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.

breaking the news

there is a fair amount of talk about how to break bad news. truth be told i think i'm fairly good at it. sometimes, however it can leave quite an impression.

i was a community service doctor in qwa-qwa. i was working in casualties when they came in. two young children had been playing on the side of the street with a spinning top when a drunk driver came careening off the tar and ran them down. apparently in his drunken state he couldn't negotiate the turn.

the patients were cousins. we shuffled them both into the resus room and closed the door. one was about four and the other was six. the bigger one was dead. the smaller one had only minor abrasions. we covered the body of the big boy and cleaned and bandaged the wounds of the little boy. then we waited for the family.

a side story here was that the drunk driver who realised he was in trouble asked me to only draw the blood for alcohol levels the next day and lie about it. he even offered me money. he didn't specify how much. i was amazed at the inherent selfishness of people. there was a dead child in the resus room and this man was only concerned about the consequences as they pertained to him and him alone.

finally two family members arrived. the old woman was the grandmother of both children. her daughter who was with her was the mother of one child and the aunt of the other child. we moved them into a closed room where i was to speak to them. there was not going to be an easy way to do this, but i remember thinking that i really hoped the mother was the mother of the living child. it would make my job easier and their job when they got home more difficult.

i started by explaining the nature of the accident. i went on to explain that these types off accidents can cause severe injury. i then as gently as possible said that one child was already dead when he arrived and we couldn't help him, but the other child was ok. the mother immediately looked at me directly, something she had not done up to that point and asked with desperation both in her voice and etched into the lines on her face;
"which one? which one is dead?" the grandmother did not react outwardly, but a tear rolled down her one cheek.

i remember clenching my jaws, hoping that the woman before me was the mother of the living child and not the dead one. the news would still be bad, but at least for her personally there would be a good slant on it.
"the older child is dead."

it looked like someone shot her. her entire body contorted and she dropped to the floor. she started screaming. the grandmother didn't move, but the tears flowed more freely down both her cheeks. between the screams of the mother of the big boy, for that is what she was, the grandmother simply said;
"this is a terrible and difficult thing"

i was shaken. i didn't want to let the casualty staff see me cry so i swallowed hard, wiped my eyes and went back to work. besides casualties was full and i didn't have the privilege of taking time off to get over my trauma. anyway it didn't compare to the woman lying crumpled up on the floor of the office sobbing .

salt water wells up

the rooms were full. i was moving through the patients as fast as i could. then it was her turn. she had presented the previous week with a 7cm mass in her breast. she worked in the medical field, so she must have at least suspected it couldn't be good. but sometimes we all hope bad things will just go away. they seldom do.

i had told her it looks suspicious of a cancer but we had to wait for histological confirmation. and now i had it. as i walked her to the room, i glanced at the report. it was cancer.

as a surgeon, i treat many people simultaneously, seeing each one for a short time. i therefore must be able to jump between thinking about someone with mild abdominal pain and someone who is facing death and back many times each day. the trivial and the grave alternate through a typical day. this was grave. i consciously slowed down.

i went through her previous examination with her. i repeated that clinically i had been suspicious of cancer. and then i told her the news, as gently as i could. this is never fun, but i think i do it better than most and i'm always encouraged that it is better for her to hear it from me than from someone with little or no empathy.

she asked questions about treatment options. as i answered i could see her mind wandering off. she was probably thinking about her family and the grandchildren whom she would not be able to see grow up. she was being human and i understood. she asked the same questions numerous times and i patiently repeated the answers.

as she sat there with a far off gaze, trying to hear what i was saying and failing dismally, her eyes slowly filled with tears. she was being brave and my heart was breaking for her. i slowed down even more, giving her time, repeating once again how we were going to fight this thing, trying to give her hope.

finally we decided on a course of action and she left. i took a short moment to get my mind back to the day's tasks and moved on.

i moved on, having seen one more breast cancer patient and broken the news once more, but for her, she had just experienced possibly the single most devastating moment in her life.

sometimes our work is very sad.