I didn't expect the patient to die but, of course, he did, and it was my fault.
While my colleagues told me that it wasn't, and I shouldn't blame myself, I knew better.
I was a bad person, and my inadequacy and foolishness were the reasons the man died.
I felt wretched.
The man had arrived at the hospital by ambulance, unconscious but still breathing, and with a weak but rapid heartbeat.
"Unknown middle-aged male," said one of the paramedics loudly as he handed the patient over to the hospital emergency staff. "Found fully dressed but unresponsive in a cubicle of a male restroom in the main grandstand at Cheltenham Racecourse at about ten past seven this evening."
I looked up at the clock on the wall-it was now half past eight.
"There is no indication of how long he'd been there," the paramedic continued. "The last race today was at five after four, so it could have been a while. Both pupils large and unresponsive, blood pressure high but stable at a hundred and seventy over one-ten, pulse one-eighty. He has symmetrical breathing and O2 saturation is at ninety-five percent. Body temperature high at thirty-nine degrees Celsius but not extreme. No obvious trace of trauma but fitted with a collar as a precaution and given supplementary oxygen at four liters per minute on-site and since, plus two hundred and fifty milliliters of IV saline en route. No sign of awareness throughout."
"Blood sugar?" I asked.
"Tested on-site at one-twenty. Retested in the ambulance. Same result."
One hundred twenty milligrams per deciliter was well within the normal range, so the man wasn't hypoglycemic-very low in blood sugar-my first guess for someone unconscious with such a high pulse rate.
"ECG?" I asked.
The paramedic pulled a long strip of pink paper from his pocket and handed it to me. "Shows typical SVT."
I glanced at the electrocadiogram trace on the paper and it certainly looked like SVT-supraventricular tachycardia-a malfunction of the heart's electrical system resulting in a resting pulse rate in excess of 150 beats per minute.
"Any medications?" I asked.
"Nothing on him and nothing given other than the saline."
"Right," I said. "Thank you."
The paramedics collected their gear and departed. Off to another Saturday night crisis.
I looked down at the man lying face-up on the gurney in front of me. He was probably in his early forties, just like me, and he didn't look unusual or remarkable, merely another patient.
He had olive-brown skin with black curly hair that was graying slightly at the temples, and he was clean-shaven under the oxygen mask. He was wearing a white shirt, spread open wide across his chest for the application of the ECG electrodes, together with navy pinstripe trousers, black socks and highly polished laced-up shoes.
As the senior physician on duty in the Cheltenham General Hospital Accident and Emergency Department, I was now responsible for his well-being and I could almost feel the penetrating stares of the three other members of my team burning into me as they waited for my instructions.
Anxiety and panic rose in my throat like a tidal wave.
I wanted to run away and hide.
I silently berated myself. Get a grip. You can do this. This is what you do all the time. Every day. Take a deep breath. Calm down. CALM DOWN!
The panic subsided-for the moment.
"OK," I said slowly and deliberately. "Let's get some bloods done-full count plus everything else. Check for external injuries, especially on the head and neck. Set up vital-signs monitors and we'll send him to CT as soon as we're happy he's stable. There must be a reason why he's unconscious."
It was fairly unusual for someone to remain comatose for so long without any visible sign of trauma, especially someone who must have been walking around at the races earlier in the afternoon. But it was also unusual for someone's heart to beat 180 times per minute.
A drug overdose came readily to mind, as did the possibility of a stroke or a brain tumor-the CT X-ray scan would indicate if it was one of those.
My team of two nurses and a junior doctor set to work removing the man's clothing and connecting him to various monitors. One of the nurses inserted a cannula into a vein on the inside of his left elbow to draw some blood. Another shone a flashlight alternately into each of the man's eyes, watching for the pupils to react to the brightness.
"Still no response on either side," she said.
In a healthy person the constricting of the pupils due to light is an involuntary reflex reaction-it happens without the individual having to think about it-and the lack of it in both eyes could indicate abnormally high pressure in the head or damage to the brain stem, but it could also be the result of having taken certain drugs-barbiturates, for example.
"Ask the lab to specifically check for a drug overdose," I said to the nurse who was filling test tubes of blood from the cannula in the man's arm. "Can we also get a urine sample?"
