the theater cap

"bongi, i have a patient who came in last night with appendicitis. can you operate him for me?"

my colleague was known to load shed and mostly i didn't really mind. that day, however, i just didn't feel like any extra work, so it took a bit of effort to fake enthusiasm.

"sure! any time." i lied. "anything special or straight appendicitis?"
"well, i saw him two days ago, but he refused operation, so he might be a bit sick." i knew what that meant. a bit sick was surgical talk for 'good luck pulling this one through'. oh well, a challenge at least.

the patient was a young man of about 27 years old. despite the fact that he was clearly in pain he still was a striking individual. he was alert and interested in my analysis of the situation. his questions were to the point and demonstrated deep contemplation about his situation. his eyes sparkled with life and potential. he touched a chord in me and i felt for him, despite the fact that he had refused an operation a day or two ago that was clearly necessary. when i examined him it was clear that he needed surgical intervention, but his pain was no longer located just in the area of the appendix, but it had spread more diffusely through the abdomen. i decided that a lower abdominal incision would be better to fully address all potential problems.

"doc, i like your cap." we were pushing him towards theater. i was wearing one of my genuine sutured for a living caps that i always wear when i'm in theater. i smiled. this sort of small talk i took to mean that he had resigned himself to the operation and was simply trying to distract himself.

"thanks." what more was there to say?

"i would love a cap like that." there didn't really seem to be anything to say to that, so i just kept quiet.

quite soon the patient was asleep and we got to work. when i opened up the lower abdomen, a thick, suppurating appendix protruded through the wound in an apparent attempt to escape from the septic abdomen that it had actually been the cause of. it had clearly burst. i smiled to my assistant.

"looks like this is going to be easy. whip out the appendix, rinse the abdomen and home free." sometimes i wish i would learn not to tempt fate with idle talk. i mobilized the caecum. and that's when i realized something was wrong. it was an appendicitis, but it wasn't caused by a stone in the appendix lumen or thickening of the lymphoid tissue in the wall. there was an obstruction in the base of the appendix but it took the form of a hard mass that had broken through the caecum and infiltrated the abdominal wall. what we actually were dealing with was a colon cancer that had incidentally caused an appendicitis. to remove the appendix simply would not suffice. i had to be aggressive.

i removed the right side of the colon with its blood supply and lymph nodes, taking a sliver of the abdominal wall along in the specimen. yet i already knew that the cancer had probably spread throughout the abdomen along with all the inflammation when the appendix burst. that would by necessity be something for the chemotherapists later. right now my priority was to do the best i could and get him healthy enough to withstand the onslaught of the chemo drugs.

the rest of the operation went as can be expected. i stuck the necessary pieces of intestine together, rinsed, placed drains and closed. the patient did well post operatively too. of course i still had to tell him that he had a cancer and not a simple appendicitis. that was not fun. i also involved the chemotherapist as soon as the histology confirmed what i already knew. finally i discharged him and left the rest to the chemotherapist.

many months later as i was walking down the corridors i happened to run into that same chemotherapist. i hadn't heard anything about the patient so i decided to ask how it was going with him.

"well, bongi, despite my advice, he refused chemotherapy and jetted himself off to china for some sort of experimental therapy where they place radioactive beads in the bed of where the cancer was. i wish him all the best but i don't think he is going to get all the best." i was upset. in a sense it wasn't actually too surprising. after all he had initially refused surgery by my colleague. he did seem to be a bit of a free thinker, even to his detriment. maybe this stupid stubbornness was one of the things about him that made me like him on some level. still i knew he had decreased his odds dramatically and it did upset me. i felt like a young promising mind was about to be cut down and there was nothing i could do. it was as it was.

i had just about managed to nearly forget the man when, once again, walking down the main passage of the hospital, as my chemo peddler walked past he gave me some news.

"guess who i admitted last night with a malignant obstruction?"

"an obstruction? do you need me to operate?" it was grasping at straws and i knew it, but i had to ask.

