097: He was at the door

Last week, I was tasked on examining patients at the ward round. I knew the male patients on the ward, I was familiar with their cases - it shouldn't be that hard. So of we went, a team of 3, going around checking our patient's medical statuses. Most were medically fit, waiting for a package of care at home, or more physiotherapy, or the delivery of equipment to their flat. We wheeled our computer and cart carrying everyone's medical notes around the corner to Bed 6.

There was Mr F, a gentleman in his late seventies. A man who has been medically fit for a week now, but just waiting for the proper setup in his care home to be in place for him to be safely discharged. His body was frail, skeletal even and his mind was riddled with dementia. I remember him as being alert some days calling for my attention from his bed, and some days too tired to open his eyes.

*Details have been altered to preserve patient confidentiality

He was asleep when I approached his bed. I tried waking him up but he was engulfed in a deep circadian rhythm. I listened to his chest - it sounded crackly. His lungs were scarred from a long history of smoke inhalation, and looking at his history, his lungs were never clear. We suggested the nurse to start him on nebulisers to ease the shaky breathing. However, I did notice a few other strange things. His breathing was irregular, it was like he was intermittently gasping for breath. And his heart sounds seem to beat in a group of threes, spaced out with pauses. I peaked at his neck, his carotid pulse was very much visible due to the lack of anything but skin shielding it from view. That was regular. So I didn't really think much of it - I convinced myself: maybe he is snoring, and maybe I didn't hear the heart quite right. His observations were stable, nothing alarming to suggest he was ill. 'Discharge planning' was the plan. Off to review the next patient.

After seeing 2 patient after Mr F, the nurse drew the curtains around cubicle 6. I looked back from examining the patient in cubicle 8 to find that both my colleagues disappearing behind the curtain. I went to follow them to find Mr F's lifeless body.

"He is gone," said the nurse.

It felt like all the blood drained from my head. Panic-stricken, I asked my senior whether I should call for help. ABCDE? Cannula? Oxygen? Something???

"I don't understand. He was breathing 5 minutes ago?" I said, "How can this happen?"

"Don't worry. He just passed peacefully. If we were to put out a medical emergency call, they would not have intervened - he has a DNACPR in place."

Did I miss something? Could I have detected something earlier? Apparently no is the answer. I told my senior the pecularities of my examination findings and she told me that they were signs of dying. Agonal breathing, irregular heart beat - he was at death's door - and there was nothing that could have been done to prevent nature from taking its course.

Still shaken at this point, she asks, "Are you ok?" "No, I have never encountered this before. He was alive a few minutes ago. But its fine, lets finish the ward round." I have seen many corpses by now, and I have encountered patients that are dying from known illnesses, but this blindsided me. I had yet to encounter a medically well patient just slip away like he did. So quietly, with little warning.

After the ward round, I entered the meeting room to tell my consultant what had happened. By then, the news had already circulated around the ward. Another staff member uttered, "Did you know it was his birthday today?"

He came into this world on the same day he left.

096: A dead squirrel

I have been cycling on my new Brompton to work. Well, from the train station to the hospital - but that still counts! I take a different route to and from the hospital. This is mainly influenced by the route's specific degree of incline. I'd rather go short and steep, as opposed to long but less steep - if this makes any sense.

Anyway, on one morning, whilst cycling up the normal steep hill I take, I spotted an unusual object of curiosity at the wedge found between the pavement and the road. It was not yet autumn, but there were auburn leaves on the street. Amidst the orangey chaos of colour was the carcass of a squirrel. It looked like its life came to a literal halt after taking a leap to far, one that landed it in front of incoming traffic. Its stomach was split in half, dried blood was on the road and flies had begun to circle its lifeless body. I wasn't its only curious onlooker, the child walking down the hill holding his school bag in one hand, had also pointed to it in disgust, saying "Whats that thing, mom?"

I swerved my bike away from it like a skateboarder avoiding an orange cone. I didn't want its fur or blood or guts on my beautiful new tyres, no way! The same child also had similar ideas - he took a few steps away from his linear route. It was as if there was an invisible no-tread zone circling at least 10 metres from the squirrel. After my split second encounter, I didn't think much of it.

However, with every passing day, I would observe the shrinking existence of the carcass. As it was on cement road, I hypothesised that its degradation process was just much slower than if it was on soil. From full but broken form, to furless meat, to bone, it was finally reduced to nothing more than fragments of specimen. After a week, one would not even be able to tell that something had died at that spot a few days earlier.

It made me reflect on death. How when a soul finally leaves its home, it will most likely become at best an object of taboo, and at worst an object of disgust. We prevent ourselves from associating or being in close contact with a lifeless body, unless that is your life's profession. Even as a doctor now when death is a commonality, there is a different feeling when we have to either certify a patient's death or when visiting the morgue. It may be rooted from the uncomfortable feeling of realisation that its fate will soon become your fate. But most times this realisation is blanketed with emotions of fear and disgust.

Ultimately, even the highest and most powerful of people, will become that dead squirrel on the road. In death, they will become mere objects to be avoided, before they are finally reduced to nothingness. And such is the (pun intended) cycle of life.