doll eyes

it affected me. not just it, but the fact that it didn't seem to affect my colleague.

i was a lowly fourth year medical student, delivering babies for all i was worth. looking back, i realize i enjoyed it. the whole 'joy of a baby coming into the world' really gave me joy that a baby was coming into the world. call me sentimental but i saw each birth as beautiful. somehow i could look past the meconeum and the amniotic fluid and the episiotomies and see what was actually going on. it was a happy time for the mother (mostly). it was the beginning of hopes and dreams. it was a new start for the baby (obviously) and for the mother and in a sense each new birth may have signified a potential new start for me.

she was excited about her new baby, but there was a cloud over her entire admission. the reason she had come in to hospital was because she hadn't felt the baby kicking for the last 24 hours and she was worried. quite soon we were worried too. not only could we detect no movement but we couldn't hear the fetal heart beat with our fetoscopes. my registrar was one of those amazing people who really felt for each and every patient despite the massive torrent of humanity that moved through the labour ward on a daily basis. this patient was no exception.

actually we all new what had happened, but the registrar wanted to make sure. i suppose she just didn't want to tell the mother her baby was dead before she had confirmed it on sonar. actually i think she wanted to use the sonar to show the mother there was no heartbeat to avoid problems of denial once the news was broken. whatever the reason i followed the whole drama as it unfolded, as did my fellow fourth year green medical students.

i remember sitting there in that small labour room where mothers are usually introduced to their new babies while the registrar ran the sonar probe over the mother's swollen abdomen. i remember her bringing the probe to a standstill over the heart. we could clearly see the heart, but there was no movement. the heart was not beating. as we actually already knew, the baby was dead. all that remained was to tell the mother. with genuine sympathy and very sensitively the registrar broke the tragic news to the mother. i saw her face drop as the realization of the loss set in. i could see her fighting back the tears. i was too.

finally it was over and we all slowly filed out to leave the mother to absorb the blow. of course we still had to decide how to deal with the problem of getting the baby out so we didn't have the privilege of dwelling on the human drama that had just unfolded before us. still i took a moment to allow myself to feel it. this involved no small amount of swallowing back the tears.

the registrar turned to us.

"and that is that. which of you is going to deliver this baby?" my colleague was the first to speak.

"excuse me, but when the baby is delivered, can we practice endotracheal intubations on the body?"

i felt nauseous and slightly dizzy. it hadn't occurred to me before then but suddenly i realized the entire humanity of what had just happened had gone completely over the head of my colleague. all he was interested in was the possible so called learning opportunity that he could get out of the 'situation'. quite frankly he had felt nothing for the baby and he had felt nothing for the mother. i couldn't help wondering what sort of a doctor he would one day turn out to be. i never wanted to be like that.

in the end i was the one that had to deliver the baby. there were a lot of tears.

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.

the graveyard

this is a difficult story to tell but if i am to be true to the complete experience of a surgeon, i do need to tell it.

one of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. he went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. at the time i thought he was being a bit melodramatic, especially seeing as though i could barely remember the names of any of my living patients. somewhat like one of our consultants i used to refer to them as the guy with the pancreatitis or the lady with the bleeding peptic ulcer. unfortunately i learned what he meant.

it was a tough call so when my pager went off at five in the morning i was not delighted to hear there was a gunshot abdomen in casualties. bearing in mind i had been on the go solidly for about 23 hours and i had a full day ahead of me, including an afternoon theater list, it was going to be tricky to juggle things. i charged down to casualties to evaluate the patient.

gunshot abdomens are slam dunks. you operate them. there are only two exceptions which you seldom see, one of them being a bullet that only passes through the abdominal wall and doesn't actually penetrate the abdominal cavity. this guy had a tangential wound passing through the left flank. his abdomen was completely soft and asymptomatic. i was amazed at my luck. he actually didn't need to be operated. the statistics said i had a 97,5% chance of being right and if we checked him out in a few hours that statistic was supposed to approach 100%. i was quite relieved. it would definitely make the day more manageable.

in the morning meeting the professor in whose firm i was working (who was chairing the meeting on behalf of the boss who was away that day) listened to me present the cases. when i got to the gunshot abdomen that was not a gunshot abdomen, he expressed extreme cynicism. he knew the statistics too but what i was describing was just not seen all that often. he, however, knew we would be doing rounds with him in about two hour's time so he told me he would check the patient out himself. i was fine with that. i knew what i had felt and the worst that could happen was that he could tell me to operate the guy.

on the rounds the prof took his time with gunshot guy. he examined him. he then examined him again. he went over the vitals and then he went through everything again. finally he turned to us all and informed the students that i was right and the patient indeed did not need to be operated. he even suggested i discharge the guy which i respectfully refused to do. i told him i'd be a bit more comfortable to observe him for one more day.

the day went on as days tend to do. just before i went to theater i briefly layed my hand on the patient's abdomen once again. all seemed well and off i went.

theater dragged on a bit and finally at about 7o'clock pm i emerged. by that time i was pretty tired and i shuffled off home, somewhat in a fatigue-induced daze. only when i was in bed in a near comatose state did i remember i hadn't checked the gunshot guy before going home. moments later i was asleep.

the next morning in the handover meeting my friend and colleague who had been on call approached me.

