Untitled

Beth, 35 ans, est en urgence absolue après avoir été victime d’un arrêt cardiaque lors d’un match de football avec son club amateur. Il y a encore quelques minutes, elle débordait de vie et d’énergie. Les médecins se luttent sans relâche pour la ramener.

Les médecins donnent tout pour la sauver.

AWAKE

Big Thanks to @cprlair for the inspiration with the CPRIC phenomenon featured in this story

[TW: Cardiac Arrest, CPR, Defibrillation, Pulmonary Embolism, Nudity, Blood, CPR-Induced Consciousness, Graphic Medical Detail]

Imogen Frost was twenty-one years old and she had been sitting at the same desk for forty-one hours out of the last forty-eight. She was a third-year law student at a university in the north of the city. Her finals started on Monday. It was Thursday. She was taking constitutional law on Monday, torts on Wednesday, and contracts on Friday, and she was behind on two of the three because she'd spent the first half of term on a moot court competition that had gone better than she'd expected and had eaten three weeks she hadn't been able to spare.

She was long and thin and had brown hair that went to her shoulders, usually kept in a clip but currently falling around her face because the clip had been lost to the chaos of her desk. She had dark eyes and a narrow face and the specific exhausted pallor of someone who had been eating Nutribars and drinking coffee as their only nutrition for three days. Her skin was greasy at the T-zone. She had a spot coming up on her chin. Her knuckles were red from where she kept gnawing at the skin when she was thinking.

She lived in a two-bed flat above a bookshop with her flatmate Tabitha. They had met at a freshers' event in first year and been put in halls together by random allocation, and had decided at the end of that year to sign a lease in second year and then again in third. They were not romantic. Tabitha was straight. Imogen was straight. They were the kind of close female friends who knew each other's cycles and had seen each other cry about boys and had shared the flu in winter and a single functional hair dryer.

Tabitha came home at six on Thursday evening with a Tesco bag containing a bottle of wine, two pasta ready-meals, and a packet of Maryland cookies. Tabitha was twenty-two, doing a biology degree, more sensible than Imogen about food and sleep. She found Imogen at her desk in exactly the position Tabitha had left her in at ten that morning.

"Imo."

"Mm."

"You haven't moved."

"I moved. I went to the bathroom. Twice."

"When did you last eat?"

"I had a Nutribar at... I don't know. One? Two?"

Tabitha put the wine on the kitchen counter. She brought one of the pasta ready-meals to Imogen's room. She sat on the edge of Imogen's bed, which had not been slept in since Tuesday night. Imogen had been sleeping on the sofa in four-hour chunks between study sessions.

"Eat this."

"In a sec."

"Now. Eat this now. I'm watching."

Imogen sighed. She turned in her chair. She pulled the tray toward her. She ate four bites of pasta, slowly, without really tasting it. Tabitha watched her. Tabitha was in her running kit because she'd just come back from a run, the particular tired-but-good look of someone who'd done ten kilometres at a good pace and was going to shower in a minute.

"You need to sleep tonight. Properly. In the bed."

"I can't. I have three days of torts to revise and I haven't looked at contracts since Easter."

"Sleep for six hours. You'll revise better tomorrow."

"Taba. I know. I can't."

Tabitha leaned forward. She looked at Imogen properly. She had been noticing small things for fifteen minutes and was now beginning to surface them.

"Your left leg looks swollen."

"What?"

"Your left leg. From the knee down. It's bigger than the right."

Imogen looked down. She was wearing baggy joggers. She pulled the left leg up. Tabitha was right. The calf was visibly larger than the right calf. The skin was slightly reddened. When Imogen pressed on it with her finger, the impression stayed — pitting, subtle, but there.

"Huh."

"How long has it been like that?"

"I don't know. I haven't looked at my legs."

"Does it hurt?"

"It's sore. I thought it was because I've been sitting all week."

Tabitha sat back. She looked at Imogen's leg. She looked at Imogen's face. She was a biology student and she had done a first-aid course and she had read health content on the internet and she had had a tutor last term who had mentioned deep vein thrombosis in the context of haemostasis. She put these things together.

"Imo. That could be a DVT."

"It's just swelling."

"That's what a DVT looks like. Unilateral calf swelling. Redness. Tenderness. You've been sitting at your desk for basically a week. That's a risk factor."

"Taba, I don't have time for A and E tonight."

"You might have a blood clot in your leg."

