Wednesday, September 10, 2008

the last goodbye

this is a story i considered not telling. somehow it comes too close to how we deal with the constant tragedy of life we are exposed to, both positively and negatively. then a post by buckeye reminded me of it.

the rotation through the military hospital was interesting in that the slog work was done by relatively junior doctors. that night one of them admitted a patient with abdominal pain. to be honest i didn't pay too much attention in the handover because he was admitted to another firm and that consultant would surely handle whatever the problem was.

late that afternoon, when the relevant consultant was no longer available, the medical officer of his firm asked me to evaluate the patient. the first thing that struck me was that the patient was in excruciating pain, yet his abdomen was soft. his face bore the deep grooves acquired from years of diligent smoking. his kidneys were going into shutdown and he was severely acidotic. i didn't even bother to check his phosphate levels. i had a good idea what was wrong. i called theater. i also let my consultant know i was going to do a laparotomy and asked him to hang around a bit before he went home...just in case. he was one of the few that was both a brilliant surgeon and a brilliant person. i knew i could rely on him.

as i started the laparotomy i spoke to my intern about necrotic bowel. i even went into detail about the thrombotic type, the emolic type and the low flow type. then i still remembered all that detail. sure enough, as we opened, loops of dark blue to black bowel came bursting out of the abdomen. the situation was dire. we all went silent. the bowel was dead from the duodenum to the transverse colon. a resection seemed pointless. i went through the bowel again, more to give myself time to think. but the mesentry was also dead and the slightest touch tore it. soon i found myself trying to control a persistant slow bleed from the base of the mesentry, but every time i placed a stitch it tore through the very friable tissue. i started becoming nervous. i called for my consultant. it was after hours but i knew he wouldn't have gone home. he would be waiting to hear how the operation went. he was just that type of man.

sure enough, moments later he burst through the theater doors. he looked into the abdomen. i explained the situation of the bleed that i just couldn't seem to control. in the knowledge that he would soon take over from me, i felt much reassured. i continued to work at getting control.

after a while i wondered why he was taking so long. i looked up to see what the delay was. the consultant was helping the anaesthetist adjust his suction which seemed not to be working. i was shocked and amazed. but i did not dare say anything. i just thought that that wouldn't take too long, so i would just need to be patient. it did take long.

after what seemed like ages the anaethetists suction was finally fixed. i relaxed again. but once again i looked up to see the consultant not scrubbing! he was wondering around theater, not really doing anything. occasinally he would chat to the floor nurse or the anaesthetist or just check all sorts of irrelevant fixtures in the theater.
'why is he not scrubbing to help me?' i thought! and then it struck me. he knew there was nothing that could be done. he wasn't going to tell me what to do, but, instead was patiently waiting for me to make the call.

"there is nothing to do here, colonel" i said. i think the corner of his mouth lifted in an almost smile.
"yes, bongi, there is nothing to do."
"should we stop now or close and send him to icu to die?" i asked. we did have a bed in icu organised.
"i think you can stop, but it is up to you." said the colonel.
"his family didn't get to say goodbye," i said, "so i'm going to close and see if we can get him to icu alive."
"ok." and then he left.

we got him to icu on high doses of adrenaline. the anaesthetist was annoyed with me. he felt it was a waste of time and resources. in a sense it was, but i felt it was the right thing to do.

once we had settled him, i went through to the waiting room to speak to his wife and son. i explained the situation. the wife asked me what his chances were. i told them he had no chance and would probably not see the next day. the son then asked me why, if it was pointless, had we closed and taken him to icu rather than just let him die in theater. i explained, as honestly as possible, that it had been my call so that they would at least have a moment with him to say goodbye before he died. the son was furious. i actually thought he was going to physically attack me. he did verbally abuse me quite a bit. i wonder what his reaction would have been if i left his father to die in theater.

after all the drama had subsided the doctors involved took a few moments to unwind over a cup of coffee. i remember a dentistry student who was doing her anaesthetic rotation. it was her first night with any form of clinical exposure. i wonder if she needed therapy afterwards.


rlbates said...

These are tough for all involved. You write so well about them. Sure hope someone helped the family and that young student.

Unknown said...

I shall gently suggest that there was a third option: close and have the family say goodbye in the recovery room.
This option would have saved the ICU staff a completely pointless admission, while still allowing the family to see the patient before he died.

walt dandy said...

Weereens pragtig geskryf Bongi. Dit was nog altyd vir my snaaks dat dit hier in Amerika taboo is vir 'n pasient om in die teater dood te gaan, maak nie saak hoe siek hulle is of hoe hopeloos hulle toestand is nie. Hier gaan almal icu toe, ten minste tot die familie "on board" is met die prognose (?sp). Ek dink dit het waarksynlik te doen met die vrees van 'n hofsaak. As jy teen die ICU besluit het, wat sou julle in die teater gedoen het? Ek bedoel hoe ver sou julle gegaan het met die onttrekking van sorg? Pressors af? Ekstubasie?
In vier jaar van mediese skool en vier jaar van residency kan ek net aan een pasient dink wat op die tafel in die teater dood is, en dit was 'n hopelose skietwond. ek sal weer se, jy moet definitief dit sterk oorweeg om 'n boek te skryf.

