Pulse by Felix Francis
For my granddaughter Emma Grace Francis
With grateful thanks to Simon Claisse, Clerk of the Course at Cheltenham Racecourse, and to the members of the jockeys’ medical team at Cheltenham, especially doctors Sue Smith, Andy Simpson and Lee Humphreys, nurses Sarah Godfrey and Sue Denley and physiotherapist Jennifer (Rabbit) Slattery.
I promise them that all my characters are fictitious. I hope they don’t mind me taking some liberties.
And, as always, my special thanks and much love to Debbie
PART 1
November
1
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 unconscious in a cubicle of a gentlemen’s toilet 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 4.05 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 per cent. Body temperature high at thirty-nine degrees but not extreme. No obvious trace of trauma but fitted with a collar as a precaution and given supplementary oxygen at four litres per minute on-site and since, plus 250ml of IV saline en route. No sign of awareness throughout.’
‘Blood sugar?’ I asked.
‘Tested on-site at six-point-five. Retested in the ambulance. same result.’
Six-point-five millimoles per litre was well within the normal range, so the man wasn’t hypoglycaemic – 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 electrocardiogram 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 trolley 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 greying 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 consultant 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 a hundred and eighty times per minute.
A drug overdose came readily to mind, as did the possibility of a stroke or a brain tumour – 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 torch 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.