"It's probably nothing."

Tabitha looked at her. Then she got up and went to the kitchen. She got her phone. She called NHS 111 quietly from the kitchen. She described the calf, the swelling, the tenderness, the redness, the sedentary context. The 111 operator asked about chest pain, shortness of breath, cough. Tabitha said no to all three. The operator said to come in within four hours. She booked an appointment at the urgent treatment centre attached to the main hospital.

Tabitha came back. "You're going to the hospital tonight. I've booked an appointment. They'll see you in about two hours."

"Tabitha, oh my god —"

"I'll drive you. It's two hours. You can bring your notes. You can revise in the waiting room."

"You can't force me —"

"I'm not forcing you. I'm just saying I've booked the appointment, I'm driving, and you can come or not come. If you don't come I'll have wasted two hours of my evening."

Imogen stared at her. Tabitha stared back. They had this dynamic sometimes — Tabitha would go around the outside of Imogen's stubbornness and neatly close off the exits — and Imogen knew when it was happening and also knew that it meant Tabitha was serious. Tabitha had pulled this twice in three years. Once when Imogen had been about to text a terrible ex. Once when Imogen had skipped her cervical smear.

"Fine," Imogen said. "Fine. But I'm bringing my notes."

"Bring your notes."

Imogen packed a tote bag with her torts textbook and her flashcards and her laptop and a portable charger. Tabitha showered quickly and came out in clean jeans and a jumper. They left the flat at six-forty. They took the bus to the hospital — Tabitha insisted on the bus because the traffic was bad. During the ride Imogen's calf, which she was now paying attention to, felt harder than she'd realised. Not painful. Tight. She pressed it again. The pitting was still there.

They arrived at the urgent treatment centre at seven-twenty.

* * *

The urgent treatment centre was in a side wing of the main hospital. A small waiting room, plastic chairs, a screen showing queue numbers, a reception desk. Imogen checked in. She filled in a form. She sat down. Tabitha sat next to her.

Imogen took her textbook out. She tried to read. The words were not sticking. She was tired and the bus journey had given her a headache. She put the book down after five minutes. She leaned her head against Tabitha's shoulder. Tabitha let her.

"Thank you," Imogen said.

"Don't thank me. Just have it not be a blood clot."

"Deal."

They were called at eight-oh-five. An advanced nurse practitioner — a woman in her forties — took them into a side room. She examined the leg. She measured the circumference of both calves. The left was three centimetres larger than the right. She pressed on the calf and Imogen gasped — the pressure on the belly of the muscle produced a deep, grinding pain. Homans' sign positive. The nurse did a Wells score. Imogen scored high — swelling, tenderness, recent immobility, no alternative diagnosis.

"I want to send you through to A and E for a Doppler ultrasound and bloods," the nurse said. "This looks very consistent with a DVT. A and E can also start you on treatment doses of blood thinners while we wait for the imaging."

"How long will that take?"

"A few hours. If it's confirmed you'll be on anticoagulation for three to six months. You might need admission overnight for the initial dosing."

"Tonight?"

"Probably."

Imogen looked at Tabitha. Tabitha looked back with the specific expression of someone who had already known this and was not going to apologise for knowing it.

They were walked across the corridor to A and E. The waiting room was larger and busier. The triage nurse took Imogen's obs. Heart rate a hundred and four. Blood pressure one-eighteen over seventy. Sats ninety-six on room air. Respiratory rate twenty. Temperature thirty-six point eight. The heart rate was up from the UTC reading and the respiratory rate was too, but within a range that could be explained by anxiety and fatigue.

"Any chest pain?" the triage nurse asked.

"No."

"Shortness of breath?"

"Not really. A little, when we walked across the corridor, but I'm knackered in general."

"Cough?"

"No."

The nurse wrote it down. She triaged Imogen as category three. She sent them to the minor injuries bay for cannulation and bloods.

They waited. A junior doctor came at eight-forty-five. He cannulated Imogen's left hand — one attempt, smooth, the cannula sliding in, the bloods drawn into four tubes. He put up a bag of saline. He told her the Doppler would happen within two hours.

Tabitha sat in the chair next to the bed. Imogen was on the trolley, propped up on the pillow, her laptop on her knees, trying to revise. The bay around them was the standard A and E bay — curtains on rails, the beeping from the next bay where someone was on a monitor, the footsteps in the corridor, the intermittent voice of the nurses calling out numbers.