"bongi, the scan shows masses throughout the abdomen and almost his entire liver is just one large metastasis. i think we are deep into the palliative stage of his treatment. an operation might actually be a form of active euthanasia." and then the words dried up. it was pointless telling each other how tragic it was that such a young man was doomed. it wouldn't help to wonder how the course could have been different if he had taken the chemotherapy when there was still a chance. it was even more futile to wonder what would have happened if he had been operated earlier or, better yet, presented earlier somehow. in the end we just walked away from each other. no words would suffice.

yet, although i could walk away from my colleague, i felt i could not just walk away from the patient. i couldn't help him as a surgeon, that i knew, but maybe i could do something else.

when i walked into his room carrying one of my very precious rlbates theater caps and presented it to him as a gift, there was surprise in his eyes. but there was something more there too. his eyes still sparkled, but most of the life had already been drained from them. his body was just the frame of what it once had been but in his eyes i could see gratitude. when i left, there was a smile on his face. i hid my face from everyone as i walked out of the ward.

two days later he passed away. it was a small gift but, maybe in that stage of the battle we call life, the gift of a smile is really not that small after all.

albatross

when i was a child we used to hear stories of old people from primitive cultures that could wish themselves dead. they could just decide to die and they would. it was disturbingly fascinating for a young impressionable boy. but as i grew older and studied medicine i realised they were no more than simple stories. or were they?

i was a lowly medical officer joining the boss' firm for the first time. i luckily learned the registrar was a great guy and i therefore could use him as a sort of shield against the usual onslaught of the boss. when i joined there was a patient who had undergone a gastrectomy the previous day for a benign condition. it fell to me and my registrar to get her back to full health. it soon dawned on me this would not be easy.

the patient was 60 something and well fed, possibly too well fed. mobilization was difficult, but that wasn't the main problem. she was of a culture where a certain amount of self pity was the norm and where showing suffering elicited great sympathy from family members. so when we insisted she start moving soon after the operation, she was not interested. what's more, her family encouraged her to just lie in bed like a lump of clay. they felt we were downright cruel to expect such things as getting out of bed of her. but i became truly worried one day when she called my registrar and myself over to tell us something in confidence.

"i want to die. help me kill myself." she said with a pan face. we were shocked. we explained that she actually had a lot of life left in her and her condition was not terminal. with a bit of effort we expected a full recovery. but a full recovery was one thing she was not willing to give us. and eternal rest was one thing we were not willing to give her. every day we would get her out of bed and walk with her and every day she would walk a few steps with a fair amount of ease and then collapse in a heap on the floor. we would then wrestle her back into bed and muster our energy for the next day's ritual. the family complained incessantly about everything we did. they wanted her to stay in bed and wait until one day when she would just be better.

after a while her son flew in from america where he lived. he came armed with dollars and instantly decided our care was not good enough. almost immediately they had moved her to a private step down facility where she was to be pampered back to health. truth be told, we were relieved. it wasn't as if we didn't have other things to do to keep our days busy and we were quite willing to give up our daily walks and wrestling matches with this patient.

about two weeks later we got a call from a local private hospital. they told us that at the step down facility the lady had adopted a very passive stance on the matter of her recovery and not moved a muscle. she had then one day apparently stopped breathing. she was intubated and shuffled off to the local private hospital where she was bundled into an icu bed where even american dollars wouldn't last too long. when the son with the american dollars realised he had no more american dollars, they phoned us at the state hospital to take over. what could we do? i turned to my registrar.

"you realise she will absolutely refuse to recover. she will be an albatross around your neck until she dies and she is going to die. she wills it so." he tried to smile but it came out as a sort of accepting expression of suffering. we took her back but her condition had worsened. other than the endotracheal tube and the ventilator, she returned with a nice hefty bedsore on her sacrum. but we were not the types to give up too easily and we immediately got to work.

