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.