"How are you feeling?" Tabitha asked at nine-fifteen.

"I'm okay. Tired. A bit out of breath. But I've been tired for a week."

"Out of breath how?"

"Like when I take a deep breath it doesn't quite feel like it's getting where it's meant to. And it hurts a little on the right side."

Tabitha sat forward. "Imo. Say that again."

"I said I'm tired."

"No. The breathing thing. You're saying you feel short of breath and have right-sided chest pain."

"Yeah. A little."

"Imogen. Those are symptoms of a pulmonary embolism. A DVT can travel to the lungs. That's the dangerous part."

"I told the nurse I didn't have chest pain."

"But now you do."

"A little. It's probably from sitting in weird positions."

Tabitha did not roll her eyes but Imogen could feel her not rolling her eyes. Tabitha stood up. She went to the nurses' station. She came back with a nurse in tow.

The nurse was in her mid-twenties, Asian, neat ponytail, badge reading SENIOR NURSE. She came into the bay with a calm efficiency. She connected the monitor. Heart rate a hundred and twelve. Sats ninety-three on room air. Respiratory rate twenty-four.

"When did the breathing start being uncomfortable?"

"I don't know. Maybe half an hour ago. It's not that bad."

"Your sats have dropped from ninety-six to ninety-three in the last hour. And your heart rate is up."

"Am I —"

"I'm going to escalate this. One second."

The nurse left the bay. She came back with the A and E registrar. Early thirties, male, harassed-looking. He examined Imogen quickly. He listened to her chest. He checked the calf. He looked at the obs.

"I think we're dealing with a DVT that has thrown a clot to the lung. I want a CTPA urgently. Start treatment dose enoxaparin immediately. We're moving you to resus until we know what we're looking at."

"Resus? Like resuscitation?"

"It's our monitored area. You're stable. But we want you on continuous monitoring. It's a precaution."

Imogen looked at Tabitha. Tabitha's face had gone slightly pale but was holding. Tabitha reached for Imogen's free hand and squeezed it.

They moved her. The trolley was wheeled out of the bay, down the corridor, into resus bay one. Resus was bigger, brighter, busier. There were two other patients when they came in — an older man in resus three having an ECG done, an unconscious woman in resus five with an oxygen mask and a team around her. Imogen's bay had a full resuscitation setup at the head of the bed — defibrillator, airway trolley, drug cabinet, ventilator standby.

Tabitha was allowed to stay. The charge nurse — the same neat-ponytailed senior nurse who'd escalated — introduced herself properly: Elena.

"Imogen, I'm going to be looking after you in here. Your friend can stay. We're going to put more monitoring on you and get you ready for the scan."

Elena put electrode pads on Imogen's chest — peeled them from the packaging, moved the hospital gown aside to stick them to her bare skin. Three on her chest, one on her left side. The cardiac monitor lit up. Sinus tachycardia, a hundred and sixteen, narrow QRS. Elena put a finger sensor on Imogen's right index finger. The sats read eighty-nine.

"Eighty-nine. Let's get you on oxygen."

The non-rebreather mask went on. Fifteen liters. The hsssss of high-flow oxygen. The reservoir bag inflating and deflating. The mask fogging with each exhale. Imogen's sats climbed to ninety-four. Not all the way up. Still low for a healthy twenty-one-year-old.

Tabitha sat in the chair next to the trolley. She had both her hands clasped between her knees. She was watching Imogen's face through the clear plastic of the mask.

"How are you doing?"

"Tired. My chest is achier now. I think because I'm paying attention to it."

"Yeah. Try not to pay attention to it."

"That's unhelpful advice."

"I know."

Imogen laughed a small laugh behind the mask. Then the laugh cut short because laughing hurt. The right-sided pleuritic pain sharpened. She grimaced. The mask fogged in a sudden burst.

Elena was nearby, watching the monitor at all times. Heart rate a hundred and twenty-two. Sats ninety-three. The numbers were drifting in the wrong direction.

The CTPA was going to happen at ten. It was nine-thirty now.

The porter came at nine-fifty. Imogen was wheeled down to CT with Elena alongside pushing the portable monitor. Tabitha was left behind in resus. The CT itself took four minutes. Imogen lay on the scanner table with the non-rebreather still on her face, the hsssss loud in the enclosed tube, the contrast being injected through her cannula. She felt the warm flush of the contrast up her arm, into her chest, the characteristic flush and the metallic taste that always came with it. The radiographer did three passes. She was wheeled back to resus.

