Mr. Johnson was really quite well when he was admitted to hospital with an acute exacerbation of his chronic obstructive pulmonary disease. I took his history, he told me to call him Alex, we chatted and I examined his chest (global reduced air entry, some crackles in the left base, short of breath at rest but speaking comfortably). I asked him whether he was worried, and he wasn’t really; he’d had infections before and they had cleared up nicely. It was alright for me to come back and be observed taking his history, he said, you need to learn.

Alex was transferred to the respiratory ward where he was given antibiotics and a little oxygen. I saw him there every morning as he slowly deteriorated; his oxygen needs rose and the simple mask he’d had when I saw him was replaced by the bulkier plastic of the BiPAP machine – non-invasive ventilation to support people struggling to breathe. I did his blood gases for a couple of days, learning again, and he was patient. He talked less, and his wife sat by his bed holding his hand.

My last day on respiratory I did his blood gas, and instead of the upbeat candour I was used to he communicated only with a nod of consent, and a grimace when I asked how he was feeling. The gas results were unchanged despite his level of treatment, and the doctor was worried. He was at the end of the line, treatment wise – the next rung up is invasive ventilation and that had been ruled out. A treatment is only good so long as you can come off it, and Alex would never have weaned off a ventilator.

I went back on to the ward after the weekend and in his bed was another patient. I spoke to the doctors – he died over the weekend. Tension pneumothorax secondary to a ruptured bulla. Sudden. Not expected, but not unsurprising. The man who spoke so cheerfully and confidently to me at his admission is dead.

That moment is all you get. The ward round doesn’t stop and neither can I. Light a candle, and move on.


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