how does it feel

occasionally i've been asked what it feels like to lose a patient. there are a few thoughts that i can share about this. firstly every case and every patient is unique so there are a spectrum of feelings that can be ellicited. two specific cases come to mind.

the first happened when i was still a medical officer in surgery. this means i hadn't officially started my training, but was working in the department with the intention to go on to become a registrar (someone in training). a patient came in who had been shot through the pelvis. he had lost a fair amount of blood but he responded well to resusitation (his blood pressure improved with the administration of fluid). he clearly needed an operation because his abdomen was very tender and rebound was ellicited (general clinical sign denoting some form of calamity in the abdomen, in this case probably due to perforated bowel). i booked theater immediately, simultaneously getting my house doctor (in the doctor hierarchy this is the most junior doctor) to order the necessary bloods etc. what happened next will be very difficult for first world people to understand, but is fairly commonplace in south africa. we waited for theater time!!! the vascular surgeons were busy operating a gunshot of some or other artery and due to staff shortages, financial constraints etc etc we were told we could take our patient next. next of course did not specify how long we would wait. i attempted to get another theater open, phoning the matron as well as the superintendent. apparently it was not possible. so i sat next to my patient and watched. i watched as he moved from stable towards unstable. i kept on filling him up with fluid and blood as required, but this is pretty futile if he's just leaking it out somewhere as fast as we put it in. he needed an operation to control the source of the bleeding. that was the fact of the matter. and so the day dragged on with me doing my best to keep the man alive while phoning the whole world to try to get an available theater and watching as he flirted on the brink of shock and finally plummeted over the precipice into shock. in total i spent about 4 hours like this, all the time getting more and more worked up. the last thing the man said before he floated off into a delirium was "doctor, am i going to be ok?" i didn't know what to say because i didn't know if he was going to be ok. i just replied that we would do everything possible to ensure that he would be ok. and so we finally went to theater. my senior did the operation. the man had been shot through his internal iliac vein (a large vein in the pelvis) and the presacral plexus (a rich network of small veins overlying the sacrum) my senior mannaged to control the bleeding from the iliac vessel eventually, but he just couldn't stop the bleeding from the plexus. by this stage the patient had probably lost about four and a half liters of blood (bearing in mind his origional volume of blood was probably around 5 liters, this is massive blood loss. his blood now consisted of the resusitation fluid ringers lactate with the occasional lonely donor red blood cell floating merrily along.) we finally packed his pelvis with swabs (an accepted dammage control procedure) closed up and delivered him to icu. (the acquisition of an icu bed in that hospital in itself is a story, but not for today.) the idea was if the icu staff could reverse his coagulopathy (get his blood to be able to clot again) and keep him alive we would do a follow up operation and remove the swabs. the first hct measured in icu was 5. ( normal about 45 but we're usually happy with about 30). that was also the only one done because he died soon after.

the next story was that of a 16 year old girl. i was a senior registrar at the time. i just happened to be in casualties seeing a patient with haemmorhoids when she came in. she had been shot about 6 times, with at least three bullets having gone through the abdomen. she was severely shocked. we simultaneously commenced a resusitation, phoned theater to tell them we were on our way (we got lucky. they were between cases so they kept theater open for us) ordered blood and plasma and phoned the icu people to tell them to make a bed available so long. we had her in theater within about ten minutes (which in our setting is somewhat of a miracle). the anaesthetist basically gave her inhalation oxygen and intravenous adrenalin as anaesthetic ( this means she was so shocked normal agents would have killed her. she was already comatose form lack of blood to the brain). we opened. i forget her exact injuries, but if my memory serves me correctly the aorta was hit (biggest artery in the body). anyway she was soon dead. i left theater, still pumped from the adrenalin rush i'd had from the whole case. outside theater her entire family eagerly awaited news. this is was not expecting. the fact that i'd been in theater for such a short time must have at least aroused suspicions amongst them that the news could not be good. i calmly explained what we had done and the injuries and the final outcome. the news of the death of a 16 year old girl is something that is not supposed to be endured by any mother or brother or father and their reaction was as could be expected. i answered what questions they had and then left them to their grief. i then went to icu to tell them they no longer needed to reserve a bed for us and also to unwind and breathe a bit.

the first death really got to me. to this day i think we could have saved him if we had gone to theater immediately. the system let him down and we were the face of the system. it's difficult not to become bitter towards the beurocrats that sit in their offices making decisions that lead to the death of people, never seeing the people they kill, while we sit through the night watching some man slowly slip through our fingers. that man had no family with him that night and died amongst strangers. it was terrible.

the second death did not affect me. she was so badly injured it was incredible that we even got her to theater. i doubt anyone would have been able to save her. i also believe that i have a nack with the telling of this sort of news to the family. i reasoned therefore that even if it was slightly unpleasant for me to be there when they hear about the loss of a dear one, it is better for them to hear it from me than from most of my surgical colleagues who tend to be too callous in these circumstances in my opinion.

i often tell people that ask what it's like that it's like reading the newspaper. when we read that someone shot and killed someone else in the paper, we're obviously affected. we might pass a comment that it's terrible or so sad or something of the kind. but it's not someone we know so we feel it at a distance. the only difference with me is i'm there to see the person that most people only read about. i can actually alsoi do something constructive.
i think there is a fine ballance that must be reached. on the one hand you must think about it as one would reading the paper. it is terrible etc, but it's not me and not mine. there needs to be some ellement of distance or we'd all have post traumatic stress disorder. but on the other hand i strongly believe we need to always remember that this is a person we're working with and as such equal to me in importance (no matter who they are). the humanity of the patient and the reason we do our job (to fix the shell thereby allowing the person to get back to the business of being human) must not be lost.

this entry turned out somewhat longer than i planned.