The results came up on the A and E registrar's screen at ten-oh-four.

Massive bilateral pulmonary emboli. A saddle embolus sat at the bifurcation of the main pulmonary artery, with extensive extension into both the right and left pulmonary arteries. The right ventricle was markedly dilated — a classic sign of right heart strain. A small infarct was visible in the right lower lobe. The clot burden was large. The haemodynamic picture was consistent with a submassive PE teetering on massive.

The A and E consultant came to the bay at ten-oh-nine. A big woman in her fifties, grey-blonde hair, direct manner. She explained to Imogen and Tabitha together.

"You have a very large blood clot in the arteries of your lungs. It's putting significant strain on the right side of your heart. You're young and otherwise well, which is the good news. The treatment for this size of clot is a drug called alteplase, which breaks clots down rapidly. The risks of alteplase include bleeding — we check your blood results to make sure you don't have a reason you shouldn't have it. If your bloods are okay, we'll give it, and it starts working within thirty to ninety minutes. During that time you'll stay in resus on continuous monitoring."

"Okay," Imogen said. Her voice was quiet behind the mask.

"I want to be honest with you. This is a serious situation. People with PEs of this size can deteriorate quickly. We are watching you very closely. If you get worse, we will need to do more aggressive things — put a breathing tube in, possibly perform a procedure to remove the clot mechanically. The goal tonight is to prevent that by getting the alteplase on board fast."

"Am I going to die?"

The consultant paused. It was the pause of an experienced clinician who had been asked the question many times before.

"The odds are strongly in your favour. You're twenty-one. Your heart is otherwise strong. The treatment usually works well. But the size of this clot means I'm not going to tell you there's no risk. If things change, we'll do everything we can."

"Thank you."

The consultant left. Elena was already preparing the alteplase. The bloods from earlier had come back within normal range — no contraindications. The fifty-milligram bolus was drawn up. The fifty-milligram infusion was put on a pump. Elena explained each step.

Tabitha was in the chair. Her eyes were wet. She was trying not to cry in a way that was both obvious and admirable.

"Taba."

"Yeah."

"I'm going to be fine."

"I know."

"I'm going to pass my torts exam."

"I know."

"I'm going to be a solicitor and bill absurd amounts per hour and take you out for fancy dinners."

"I'm going to hold you to that."

The alteplase went up. The bolus over one minute. Then the infusion. Elena started the pump. Ping. Whirr. The drug began running. Imogen looked at the pump, then at the monitor, then at Tabitha.

Heart rate one-twenty-eight. Sats ninety-three on fifteen liters. Blood pressure one-oh-two over fifty-eight. Dropping.

* * *

Ten minutes into the alteplase infusion the trace changed.

The narrow complexes that had been sinus tachycardia at one-twenty-eight widened. They became irregular. They became fast. A run of wide beats at a hundred and sixty. Then another run. Then a sustained run that didn't stop.

"VT," Elena said, calmly. "Sustained. Imogen, stay with me. Can you feel your heart racing?"

"Yes." Imogen's voice was thin. "It's thumping. My vision is going funny."

The blood pressure reading came through — seventy-two over thirty-six.

"She's unstable. Going to cardiovert."

The A and E consultant was back at the bedside in under a minute. The registrar was also there. The crash team was being paged.

"Imogen, your heart is in an abnormal rhythm because of the strain from the clot. We need to reset it with a synchronised shock. You'll be given a sedative first so you don't feel it. Okay?"

"Okay."

"Tabitha, I'm going to ask you to stand against the back wall please."

Tabitha stood up. She backed against the wall. Her hands were flat against the wall behind her. She was crying now, quietly, without sound. She did not leave.

Elena untied the hospital gown at the back and pulled it open at the front. Imogen's bare chest was exposed — the electrode pads already on, the pale skin, the narrow ribcage of a thin twenty-one-year-old. Elena placed the defibrillator pads over the existing electrodes. One below the right collarbone, above the right breast. One on the left side, below the left breast. The pads were cold. The gel was cold. Imogen's skin prickled.

The anaesthetist had arrived. She drew up ten milligrams of propofol. She pushed it through the cannula in Imogen's hand.

"Count backwards from ten, Imogen."

"Ten. Nine. Eight —"

Gone.

"Charging. One hundred joules synchronised. Clear."