Kerry said...

I would reckon that the son would have been emotional and aggressive regardless of what you'd done. That was maybe just his way of dealing with his father's death.
Thanks for a great blog, btw, I've been reading you for about a year now, and am glad I can follow you on Twitter to have quick access to new posts!

Bongi said...

thanks ramona.

quietusleo, yes that is another option. this guy was not going to make any trip anywhere without inotropes. i think he would have died before we mannaged to rush the family in. in icu we could at least maintain the facade of life for an hour or two.

walt, dankie. dood op die tafel is ook glad nie 'n goeie ding hier nie, alhoewel ek dit al so 4 keer gesien het. mense vermy dit, amper ten alle kostes, hoofsaaklik as gevolg van al die papierwerk wat daarmee saamgaan.
prognose is reg gespel.
die besluit het om inotrope gewentel. as ons hulle gestop het, sou die pasient binne enkele oomblikke dood gewees het.
ek dink my konsentrasievermoe is te kort om 'n hele boek to skryf, maar dankie dat jy dink dit die moeite werd sou wees.

kerry, thanks for your kind words.

Karen Little said...

Was this consultant the one with the very cool number plate (y'know, referring to his rank and an organ he often operates on...) In english he had the same name as a Cluedo character. I always really liked him.

I saw a case like this one last year - it was awful. It's so sudden and hopeless.

amanzimtoti said...

I think you absolutely did the right thing. I don't think it was a pointless admission to ICU at all, afterall, why do we practice medicine? It's not to for our own benefit or to to make life easier for ourselves or the hospital staff, but for the patients and their families. So they can go about the business of life. In the end, I'm sure that son was glad he got to say goodbye.

Bongi said...

i actually thought there would be more discussion on the action my consultant took. i mean he didn't act as if there was a human being just about to die. don't get me wrong, i thought what he did was exactly right, but i thought there would be voices of dissent.

the other point that i only hinted at was the abuse we often take from joe public out there. it is a very disheartening part of the job. whether the son appreciated what i did or not (i think later on he would have) his verbal abuse was not easy to deal with. it never is. maybe that is a topic for another post altogether.

Dragonfly said...

What you did in allowing the family to say goodbye was right...but can be a hard or unpopular decision when resources are scarce. Your consultant did the right thing but he maybe could have stepped in a little earlier to clarify the plan if it was obvious you were waiting on him.
I have a nurse friend who was once punched in the face by a patients son so hard that she got a subarachnoid haemorrhage after he was told of his fathers prognosis. (Her nursing supervisor told her it must have been her attitude, prompting her immigration to greener pastures a few months later). People can act in irrational and uncivilised ways when grieving.

amanzimtoti said...

The abuse from patients and their families is difficult to accept, but you have to bear in mind that sick and dying people and their families aren't exactly behaving under normal circumstances. They sort of lose their humanity in a way. It's like surgeons who get aggressive in theatre. It shouldn't be that way, but it's not really personal, it's a coping mechanism.

Bongi said...

dragonfly, i think my consultant did exactly the right thing. he probably would have calmly waited there until the patient died if i hadn't made the decision. he used the situation to teach me something. that is exactly the fine point i thought there would be dissent about. in fact it is that point that almost made me not tell this story. and in a sense it is that point which brings across the detachment that sometimes exists between surgeons and 'real' people.

amanzimtoti, i am not impressed by surgeons who get aggressive in theater. it is simply not acceptable. maybe under these stressful situations (death in the family and a tense operation) all the inhibitions are removed and in fact the real nature is demonstrated. it is maybe an ideal moment to actually see what the person is really like.

Mitch Keamy said...

Hi Bongi. Being present at these terrible moments, I think in a strange way is a great privilege; over 30 years in anesthesia and critical care I vividly remember the moments of tragedy and triumph with the same sense of having "lived" the calling. When these situations arise, by the way, I encourage the surgeon to "scrub out" and talk to the family while I drip in the epi...

best regards to you


Bongi said...

mitch, thanks for the comment.

yes i agree. i once told a student that i enjoyed breaking bad news. not that i like to be the carrier of bad news, but more because i do it well and it is better for them, to hear it from me than someone else. but you also hit the nail on the head by saying that it also has to do with living the calling.

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DHS said...

I think you did a wonderful thing there, but I'm not sure that saying goodbye to someone with a pulse driven by maximum inotropes is much different to saying goodbye to someone without a pulse.

Just for my own education: I've always measured lactate in suspected ischaemic bowel; is phosphate a better marker?

Bongi said...

dhs, essentially, especially to medical like people there is indeed pretty much no difference between this guy's inotropic driven pulse and no pulse. yet for the average person, a pulse means alive and alive means you can say goodbye before they are dead. this is not at all scientific of course, but hopefully on the perception of the family it was important.

both lactate and phosphate are unfortunately late markers. by the time they are raised the patient is already in deep trouble. we used to measure acidosis and phosphate. a high index of suspicion is the real marker in the end.

DHS said...

the phosphate comment saved the life of one of my patients. there you go, bongi, saving lives halfway across the world with your blog.