Within a few days of qualifying as a doctor in the 60s, I found myself working overnight in the Casualty Department of a large city hospital. These were the days before emergency medicine emerged as a specialty and had permanent medical staff.
The initial management of the most acutely ill patients was initiated by the most junior staff. Fortunately though, there were some very experienced nursing sisters on hand to offer support and guidance. Although more senior medical staff were available (but in bed in the doctor’s residency) there were times when I was the only doctor in the department. It was a most unsatisfactory arrangement, unsafe for both doctors and unsafe for their patients.
It must have been about three in the morning when the telephone rang in the tiny bedroom (probably an ex-broom cupboard) in which a bed was available for the duty doctor to sleep as and when the flow of patients allowed.
“Sorry to trouble you, Doctor,” it was Sister’s cheerful voice, “but I’ve got a little job for you.”
“I’ll be right there Sister,” I replied, immediately fearful that the case might be beyond my experience.
I slipped into trousers and shirt, pulled my white coat over the top, and within a minute was back in the department – only to be surprised to discover all the cubicles were empty. An ambulance man, however, was hovering in the corridor. He had a mug of tea in his hand. The kettle in the casualty department was one of the most frequently used items of equipment.
“Oh, there you are Doc,” he said. “I’ve got a B.I.D. for you.”
Doctors use many abbreviations, but this was not one I had heard before.
“You’ve got a what?” I said.
“A B.I.D. in the back of the van, Doc.”
Embarrassed by my ignorance, I stalled.
“I’ll be with you in a minute,” I said and slipped into the office to find Sister.
“What on earth is a B.I.D?” I asked.
“A Brought in Dead,” she replied.
I had no idea what I was supposed to do with a ‘Brought in Dead’ until Sister explained that it meant that the ambulance men had somebody whom they believed to be dead, possibly somebody who had just collapsed and died in the street, “And my role?” I asked.
“Well,” she explained, “the ambulance crew are not qualified to certify death. That’s a medical responsibility so they need you to certify that the patient is indeed dead.
If they are ‘brought in dead’ obviously there’s nothing a hospital can do for them. So we don’t allow them to come through our front door. Instead they go to the city morgue to be dealt with by the Coroner. The ambulance crew need you to sign the death certificate for them.”
Immediately alarm bells started ringing in my head! I had spent five long years at Medical School learning how to make hundreds of different diagnoses but always on the assumption that the patient was alive. I knew the difference between tetanus and tetany; I could diagnose scabies, scarlet fever and syringomyelia; I could even tell you the life cycle of the schistosomiasis parasite, but no one had ever told me how to be absolutely certain, beyond all doubt, that someone was dead.
I knew of course to take a pulse and listen for a heartbeat; but for how long should you listen? Five minutes, ten minutes, half an hour? I’d been a boy scout and learned that if you held a cold mirror in front to the mouth and if condensation formed you knew the patient was alive; but what was the definitive test of death?
It was certainly a diagnosis I couldn’t afford to get wrong; I didn’t want to feature in a ‘Patient wakes up in City Morgue’ newspaper story.
Nervously I went with the ambulance man into the back of his ‘van’, as he called it, but I needn’t have worried about getting this particular diagnosis wrong. The body was in an early state of decomposition, having been found by a caretaker in the back yard of an office block known to be frequented by the homeless. The smell was overpowering.
I felt for a pulse, listened for heart sounds, and checked the reflexes in his eyes, much to the amusement of the ambulance man who clearly regarded such tests as unnecessary.
“Best to be sure, eh Doc,” he said with a wry smile on his face.
I duly pronounced the patient dead and signed a death certificate. Fortunately there was no requirement to make any supposition about the cause of death. All that was necessary was to certify that this decomposing corpse had indeed died and I had no hesitation about this.
I washed my hands thoroughly and returned to my room but it took me some time to get to sleep! I resolved that in the morning I had to find out the definitive diagnostic test for death.
Quotation for the day
Either he’s dead or my watch has stopped. Groucho Marz 1890 – 1977