everyone was surprised when we actually managed to get her off the ventilator in less than a week. a few days later we had her back in the ward and a few days after this we even commenced our daily excursions with her. during this time once again she asked us to kill her. she assured us she wouldn't tell anyone if we did. somehow that seemed self explanatory to me but i decided not to point it out. anyway we refused, once again saying that she was not terminal and with a bit of hard work should recover completely. she wasn't happy with us telling her what to do, even if what we were saying was that she should recover. apparently, she assured us, her family were much more sympathetic. they didn't force her out of bed daily for example. we tried to look more understanding from then on when we forced her out of bed. i think it worked to an extent because just before i was rotated out of the firm and to the other hospital, we actually discharged her back to her understanding family. i was delighted, but my senior was less so. you see, he was staying on in that firm and he knew she was going to do what albatrosses do. she was going to bounce right back to him. i pretended to care but it was his albatross and not mine. i was just too delighted to finally get away from a situation that i knew would turn out badly.

and so life went on as it tends to do. i settled into my new firm and soon even forgot about the albatross. i couldn't for long though. quite soon my previous registrar phoned me. he said only one thing but the pain in his voice said so much more.

"the albatross is back." i expressed dismay and even tried to sound surprised, but it just came out as insincere, which is exactly what it was. i considered asking a bit about her condition but somehow it seemed it would rub salt into his wounds. i even considered making a light hearted joke about him granting her her wish and helping her over the threshold into the hereafter. i was just afraid he might take me seriously, so i said nothing.

not too long after that phone call i got a message on my phone.

"the albatross has flown". she was dead. she had finally managed to bypass all our attempts to get her back on her feet and despite everything we had done, against overwhelming odds, she had wished herself into the grave. in a way i was even quite impressed with her.

since then i too have had an albatross or two. i suppose it goes with the job.

difficulties

in my post mopping up there was a comment stream that had a bit to do with doctors needing to become detached in order to survive. recently this whole issue was unfortunately brought brutally home. it reminded me of an incident many years ago.

our firm had only two private external consultants which basically meant we didn't have all that much supervision and good luck trying to get a consultant out at night. they did, however do two so called academic rounds with us each week.

one day on rounds we arrived at a patient. the student started presenting. it was a lady slightly advanced in years who had presented with sudden deep painless jaundice and a palpable gallbladder. as could be expected a ct scan was done which confirmed a mass in the head of the pancreas. even before we had histology we all knew this was a pancreas head cancer, a condition with a fairly dismal prognosis. her mass was large and there was already spread to the liver.

the consultant listened to all the findings and then, without a word, walked away. we faithfully followed him. when he got to the door, he stopped and turned to us.

"now why did i just walk away?" he asked. we all gave the usual blank stares. "because there is nothing we can do for her." he said with a chuckle. those of us who needed to be in his good books gave the obligatory half hearted laugh. i could just manage a smile that i think came out more as a grimace.

you see i just felt we are not there only to fix the machine in which the person is housed but also at least in some way to mean something to the person too. i was not comfortable. afterwards i went back to the patient and spent some time explaining that although we could not cure her, we would do everything we could to make things at least a little better.

but these things are difficult. recently i once again diagnosed a delightful old lady with pancreas head cancer and once again it was beyond surgery. in the end she went for chemotherapy and had a stent placed to resolve the jaundice. but these measures only hold back the inevitable temporarily. and sure enough after a while she was back.

when a follow up scan was done the cancer was all over the place and there were quite a few other dismal findings. the chemotherapist had asked me whether she needed an emergency operation that night and the answer was a resounding no. strictly speaking i needn't have been involved any more.

but the next day i stopped by to say hello. the patient was grateful and, although in my capacity as surgeon i was doing nothing, in my capacity as human being i felt i just might be making a small difference. later that day the chemotherapist phoned me to tell me the kidneys had packed up. this was probably a pre terminal event and although neither of us said it outright the meaning hung in the air oppressively. the chemotherapist was also sort of telling me my involvement was no longer needed. i had known this for a few days actually.

the next morning i just didn't want to see her. the situation was so hopeless and it was just difficult for me to deal with it. but then i realised if it is difficult for me, how much more difficult must it be for her? after all it was her life that hung in the balance. i would survive and move on. i would get over it. i would not be the one feeling alone in the face of overwhelming odds. i knew what i needed to do.

i just kept on visiting her, usually just to say hello so that she would know she was not totally alone. i did not detatch and allowed the frailty of the human condition to influence me as the human i am.