I had been asleep for perhaps 20 minutes when my phone rang.

"Hello doctor. I'm calling from ward 4. There is a patient here with a chest drain in, she's complaining that it's painful."

"Alright, I'll be down later."

Not an emergency, so I went back to sleep.

Then my phone rang again 20 minutes later.

"Hello doctor, we have an expected death in ward 5. Please come and certify."

Medical emergency this time. I trudged down the stairs, clouded by tiredness, and did all the legal things, filled in the forms. Trudged back upstairs in a zombie state, and fell asleep.

Ten minutes later, my phone rang yet again.

"Doctor, I'm calling from overnight ward. I want to know if the patient Mr. John is for code."

Mr. John, the strange guy with emphysema. I sat up straight. "Why? Is he desaturating? (Not absorbing oxygen so well anymore)?"

"No, he's restless."

A long paused passed.

'For code' in this world means for resuscitation. Essentially, when someone comes in at the end of their life, or at the end of a long and serious illness, we allow them to pass away. We don't do CPR or intubate them or cut them open to save them. We make them comfortable, correct anything that we can, but allow them to go, as peacefully as possible. 

The reason for this is twofold, firstly we are allowing nature to continue along her way, because if you resus that patient,w hat are you bringing back? and secondly, if we use all those resources and block that bed, you are potentially blocking that bed from someone who is fit and healthy but has perhaps been in a car accident, and has a far, far better chance of survival. 

But tot call me in the middle of the night and ask if someone is for code or not? Why? What is it going to change?

I felt heat rise in my cheeks. This has been an issue of contention in an overburdened and overcrowded hospital: sometimes, when you write not for code in the file, that patient gets treated differently by some members of staff, almost as if it is okay to give up on that person. So we often don't write it down. 

"Okay, he is restless.... do you want sedation?"

"No, I just want to know if he is for code."

I was stunned by this. "What difference does it make?"

"Well," I could hear the irritation in her voice, "if he goes to the bathroom and he collapses I want to know if we should call for resuscitation."

I was stunned, still. "But he is stable right now isn't he?"

"Yes, but he's restless." I could hear her exaggerated sigh, like I was thick as a brick wall.

"Sister, I'm really not sure why you're phoning me."

I had admitted seven patients to overnight ward that night, one of whom was the man with an overwhelming amount of pathology. In none of the files had I written for code or not for code.

"I just want to know if he's for code or not!" She snapped.

"Yes, he is for code, all patients are for code unless specified."

The phone line went dead.

I was furious at this point. I let the phone fall from my ear and sighed. The audacity to phone me like that, at 00:15, to ask such a question. I was irate. I took a deep breath. I wasn't getting to sleep any time soon, and I had to go and see this patient and decide what the heck was going on for myself. But I needed to calm down so I wouldn't yell that this sister.

So I went to see the girl with the chest drain. 

She had come in from private, and had a drain placed for a spontaneous tension pneumothroax (a random and unexplained occurrence where air enters the chest cavity and crushes the lung, a life threatening emergency). She was stable now, with the drain in to remove the air outside of the lung so she could breath. 

She explained that she had pulled on the drain and felt a pop. When I examined the drain, it was 100% perfect, and very clearly placed in private, where they had the resources to secure the drain with way cooler securing tape than what we had. She explained that she also had a pain in her neck when she touched a certain area. I told her that I wasn't worried about what she was telling me, it didn't sound like any kind of emergency. 

She didn't like that answer, because she explained the whole story again, as if I hadn't been there listening the first time. I once again explained that I wasn't worried, and was tempted to tell her that if it hurt when she touched her neck, she should simply not touch her neck. 

It took 20 minute to get away from this encounter, much to my sleep-deprived irritation. But I kept the irritation bottled, and felt I had calmed down enough to go and see the restless man. 

I arrived at overnight ward and immediately spotted him, standing next to his bed, trying to take off his hospital gown, entwined in his drip and oxygen cables; a chaotic mess. 

I washed my hands first, walking past Mr. P. His breathing was still a loud gurgling noise. 

"Are you okay, sir?" I asked as I passed him.

"Yeah," he said, nodding. 

I approached Mr John in his chaotic mess and asked gently what he was doing. 

"I feel hot," he said, "I want to go outside for some air."

"Sir," I said, pointing around, "you see all these people? Imagine if we just let anyone out for fresh air? Then if something went wrong or someone collapsed, how would we be able to help them out there when all of the equipment is in here?"

"Oh," he said, "okay. But I feel hot."

"Here, let's sleep out of this cover and without this long sleeve," I helped him out of his tangled mess and he lay on the bed. I checked his vital signs then, just to make sure. All were in normal limits, his oxygen levels were in the normal range. I breathed a sigh of relief, and made sure the oxygen was flowing at an acceptable rate, considering his pathologies. He calmed down.

I made a note in the file, that I was called to assess him, his vitals were stable. And then I made a note: patient is for code unless specifically documented. And I highlighted it aggressively. 

I noticed the sister floating on the periphery: seeing a patient in the next bed, carrying on around me without actually approaching me at any time. She came to assess his vitals after I had made the note. 

"Sister," I said gently, "are you the person who called me?"

"Yes," she said, "it was me."

"Sister. I know that sometimes we are going to disagree. But we are professionals, we should be curtious to each other. Please don't put the phone down on me like that next time."

"I did not put the phone down on you!"

"Really? Because I don't think we finished the conversation or said goodbye to each other."

"I thought the conversation was over." 

"Okay. In the future let's just speak kindly to each other."

She was quiet for a moment. "I cant believe you are talking to me like this!"

I paused. "I am speaking to you calmly? I think we should be professional."

"You know what? You have a real attitude problem," she spat.

I was stunned yet again, and instead of engaging, I decided to walk out quietly.

I tried to sleep, but not ten minutes later, the phone rang again. It was overnight ward. What now?

"Hello doctor. Patient P isn't breathing anymore."