When there is Silence

When there is Silence
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Picture Credits: Ryan McGuire

‘The patient in room six is dead.’

Edward, twenty-five years old and in a thick ironed shirt, takes the binder of notes from a nurse and drops the weight of them on a desk. He opens them at the last page and reads the hurried scrawl.

‘He’s been dead since he came in,’ he says.

Nurse Grace waits for him to look up at her from the notes, then puts a hand on his shoulder. ‘His family will be here soon,’ she says. ‘Tell them he’s dead.’

Edward takes the notes behind the nurses’ station. He opens the thick brown wad, places his arm across them and then rests his head. A couple of chocolate wrappers have been left on the desk and the red foil reflects the white halogen from the lamps above. Edward plays with the wrappers, blowing at them gently from centimetres away, watching the reflected light shimmer against white marble.

Edward’s pager bleats. He sits up, checks the number and reaches for a phone.

‘It’s Paul on Havering ward. Four patients still need blood.’

‘Anything else?’

He hears the connection cut, but keeps the phone to his ear as he sees two people enter the ward: family. They are in a fluster, the woman pressing the door release switch in rapid bursts, continuing even as the electric doors begin to swing open. She is wearing a green puffer jacket. Edward hears her asking Nurse Grace to see the Consultant immediately. He sees her wipe her nose with the back of her sleeve. She has been crying. A man in an old brown suit jacket follows her a few paces behind. He nods at Edward.

‘Evening, sir,’ he says.

‘Sorry,’ Edward says into the phone. The ‘sir’ was surprising. ‘I’ll be with you in a minute.’

Nurse Grace takes a black cardigan from the nurse’s station. She does this to soften the clinical blue uniform. Her and Edward have exchanged these kind of tips since the start of his placement, looking out for each other. She takes the family to room six. Edward ends the fake phonecall. He reads the rest of the notes: Mr. Davian Lawrence, seventy-six, heavy smoker; collapsed this morning with a large haemorrhagic stroke. Treatments, tests, tubing… Neurosurgeons assessed but won’t operate.

Nurse Grace comes out of room six and carefully closes the door. She re-ties her hair.

‘They want to see a Consultant,’ she says to Edward.

‘Why didn’t they operate?’ he asks.

#

In room six, the woman in the green jacket is sitting on a plastic chair by Mr. Lawrence’s bed, holding his hand. Mr. Lawrence’s chest rises and falls with the ventilator:

Pshhhhhh—ft-ft—Pshhhhhh-ft-ft

The man in the brown jacket is standing by the door and greets Edward as ‘sir’ again.

‘We want to see the Consultant,’ the woman says, standing up.

Edward pauses. He remembers the Pathologist’s lecture about difficult families: there is always a path to empathy. What do you see in them? Yourself?

‘My name is Dr. Norrie,’ he says. ‘I just need to examine your father, if that’s ok?’

Edward takes a few steps towards Mr. Lawrence, aware that everything he does is being watched carefully. This minute of silence will be important for communicating the seriousness of the situation. There are choices he makes in the way he performs. First, he takes Mr. Lawrence’s hand, not to examine it, but to begin with an action that seems gentle, mirroring the care of his daughter. Then he flips Mr. Lawrence’s wrist to find his pulse in a swift, well-practiced action, hoping to show that he has experience, despite his relative youth. Pretending to count the pulse gives Edward the time to consider how he will break the news to her. The silence extends its warning. With every small concerned look he gives during his examination, he is helping them to prepare.

‘We bought dad his ciggies,’ says the man in the brown jacket. Edward notices that his tie is too long. It is dangling over the bed by Mr. Lawrence’s feet.

Edward completes his performance by placing a hand on Mr. Lawrence’s shoulder. ‘Do you mind coming to the office?’ he asks.

#

Nurse Grace is already sitting in the office. Edward sees that she is holding the white envelope containing leaflets on bereavement, instructions for contacting funeral services, how to register a death. He remembers the leaflets in detail. Mr. Lawrence’s son is smiling, still calling Edward ‘sir’. His daughter is leant forwards on her chair. She looks aggravated, cracking the knuckles of her fingers one at a time.

