Wednesday, March 23, 2011

doing nothing




surgeons are not so good at standing back, yet sometimes doing nothing is exactly what needs to be done. i remember one time that this turned out to be slightly humorous in a morbid sort of way.

i was in my vascular rotation which was not too much fun (except for a short moment). generally if a patient came in in the late afternoon requiring an operation, your entire night would be destroyed. and there was pretty much nothing worse than an abdominal aorta aneurysm (aaa). scratch that. a bleeding aaa was a lot worse than an aaa. so when casualties called and said they had a bleeding aaa my heart sank.

the patient was pale and clammy and his heart was racing. but the thing that struck me the most was his age. the man was 89 years old. the casualty officer also mentioned that he had previously been diagnosed with ischaemic heart disease. so, in summary we had a man just this side of ninety with comorbidities and a condition that was know to kill most of its victims thirty years younger than him. the chances of him surviving the operation were dismal. i called my senior.

my senior (the vascular fellow) examined the patient and went through his file. like me he concluded that an operation would push him over the cliff whose edge he was standing next to. in consultation with the patient's son, the decision was made to make the patient comfortable and leave him to the inevitable. i confess i had the thought that at least i'd get to sleep, but i also knew the sort of sleep one gets while waiting for death to take one of your patients is a broken and rocky sleep.

the next morning i arrived for my rounds. i hoped the patient was dead but when i walked past his son just outside the ward i knew i would find him alive in the ward. after a patient dies the family always seem to flee the hospital. the stress of the night was etched into the face of the son. i could tell his night had been worse than mine.

sure enough when i entered the ward, there was the old man lying in bed just where i had left him the night before. it seemed the pain medication was working though. he wasn't quite as restless as the day before. i walked into his room. i didn't bother checking his vitals. what would be the point? he looked up at me. i was surprised to see he was doing so well. i remember hoping the fellow hadn't told the family it would be all over by the morning because the old man seemed to be set on proving him wrong. the one problem with him still being alive was that i'd have to take over the role as the intermediate with the family. the fellow would make himself scarce now that the initial footwork had been done.

i greeted the old man.

"môre oom." i said. he looked at me.

"môre neef" he replied, using a greeting that had gone out of circulation many years before i was even born. i smiled. he seemed quite spritely for someone in his position. but his next statement really gave me a chuckle.

"neef, is it true that you are not going to operate?"

"yes it is true, oom." i replied.

"well then if you are not going to operate why don't you send me home? there are things i need to do on the farm you know." how could one not admire that sort of attitude? i smiled broadly.

he took another day and a half to die. it was tough on his son, but i suspect he sucked the marrow out of every one of his last moments of life.

23 comments:

Kalei's Best Friend said...

It seems as tho people do get that extra sense of when they are going to die.. Is it the acceptance that allows them to go down that path? or is it the body telling the mind that its 'time'? I've known a few that have gotten their affairs in order. My grandfather did and that was when he had become quite ill...

skylarmacrae said...

I always find it interesting how those who havent much longer to live compel us to live life to the fullest. Your patient realized the brevity of the time he had left and he wanted to be doing something with it. I respect your decision. It was undoubtedly the correct one. I will say, however, that it's disheartening to know that such a life had to end. Those are the kinds of people I want surrounding me.

chrisd said...

This gentleman was amazing. I wonder if the Baby Boomer Generation, who are basically the children of this man, I wonder if we will be as no-nonsense and full of life to the end.

cams said...

Facing a death on the side of a patient is very scary. They were afraid of being alone and left those people near to their hearts. This old man was very brave enough to face the truth that he was near to face his death. And he wants that before he dies he had done something that would make his family be happy. Patients should be taken cared of.

Renny said...

'...sucked the marrow out of every one of the last moments of his life'- love it. I hope I live my life like that.

William said...

beautiful, living life on his own terms up until the last breath.

Alex Wilde - El Experimento said...

It must be a real tough job to be a doctor. You want to do something and yet doing something makes the situation much worse. You don't have to feel guilty about anything, you are doing what is right.

Sub-Radar-Mike said...

such an inspiring tale, thank you

@tweatcyn said...

At age 58, my dad had an aaa. He was kept in the hospital the first 24hours just determining if he was fit for surgery. They said he might die during surgery but would definitely die without it. My sister was pregnant 7 months with is 1st grandchild at the time. He miraculously survived the aortic graft surgery and lived another 6 months, long enough to meet his granddaughter. I believe he held on to life for this very reason.

The Edge Columns said...

My dad went through much the same process last year. He was 88. I flew halfway across the continent to be with him and met with the docs.

By the next afternoon I'd convinced them that he could take the operation, even at his age. They air-vacced him to the nearest big city a thousand miles away, did the operation, a triple bypass and a few extras (a valve job, I think), and flew him back a few days later.

That was a year ago. Dad is fine. He's had time to take care of a lot of things, including my mom, who just a few weeks ago fell on ice and broke her pelvis. (She's only 81.)

Life, as you well know, is the struggle. Some folks can, others can't, and most can't afford to. Which is a much bigger problem in the US than up here in Canada with socialized medicine.

Anyway, good post. Thanks.

Positive Thoughts said...

See the power of positive thoughts within you. God bless you

Zarko said...

Everything is supercool on this blog. Than you very much!

Qobo Reloaded said...

Really enjoying your posts I find them more intriguing than Greys' anatomy and ER put together. "The graveyard"- really sad. My sister is also a doctor in Mpumalanga, I don't spend much time with her so it's great to get an account of what you guys go through.

Wynner said...

As a pediatric/NICU nurse who works solely with chronic and terminal infants and children (and of course their families), I have seen death come far too many times. However, in saying that, children are far more graceful and accepting of the dying process when it does come. They have such AMAZING perspective, in part, they fiercely protect their parents.
I have not seen the same when working with adults, we always have more to do, a better way to do it, an idea about what is going to happen, what needs to be next, a plan, don't we?
I love this example of a man whose life has been well worth living. A man who realizes in medicine there are so many things we can do to prolong days....but there are many times when prolonging days dramatically decreases the quality of a patients life.
Love your blog.

Merkin said...

I've always wondered how doctors don't take their work home with them.

Adam B said...

My grandfather had this exact situation and my family decided the same solution. Aortic aneurysms scare the crap out of me as they are one of the least "talked about" disorders (heart attack and stroke being broadcast all over the drug company commercials) but I recently went and demanded an abdominal ultrasound from my doctor anyway recently - he thought I was crazy since I'm only 40 years old.

Anne said...

New to the blogs and finding yours very interesting. Thanks. :)

Mr.Majumder said...

Wonderful comment....i can see why your blog recieved so many awards!

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Other Things Amanzi,


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Miss Purple Stethoscope said...

That was a very heartening story to read. We are supposed to go at some point, that's the way of the world. And it sounded like your team offered him the most dignified and least traumatic option.

Andrew said...

Glad I found this. Interesting read.

evie said...

you are an amazing man!!!!!!!!!! its really awesome to have people out there that are doing exactly what you want to do. i want to be a missionary surgeon when i grow up, reading your blogs have really helped confirm that. i am about to go on my first missionary trip my family is moving to mexico i am very excited!!!

Amanzi Down Under said...

The scariest anaesthetic I ever did was a ruptured AAA. The old geyser was "'avin' a pint with the lads" when the pain started.

I watched him being filleted like a fish and surrounded by a chaotic mob of surgeons and perfusionists and I knew he would be in ICU for days.

I could not help but wonder if it would have been better and more dignified if he had simply finished his beer, said goodnight to his friends and dropped dead on the walk home.