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.

mopping up

sometimes before you are even called the sh!t has already hit the fan. the mopping up is not fun.

i was on call. as usual i was hanging around in the radiology suite (i spend a lot of my free time there sharpening up my ct scan reading skills. the radiologists even think i'm a frustrated radiologist, poor fools). the urologist phoned me. he had a nervous laugh. most types of laughs of urologists i quite enjoy. but the nervous laugh i do not. he then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. i quickly called the scan up on the monitor and sure enough there it was. the patient was mine.

there was an 8cm aneurysm. but just anterior to this there were signs of recent retroperitoneal bleeding. this was not good. the guy was just one step away from a fatal rupture. i phoned my vascular colleague in pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. then another call came through.
"doctor, the urologist says i must call you about his patient. he says it is now your patient. something has happened." i knew i needed to run.
"i'm on my way!"

as i rushed through the ward i saw what must have been the family. they were all looking anxious and some had tears in their eyes. i rushed on. i needed to focus.

in the patient's room it looked like well orchestrated chaos. lying on the floor was a massive man who was as pale as a sheet. the casualty officer was intubating. a sister was doing cpr. the urologist looked up.
"glad to see you! well then i am no longer needed. see you around." and with that he walked out. someone was trying to place a drip with little to no success. a large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. i needed to take control. only thing is i had seen the scan and i knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).

i told the nurse to stop cpr long enough for me to check for signs of life. there were none. she continued. i then did some basic tests to gauge brain stem function. there was no detectable brain stem function. i called it right there.

after a dramatic unsuccessful resus there is usually an eery silence in the room. maybe it is a sort of respect for the departed or maybe it has to do with confronting one's own mortality. i think it has a lot to do with thinking who is going to say what to the family.
"are you going to speak to the family?" i asked the casualty doctor. i had to try.
"no! you are!" great! i thought. i walk in on the closing act and i'm left with the hot potato.

i took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. then i went quiet. i needed to focus.

the family had been taken into the sisters' tea room. they then sent me in. the mopping up had begun.

i have spoken before about breaking bad news. fact is it is never easy and i'm not sure there is any easy way to do it. i try not to leave the family in the dark too long. once they know i try to be as supportive as possible and to answer their questions as best as i can. usually i am struck by the human tragedy and i allow it to affect me as it should. sometimes when i have been overcome by the relentless nature of my work i must stand back and observe. this was one of those times.