Everyone stepped back. The defibrillator whined. The tone sustained. The registrar pressed the button.

Ka-chunk. Imogen's body jumped on the trolley. Her chest lifted. Her bare breasts shifted. Her arms jerked outward. She fell back onto the mattress.

The trace: narrow complex. Sinus. Sixty-four.

"Converted. Rhythm is sinus."

The room exhaled. The blood pressure came up on the auto-cuff: ninety over fifty. Not great but present. The sats climbed to ninety-five. The alteplase was still running. The cardioversion had given them a rhythm to work with.

Imogen was unconscious from the propofol. Elena pulled the gown closed loosely over her chest, leaving the defibrillator pads accessible in case they were needed again. She repositioned Imogen on the pillow. She wiped the gel from around the pads. Tabitha came back toward the trolley, cautiously.

"Is she okay?"

"She's okay. The rhythm converted. She's going to be groggy when the propofol wears off — about ten minutes — but it worked."

"Thank God."

"We're not out of the woods. The clot is still there and the alteplase is still working on it. She may deteriorate again before things get better. But for now she's stable."

Tabitha nodded. She stood at the side of the trolley. She looked at Imogen's face. Imogen's eyes were closed. Her mouth was slightly open. The oxygen mask was back on — the non-rebreather — and the reservoir bag was inflating and deflating gently with each slow propofol-dampened breath.

"She looks so young," Tabitha said.

"She is young," Elena said.

"I know. I know but she looks — she looks like when we first met."

"Sit down. Take a breath. She's stable right now."

Tabitha sat. She put her head in her hands. She breathed.

Imogen began to stir at ten-thirty-six. Her eyes opened. Unfocused at first, then tracking. She looked at Tabitha. She looked at Elena. She looked at the mask. She brought a hand up to the mask.

"Leave the mask on, love," Elena said. "You had an abnormal heart rhythm and we had to give you a shock to fix it. You're okay. You're in the hospital."

"Did it work?"

"It worked. Your rhythm is normal now. The alteplase is still running. We're watching you closely."

"Taba?"

"I'm here, Imo."

Tabitha took Imogen's free hand. Imogen squeezed back. Her grip was weak.

"I'm tired," Imogen said.

"I know."

"My chest hurts."

Elena leaned over. "Describe it."

"Deep. In the middle. Heavy."

Elena looked at the monitor. Sinus at seventy-four. Sats ninety-four. Blood pressure ninety-two over fifty-four.

"I'm going to let the doctor know."

* * *

At ten-forty-two Imogen's heart rhythm deteriorated again.

The monitor trace widened. The sustained VT came back. Rate a hundred and sixty, then one-seventy. The propofol had worn off. The alteplase hadn't yet broken down enough clot to relieve the right heart. The right ventricle, working against the obstruction, had exhausted again.

"She's back in VT."

Elena was already on the defibrillator. The pads were still on. She pulled the gown open again. The consultant was in the bay within thirty seconds.

"Sustained VT. BP sixty-four over twenty-eight. She's lost a pulse."

"Pulseless VT. Treat as cardiac arrest. Start CPR."

Elena climbed onto the side of the trolley. She placed the heel of her hand on Imogen's sternum between the pads. She interlocked her fingers. She pushed.

The first compression was deep. Five centimetres. Imogen's thin chest flexed. Her bare breasts shifted with the force. Her body rocked on the mattress. The mask moved on her face. Her eyes were closed.

Push. Release. Push. Release. A hundred and ten per minute.

Tabitha was against the wall again. Her hands were on her mouth. Her shoulders were shaking.

"Charging. Two hundred joules. Clear."

Elena lifted off. The defibrillator whined. Ka-chunk. Imogen's body jumped. Her bare chest lifted. She fell back.

The trace: VF.

"Resuming CPR."

Elena was back on the chest. Push. Release. The anaesthetist was at the head of the trolley. She took the non-rebreather off. She placed the BVM over Imogen's face. She squeezed. Whoosh. Chest rose. Whoosh.

"Adrenaline one milligram."

The drug went in through the cannula. Flushed with saline. The compressions circulated it.

Two minutes. Rhythm check. VF.

Ka-chunk. Third shock. VF still. Compressions resumed.

Then Imogen's eyes opened.

Elena saw it first. She was mid-compression, her hands between Imogen's breasts, pushing, and she looked at Imogen's face because the muscle-tension in Imogen's jaw had changed. Imogen's eyes were open. They were unfocused at first, then tracking. They found Elena's face. They focused.