Seeking to discover what was wrong with the man was a bit like a murder mystery in an Agatha Christie novel, with me taking on the role of the detective. There were many possible suspects for the cause of his condition and I had to determine the guilty one by eliminating each of the others in turn.
I let my team do the intricate work while I stood back trying to take in the bigger picture.
On the periphery of the group hovered a very young-looking uniformed policeman.
"Can I help you?" I said. "I'm Dr. Rankin, Chris Rankin. I'm in charge of A&E this evening."
"PC Filippos." He instinctively put out a hand but I didn't shake it because I was wearing sterile latex gloves.
"Filippos?" I said.
"Yes." He smiled. "Half Greek. I came in with your patient." He waved a hand toward the man on the gurney. "The racecourse called us first. They thought he was drunk. It was me who called the ambulance."
I had wondered why it had taken so long for the man to get to the hospital.
"Well done," I said to him.
"What's wrong with him?" the policeman asked.
"I'm not sure yet. We have to run some more tests. But I don't think he's drunk."
There was a slight trace of alcohol on the man's breath but not the usual overpoweringly sweet aroma of the unconscious drunk. I was well used to dealing with those on a Saturday night. We called them VIPs-very intoxicated persons.
"Any idea who he is?" I asked.
"None at all. I searched his pockets while waiting for the ambulance. All he had on him was eighty-two pounds in cash and one crumpled bookmaker's betting slip. No cards, no wallet, no keys, nothing."
"He must have had a coat," I said. It was far too cold in mid-November to be at the races in only a thin shirt.
The constable nodded. "He did, and a jacket and tie. I have them bagged up." He lifted a clear plastic bag to show me. "Shall I take the rest of his clothes to add to it?"
"He'll need them to go home in."
"If he does go home," the policeman said flatly.
I glanced at him. "Do you know something I don't?"
"No," he said, but I wasn't sure if he was telling me the truth.
One of the nurses interrupted us. "Dr. Rankin, we're ready for the CT."
"Excuse me," I said to the policeman. "I have to go with the patient."
"I'll wait here," PC Filippos said with determination.
I raised my eyebrows at him in surprise.
"It's probably not necessary," he said, "but I'll wait anyway. Then, if he does come round, I'll be able to inform his family. He reminds me a bit of my dad, you know, in looks and the way he's dressed. I'd want someone to tell me if my dad was found unconscious in a racecourse restroom."
"You can wait in the relatives' room," I said. "There's a coffee machine in there."
The CT scan was clear-no visible clots or bleeds in the brain, and no tumor.
More suspects had been eliminated.
I began to feel shaky again.
Stop it. Keep control.
I looked at the monitor that showed the man's heart beating 196 times per minute, even higher than when he was brought in. And the cardiac trace on the screen was becoming increasingly random, strikingly different from the nice smooth, repeating pattern produced by a healthy organ. But, in spite of the irregularity of his heart, his blood pressure was holding up, indeed it was far too high, and the oxygen saturation was steady at 98 percent.
"I'm worried about him," I said to my senior staff nurse.
We had been unable to obtain a urine sample for a dip drug test. Did that indicate that his kidneys were not working properly? I also thought his skin displayed the slight yellowing of jaundice, so was there a problem with his liver function?
Both could be a direct result of his cardiac arrhythmia.
In medicine, as in life, one initial problem could all too quickly spawn a whole raft of secondary troubles.
The blood-test results should give us the answers but we were still waiting for those to come back from pathology. Nothing, it seemed, happened quickly on a Saturday anywhere else in the hospital. But accidents and emergencies didn't respect the normal working week. Indeed, Saturdays and Sundays were by far our busiest days.
"His pulse is still far too fast and getting very irregular," I said. "His heart's clearly tiring. If it is SVT, then it's high time we tried to reset his rhythm back to normal."
I took a deep breath.
"We'll give him six milligrams of adenosine," I said decisively.
"We don't know what else he's taken," the staff nurse said with a note of caution.
Adenosine was an antiarrhythmic medication used to slow an abnormally high heart rate, but it could occasionally react badly with some psychotic drugs.
