing as a Teaching Hospital.  There are only Learning Hospitals.  We had accrued knowledge and experience by peddling and trafficking in information by word of mouth, the oral tradition.  Thus, the nightmarish, medieval, corrupt, exploitative, sleepless training: “See one, do one, teach one.”

Mary Heenan grabbed my elbow.  “Resus.  It’s a hanging matter.”

He was middle-aged, overweight, double-chinned, balding, and moustachioed.  He wore nothing but an expensive-looking silk dressing gown, and a silk cravat in the same pattern, claret-red with Chinese lettering in green.  The cravat had become a noose which the paramedics had loosened.  I   could see the constrictive erythematous abrasion all around the neck.  The patient’s nipples were skewered by hatpins.

“What on earth…”

“Watching blue movies.”

“The things we do.”

And unlike the near-drowned child, this man was very unwell.  Airway… breathing… circulation…  Eyes open to pain, localising pain, incomprehensible grunting.  He needed a rapid sequence induction.  Could he have a spinal injury?  Better assume so, protect the neck, and paralyse and intubate in the neutral anatomical position.

Yolande came back.  “No good.  I can’t get my thumbs into his mouth.  Would sedation help?”

“What?”

“The dislocated jaw.”

“Oh that.  Unusual if he doesn’t have an open mouth.  Are you sure of the diagnosis?”

It was my mistake.  I should have gone to see the patient at this point.  Yolande shrugged. “What else could it be?”

“I’ve seen a drug dystonic reaction mimicking a dislocated jaw.  Is he on something?  Did somebody slip him something in the pub?”

“I’m not sure.  I’ll check.”

Mary Heenan said, “I’ve got as cast iron a stomach as anybody.  I don’t mind blood, I don’t mind pus, or vomit, or even sputum, and I’ll take any amount of crap, but this is too much.”

“What is it, Mary?”

A sallow, unkempt man lay in Room 10.  There was a piece of tulle over a substantial lesion on the outer aspect of the left upper arm, held in a stout Gamgee.  Mary slipped on a pair of gloves.  “Ready?”  She took the dressing down.  The patient’s wound was seething.  Maggots.  Mary said, “I’m sorry, I can’t deal with this.”

“It’s okay.  Get somebody to put hydrogen peroxide on the wound and leave it for half an hour.  Then he can take a shower.”

Yolande was back.  “I don’t think it’s a dystonic reaction.  I still think it’s a dislocation.”

“Are you still dealing with that jaw?  Come on Yolande, we need you.  Send him to X-ray for tempero-mandibular joint views, open and closed.”

It was my mistake again.  I should have recognised a request for help, and gone to take a look.  Instead, I looked into Theatre 1.  Lawrence was suturing to music.  Mozart.  I thought, great!  I’m running round like a headless chook, Yolande’s fixated on a jaw, and Lawrence is listening to Mozart.  Meanwhile outside in the ambulance bay in a gale force wind the ambulances were disgorging.  I spent an hour darting between the broken wrists and ankles, the dislocated shoulders, falls, assaults, crashes, collapses, and the stigmata of hitherto undescribed states.  Suddenly the department was full of big heavy tattooed men in black leather jackets.

“Mary, I don’t want to alarm you, but I’ve just seen an emblem belonging to the Power, and a tatt belonging to the Mob, and when they run into one another, there’ll be hell to pay.  Get the police.”

“They’re on their way.”

The first of the stabbings from the hotel fracas arrived.  “Tension pneumothorax.  Drain, please.  No – skip the X-ray.  Where are Lawrence and Yolande?  Get them in here.  Next!”

“Doctor to Resus 3!”  A girl of 16, unconscious, unresponsive.  The attending staff nurse held up the empty pill bottle.  “Barbiturates.”

“Really?  How old-fashioned.  How long ago?”

“Twelve hours estimated.”  That was really bad news.  Another crash induction.  Yolande came in.  “What’s that?”

“Barbiturates.”  I turned down the right lower eye lid.  “See that?  See the conjunctival oedema.  That’s ‘the tear that never falls’.”

Karen Jones and Mary Heenan came in together.  “That was ambulance control.  Big crash at Ramarama.  Car versus car versus truck.  Six patients, status 3.

Well, just keep working away.  It could be worse.  It could be an earthquake, or a volcanic eruption, or a nuclear holocaust.  I said, “I think it’s time to declare a state of ‘Acopia’.  We’ve run out of hands.  Send for reinforcements.  Are the orthopods scrubbed?”  And Yolande was still messing around with a jaw.

“I got the TMJ views.  Pity I can’t interpret them.”  I took the films and held them up to the light.

“Normal.  See, this is open, this is closed.  See the condyle of the mandible riding forward on the temporal bone.  It’s within normal limits.”

“Well if it’s not dislocated, I don’t know what we’ve got.”

I did what I should have done two hours before.  “Take me to him.  Let’s carry out a quick Grand Round, before the next wave arrives.”

They all lay around, like the wounded on a battlefield, drunks, stabbing victims, overdoses, asthmatics, dislocations and fractures, and the man with the maggots.  I counted six policemen.  The leather jackets had receded into the background.  I looked into Theatre 1.  It was empty.  Completely empty.  The portable CD player and speakers had vanished.

Yolande found her patient.  She swept the curtain of the cubicle aside.  “Here.”

I felt myself blanch.  “He’s got tetanus.”

 

 

 

 

 

 

 

 

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