"She's awake," Elena said. "She's awake during CPR."

Imogen's lips moved. The BVM was over her mouth. The anaesthetist pulled it back slightly.

"Please." Imogen's voice was thin, air being pushed out of her lungs by the compressions. Each word came on an exhale forced by a hand on her sternum. "Please stop."

"Imogen, your heart has stopped. We have to keep going. The compressions are keeping blood flowing to your brain. If we stop, you'll lose consciousness again."

"It hurts."

"I know. I'm so sorry. I know."

The phenomenon was CPR-induced consciousness. It happened rarely — maybe one in every three hundred codes — and it happened when the compressions were effective enough to perfuse the brain adequately while the native heart was not functioning. The brain was getting enough oxygen to wake up and register what was happening. What was being registered was a pair of hands pressing five centimetres into the sternum a hundred and ten times a minute, the force of compression moving the ribcage, cracking cartilage, displacing organs.

"Tabitha," Imogen said.

Tabitha came off the wall. She came to the head of the trolley. She could not get close to Imogen's face because the anaesthetist was there, but she could stand at an angle. Imogen's eyes tracked to her.

"Taba."

"I'm here. I'm here, Imo."

"It hurts so much."

"I know. I'm so sorry."

"Am I dying?"

"You're — they're trying to —"

"I can feel them pressing. Every push. Oh my god. Taba, every push —"

"I know. I know. I'm so sorry."

The consultant was there. She was looking at Elena. She was looking at the trace. She was looking at Imogen's face.

"Give her ketamine. Twenty milligrams. Don't stop compressions. We can dissociate her without compromising the circulation."

The anaesthetist drew up the ketamine. She pushed it through the cannula. Imogen's eyes did not immediately close — ketamine took about thirty seconds to take effect.

Imogen looked at Tabitha during those thirty seconds. Her eyes were wide. The compressions continued. Each push forced a small breath out of her. Each exhale was a word.

"Taba."

"I'm here."

"Don't let them stop."

"I won't."

"Keep going. Please."

"They're not going to stop. They're going to save you."

"Tell — my — mum —"

"Imo. Imo, don't. You can tell her."

"Tell — her —"

The ketamine took hold. Imogen's eyes drifted. Her face slackened. The lids dropped. The awareness was gone. Her body continued to move with the compressions but the consciousness had been pulled under by the drug. Tabitha let out a sound that was not a sob and not a word, something in between.

"Keep going," the consultant said. "Ka-chunk. Fourth shock. Two hundred joules."

Elena lifted off. The whine. The pause. Ka-chunk. Imogen's body jumped. VF, still.

"Continue CPR. Adrenaline. Amiodarone three hundred."

The drugs went in. The compressions continued. Tabitha was back against the wall. She was watching. Her face was wet with tears. Her hands were pressed against her mouth.

The code continued. Six minutes. Eight. The compressions went through rotations — Elena out, a male nurse in, then another rotation. The depth stayed good. Ten minutes. The alteplase was still running. The logic had been that alteplase running during PE arrest was the right thing, and a second bolus of alteplase had been given at six minutes into the arrest, a rescue dose.

Twelve minutes. Rhythm check. VF.

Ka-chunk. Fifth shock. VF.

Fourteen minutes. Sixteen.

Imogen's chest was bruising visibly now, the skin between the pads darkening to a deep red-purple. The defib pads were pulling at the adhesive with each compression. Sweat on her skin was loosening them. Her thin ribcage was showing the marks of the compressions. At the eighteen-minute mark the left third rib cracked. The nurse doing compressions felt the give. She kept pushing.

Eighteen minutes. Rhythm check. Asystole.

"Continue. Adrenaline."

Twenty minutes. Asystole.

The capnography was reading four. The body was no longer metabolising effectively. The CPR was circulating blood that could not carry oxygen. The tissues were starving at a cellular level.

Twenty-two minutes. Rhythm check. Asystole.

The consultant looked at Elena. Elena looked at the consultant. The consultant looked at Tabitha against the wall. She looked back at Imogen. The room was quiet except for the compressions and the whoosh of the BVM.

"Any objections to stopping?"

The team was quiet.

The nurse on compressions kept going for another six beats before stopping. She lifted her hands from Imogen's chest. The BVM was lifted from Imogen's face. The room was quiet.