"I think we'll have to take that chance," I said. "Have you checked him for puncture marks?"
"I did, and I couldn't find anything obvious."
Puncture marks in the skin were telltale signs of an intravenous drug user-and we saw far too many of those.
"We could just wait for the results of the bloods," the staff nurse said. "They'll surely be back soon."
If it had been a weekday between eight and six, I'd have simply phoned a specialist from the coronary unit for some advice, but, at nine o'clock on a Saturday evening, they'd all be either at home watching television or out socializing.
Should I page the on-call duty cardiologist? Drag him into the hospital from his dinner?
I was the senior physician here. If I made the call, the duty heart doctor would be my junior. So it would be my decision anyway.
Do nothing or do something?
Which was right?
I could feel the ends of my fingers beginning to tingle and my right knee began to tremble slightly.
Breathe, I told myself. In through my nose, hold for a second or two, and out through my mouth-just as I'd been taught.
Breathe deeply, and again, and again.
The trembling in my knee slowly died away.
I looked again at the now-alarmingly uneven rapid trace on the monitor. Even if I paged the heart specialist, I was worried that the patient's condition might deteriorate before he arrived.
"I don't think we can wait any longer," I said.
"OK," the nurse said. "I'll get it."
"Also get someone in here with the shocker."
She went off, leaving me alone in the cubicle with the patient.
I glanced down at the man.
He appeared even more vulnerable than when he'd first arrived, probably because all his clothing had since been removed, replaced by a faded blue hospital gown that was not properly secured around his shoulders.
It was not that uncommon for unnamed trauma cases to arrive at A&E, such as lone pedestrians knocked down by cars, but I thought it was a little odd for someone wearing a pinstripe suit plus a tie to have no identification on him whatsoever.
I touched his forehead. It was damp with perspiration.
"Who are you?" I asked quietly into the stillness. "And what's wrong with you?"
He didn't reply. I hadn't expected him to. Instead the monitor above his head simply went on showing me his erratic pulse and over-high blood pressure.
The staff nurse returned holding a small syringe containing the adenosine and a much larger one full of normal saline solution that would flush the drug around to the man's heart.
She was followed in by one of the emergency junior doctors, who was pushing a small metal cart on which sat the shocker-the electrical defibrillator that would be used to give the patient's heart a restarting electric shock in the unlikely event that the adenosine caused a cardiac arrest.
The staff nurse connected both the syringes to the cannula on the inside of the man's elbow such that their barrels sat at right angles to each other.
"OK?" she asked, looking straight at me.
"Ready?" I said, looking at the junior doctor.
"Can I assume that the patient doesn't have a pacemaker fitted?" he asked.
"He does not," I confirmed. It would have been obvious on the CT scan. But it was a good question. Shocking someone who had a pacemaker was still possible but greater care was needed in positioning the electrode plates.
"OK," said the doctor. "I'm ready."
"Right," I said. "Go."
The nurse rapidly depressed the plunger of the small syringe and then immediately followed it with the complete contents of the larger.
Adenosine was rapidly metabolized by red blood cells with a very short half-life. Consequently, it was important to give it very quickly, together with a large bulk of saline, in the hope that enough of the active drug makes it to the heart to cause a temporary block in the atrioventricular node, which in turn should reset the heart back into a normal rhythm.
Our three sets of eyes were firmly fixed on the monitor screen. If the adenosine was going to work, it would do so almost immediately.
Initially, nothing happened, but then the trace went flat as the drug arrived at the heart and the block occurred.
I held my breath.
It was only a few seconds but it seemed like an age before any spikes reappeared. Erratic at first, then more regular, but still overly fast, the pulse counter almost immediately going back up to over 190.
The adenosine had failed to do the trick.
"Bugger," I said.
"Double the dose and try again?" asked the staff nurse. It was normal practice.
I nodded and she went off to fetch new syringes full of drug and saline.
"Are you sure it's SVT?" asked the junior doctor.
"No," I replied, "I'm not sure. We're still waiting for the results of his bloods to come back from the lab."
We stood in silence and waited.
"Double adult trauma call, six minutes," said a seemingly disembodied voice over the department public address system.
Saturday night in A&E.
Busier than an ice-cream seller in a heat wave.