It is best not to delay.

‘I am really sorry to have to tell you this. But your father has passed,’ Edward says, and then wonders why he has phrased it so poorly after so much practice. ‘The ventilator is…’

He cannot continue with his speech because the son has transformed. He is bent over. He wails. It comes from his stomach, from his skin. He is smaller than he was, his jacket shoulders are up above his neckline and engulfing his slight, arched frame. He is holding his eyes and sobbing with an intensity that Edward recognises. It is loud, genuine. He has to make space for it.

The daughter has not changed her position. She has not tried to comfort her brother.

‘Dad is still breathing,’ she says. ‘You’re giving up on him.’

Edward waits to answer, not wanting to seem sharp in his reaction. He is desperate to smoke.

He tries a different approach: ‘I can see that you’re…’

‘You have to give him a chance,’ she says.

‘Your dad has had a very large bleed,’ Edward says. ‘He won’t recover. The ventilator is breathing, but he is not.’

Nurse Grace, who has a hand on the son’s back, holds out the white envelope. ‘If you need more time with your father…’ she begins. But the daughter stands up, snatches the envelope from her and points it at Edward.

‘You’re going to kill him,’ she says.

#

The next hours of Edward’s shift follow the usual pattern. What promises to be a quiet night on a well-run ward, becomes more complicated as the hours pass. One patient’s oxygen levels drop suddenly, the night-shift radiologist is called. Blood results that are missing turn out to be the most important, most urgent; and all the while the metallic bleating pager. Every task is made harder by the lingering feeling Edward has, that he has not managed room six well.

Bleat!—Bleat!—Bleat!

Havering Ward. Edward picks up the nearest phone and dials through, telling them he’s on his way.

#

In the corridor between HASU and Havering, Edward is away from the noise. No-one is trying to get his attention, no-one is watching him, but in the relative hush, Edward thinks he can hear music. At first it is so soft that it hardly exists above the low hum of the elevators. But as he moves closer to the ward the music is surer, more precise, coming from somewhere other than himself. It is a piano—four minor chords in series, building in volume and then resolving on a soft bass note. It is late. Edward is annoyed. He enters Havering ward, rushes past the nurses station to the rehabilitation room at the back. There is music.

Lilly Beale, eighty-four and paralysed down her left-hand side, is playing the piano with her left arm propped up on a bar. Her fingers are moving as if released from their palsy by a charm. Nurse Paul is sitting beside Lilly, helping to position her arm and nodding encouragingly at her. Edward stands at the door unnoticed, watching Lilly play the chords. He thinks of Mrs. Campbell in room four who needs to sleep; her greying skin and darkening eyes, the erosion in her stomach, the shaking necessity to drink. He stares down at the pattern on the linoleum floor. The harsh hospital lighting reflects off the blues, blurring the edges of the patterned white circles and causing them to tilt.

’It’s late.’

‘Dr. Norrie.’

Mrs. Beale stops playing the piano. The sounds of the ward, which were smothered by the piano until now, return. They are just as loud.

‘Amazing isn’t it?’ Nurse Paul says. ‘The Physio says it’s muscle memory. Retraining.’

‘The trick is to ignore her left hand,’ he says. ‘Forget that she’s playing.’

#

Edward’s pager begins. Bleat!—Bleat!—Bleat! Bloods need taking. Bleat!—Bleat!—Bleat! A new patient coming up from emergency. Bleat!—Bleat!—Bleat! Mr. Moise has fallen out of bed and needs a neuro assessment. Bleat!—Bleat!—Bleat! then Bleat!—Bleat!—Bleat! and then Bleat!—Bleat!—Bleat! With no time to see which number is bleeping at him. Bleat! Three one five four Bleat! Three nine four… Bleat! Zero one… Bleat!—Bleat!—Bleat!

Back on HASU Nurse Grace tells Edward that the Consultant is coming in to talk to Mr. Lawrence’s family. Edward feels an urge to look in on Mr. Lawrence again, check back on the ventilator. Nurse Grace sees that he is stressed, asks if he wants a cigarette. But there is no time, since another bleep sends him to Bexley ward.