The consultant looked at the clock on the wall. "Time of death, twelve-thirty-six."

She turned to Tabitha.

"I'm so sorry."

Tabitha came off the wall. She walked to the trolley. She looked at Imogen. Imogen's eyes were closed. Her mouth was open. The BVM had been removed. The defibrillator pads were still stuck to her chest, the electrode pads between them, the bruising visible. The gown was open. Her thin body was exposed from the neck down. Tabitha reached for the edge of the gown and pulled it across her chest, then adjusted it, the way she had adjusted Imogen's clothes many times over three years of flatmatehood — when Imogen had fallen asleep on the sofa in just a t-shirt and Tabitha had covered her with a blanket. The same motion. Different meaning.

Tabitha sat in the chair by the trolley. She took Imogen's hand. The hand was warm. The warmth was going to leave. She held it while the warmth was still there.

* * *

Elena stayed with Tabitha for about fifteen minutes. She didn't say much. She brought a cup of water. She offered tissues. She went to make phone calls.

Imogen's mother was contacted at twelve-fifty-eight. She lived three hours away. She was already awake because Tabitha had called her from the waiting room at nine-thirty to say that Imogen was in hospital and being assessed. The mother had been driving when Imogen's heart had stopped. She was halfway there. She would arrive at two in the morning.

Tabitha sat with Imogen's body until Imogen's mother arrived. The nurses left them alone for most of that time. Tabitha held Imogen's hand for the first hour. She let go after that because the warmth had gone out of it and she wanted to remember the warm hand.

Imogen's mother arrived at two-oh-nine. A small woman, red-eyed, unsteady. She stopped at the curtain. She looked at her daughter on the trolley — the closed eyes, the open mouth, the gown closed over her chest but not tied, the hair spread across the pillow.

She walked to the bed. She sat on the edge of it. She looked at Imogen's face. She didn't touch her for a minute. Then she did — she put her hand on Imogen's cheek. The cheek was cool.

Tabitha stood up. Imogen's mother looked up. She looked at Tabitha. She said "you were with her" and Tabitha said "yes" and Imogen's mother said "come here" and Tabitha went to her and Imogen's mother held her, the two of them at the side of the trolley, a student flatmate and a woman who had lost a daughter.

The body was moved to the mortuary at three. Imogen's mother signed paperwork. Tabitha helped — she knew Imogen's date of birth, Imogen's middle name, the name of Imogen's GP.

They left the hospital at three-forty. Imogen's mother drove Tabitha home. The drive took twenty minutes at that hour. Neither of them spoke for most of it.

At the flat Imogen's mother came up to see the room. She had asked to. Tabitha couldn't say no. They went up the stairs. Tabitha turned the lights on. The flat looked the way it always did — a little messy, a little lived-in — except that Imogen's room was still set up for an exam that wasn't going to happen. The textbook open to a chapter on consideration in contracts. The pasta ready-meal half-eaten on the desk. The laptop on sleep. A highlighter without the cap on. A half-empty glass of water.

Imogen's mother stood in the doorway. She looked at the desk. She looked at the bed that hadn't been slept in since Tuesday.

"She was working so hard," her mother said.

"Yes."

"I told her to take breaks."

"I know."

"Did she eat today?"

"Four bites of pasta. At six."

Imogen's mother walked to the desk. She closed the textbook. She put the cap back on the highlighter. She picked up the half-eaten pasta and took it to the kitchen and put it in the fridge as if it might be wanted tomorrow.

Tabitha sat down on Imogen's bed.

They stayed there for a long time. The pre-dawn light came in through the window around five. Tabitha made tea at some point. Imogen's mother drank half of it. She slept for about twenty minutes on Imogen's bed, then woke up, disoriented, and remembered where she was and why.

She left at seven, to go to the hospital to arrange the release of Imogen's body for transport back to the family home.

Tabitha was alone in the flat.

She sat on Imogen's bed for a while. Then she got up. She went to her own room. She lay on her own bed in her clothes. She did not sleep.

The bookshop below the flat opened at nine. Tabitha heard the shutters go up. She heard the delivery van that always came on Fridays. She heard the bell on the bookshop door as customers came and went. The ordinary sounds of a Friday morning continued without reference to the fact that on the floor above, a flatmate was lying in bed and a bedroom was empty.

(Rebloggers will get unedited versions in their in box)

Alguien para hablar de resus?? ❤️