Bleep: Mr. Childs, ninety-four, End of Life Pathway. Nil-by-mouth. Edward scans through the notes when he arrives. Son has asked if he can bring in a beer tomorrow for his dad. Ask on-call doctor.

Edward turns over the page. This is the last entry. He sighs—why can’t this wait until the morning?

Patient is not advised to take any fluids by mouth: risk of choking, Edward writes, and then closes the notes. He looks down his list of tasks and catches sight of his watch. He stares at the second-hand moving and becomes aware of the silence on Bexley ward. It is something remarkable. When his pager is not bleating and he is not scribbling notes or rushing between wards, the hospital can be noiseless. The racket he thought he was hearing was only a projection of the endless list of tasks in his head. He wishes he could switch it off, for the patients to stop hassling him. If only their issues could go unnoticed.

Edward re-opens Mr. Childs’ notes and continues writing. On this occasion, however, Mr. Childs and his son should be allowed to share a beer. He is on an End of Life pathway. They know the risk.

#

On the way back to HASU, Edward takes the stairs. He climbs three flights and at the top he pauses to listen. He can hear the piano chords again, he thinks, but if he concentrates he can make the sound disappear.

On HASU, Nurse Grace is standing at the entrance waiting for Edward. She nods towards the doctor’s office.

‘Dr. Andrews is with the family,’ she says.

Edward brings up Mr. Lawrence’s brain scan on the computer, knowing that the Consultant will want to see it. He looks at the thick white circumference of skull and the wisps of grey matter bundled over to the right-hand side. Pushing against it is a giant white ball of blood. It is death. It grows, shoving itself against memory and personality, the ability to control a limb or to blink; to listen to a name and repeat it. Desires, madness, a capacity to suppress them both, gone. It was over a long time ago. Anything left is just noise. At the borders of the remaining grey tissue, a bright white flame of active bleeding. This blood—how did he unlearn the horror of it?

Edward turns off the screen. He feels the computer monitor had been screeching at him. He takes a deep breath in and two sharp breaths out. Edward takes the batteries out of his pager. He places them on top of the red foil wrappers. They crackle and slam like thunder. He looks for Grace, but she is gone. He is shaking.

Standing up, Edward is knocked back by the force of noise on the ward. Mrs. Fairway is shouting again, an oxygen alarm pings and the slow hiss of the ventilator becomes shrill. Edward steps back, finds the handle to the medicine room, enters the code and slips inside.

He pictures himself lifeless, silent. His face blue and mottled. His eyes sunken, bruised. He sits on the floor and opens a cupboard, knocking boxes of paracetamol and antibiotics to the floor. At the back he finds a white plastic bag that Nurse Grace has kept for him with his cigarettes and pills.

In thirty minutes in room six, Mr. Lawrence will be lying still, except for his chest, which will continue to rise with the rhythm of the ventilator. Edward will be standing next to the bed. Whilst watching Mr. Lawrence’s head, he will be able to see two realities. In the first he will see Mr. Lawrence sucking air into the tube, his desire to live drawing oxygen from the machine. And in the second, he will see it as it is. There is nothing here that is alive. The movement is an abuse. Edward will take two cigarettes, put one between Mr. Lawrence’s lips and take the other for himself. He will hold the cigarette in his right hand. With his left he will hold a finger against the switch.

Pshhhhhh—ft-ft—Pshhhhhh-ft-ft—Pshhhhhh…

When there is silence, there is peace.

Daniel Hutley

Daniel Hutley is from Essex in the UK. He now lives in Melbourne, Australia. He has published short stories in Gargouille Journal, the Visible Ink anthology and Storgy magazine. He came second place in the June Shenfield poetry award and in the John Shaw Neilson poetry award. He has featured at poetry gigs around Melbourne. danielhutley.tumblr.com

Daniel Hutley is from Essex in the UK. He now lives in Melbourne, Australia. He has published short stories in Gargouille Journal, the Visible Ink anthology and Storgy magazine. He came second place in the June Shenfield poetry award and in the John Shaw Neilson poetry award. He has featured at poetry gigs around Melbourne. danielhutley.tumblr.com

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