"your patient was a bit dizzy last night, but don't worry. i checked him out and his abdomen is fine." i just gave him a bolus of ringers and he's fine. my spine went cold. i thanked him and smiled but my face belied what was going on in my mind. the same words went through my mind over and over again. young men don't get dizzy unless there is something wrong. young men don't get dizzy unless there is something wrong.

i ran down to theater and booked him on the emergency list for a laparotomy. then i went to the ward again. still his abdomen was completely asymptomatic, but his pulse rate had risen slightly. that was enough for me. i told him we wanted to operate and he consented. thereafter i went to negotiate with the anaesthetist to try and push for the earliest possible gap. he assured me he would help directly after a caesarian section that was about to be done.

it was too late. the patient crashed just before he was supposed to go to theater. there was a massive resuscitation followed by an operation. at operation the bullet had traversed his abdomen for only about 2cm, but that was enough. there was a small hole in the bowel which had been leaking all night. but despite this the operation went well and we delivered him to icu in a fairly good state.

as sometimes happens to good people and seems never to happen to bad people, the patient then plunged into a full blown sirs response. thereafter it was a two day downward spiral before the patient passed away. there was just nothing we could do. i felt terrible.

i knew i was the one who had made the initial call not to operate. it didn't help that a prof and a senior registrar had separately evaluated him and agreed with me. i also knew i had not reevaluated him that fateful night when i had wandered home in a barely conscious state. i had also not emerged from my bed to find my way back to the hospital once i had realized my oversight. also soon after his death i was to learn that he was making a massive difference in the lives of the youth in his community and steering them away from lives of crime. all in all he was a very good man and we were all poorer for him no longer being alive.

i suddenly knew what my friend meant when he had spoken about the graveyard in the most secret corners of our minds. i knew i had someone whom i was going to bury in mine. i also knew i would never forget him and i would never get over it.

engraved on the tombstone i still clearly see his name. his name was prince.

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.

you can't win them all

the myth of the glory of war is perpetuated in part due to the fact that the stories are only told by survivors. if the guy that took one through the neck in no man's land in world war one and then slowly faded away in a mess of saliva mixed with blood, lying in his own stools, crying for his mother were to tell his story from beyond the grave it wouldn't look so glorious at all. it would maybe be a better reflection, though, of the reality of it. in a certain sense we run the risk of glossing over medicine too. i would hope this blog does not.

i am extremely affected by the patient calling out to me to save him in strained monosyllabic speech at the last moment of his life. it is almost too much to bear. and yet i am the survivor. i walk away to live another day or to tell the story or to enjoy a sunrise in the african bush.

i remember him well. he was a kidney failure patient who was leading a fairly normal life thanks to the wonder of peritoneal dialysis. he was the breadwinner for an extended family even. and then he got the call.

there was a kidney available. i was even involved in procuring the kidney (this is always a sad and poignant story in itself. it is the coming together of life and death, of hope and despair) . the relevant tests were done and this specific patient was found to be the best match. quite soon he was in the hospital going through the needed preoperative preparations. after the usual administrative delays that are so particular to south african state medicine we even actually got him to theater and without too much fanfare soon had the new kidney in and peeing like there was no tomorrow. everything was going so well i almost thought it was too good to be true.

after theater he did well for about three days before things turned. initially it was just a decrease in the amount of urine the kidney was producing but soon it was so much more than that. without going into too much detail, the patient developed systemic inflammatory response syndrome (sirs). this put pressure on his new kidney which started faltering. he developed water retention which put strain on the lungs which were already under pressure from the sirs that he had. after that things started spiralling downwards.

we had long given up on the kidney and put the patient back on dialysis, but nothing seemed to make the situation better. then two days before my rotation in the transplant firm ended the patient collapsed in the ward. i happened to be there and commenced a full resus.

i remember clearly the terror i felt at the prospect of the patient dying. his heart wasn't supposed to have stopped! he was supposed to do well. i felt terrible! but with a bit of good luck i brought him back from the brink of death and delivered him to icu with a tube down his gullet and highly dependant on inotropic support (his heart was dependant on drugs to maintain a barely survivable blood pressure). his kidney had long since ceased to function and we dialysed him constantly at a low rate to try to not put more strain on his borderline heart. then i was rotated to the icu unit, so in essence i followed my patient there.

his sirs just got worse and soon he developed a coagulopathy (the normal clotting mechanisms in the blood stopped working) and was soon bleeding from every orifice. we gave him what we could for that but the fine balance between not giving too much fluid yet giving the needed clotting factors and the balance between dialysis and the heart that was on the verge of giving up altogether was very difficult to manage.

the last night i remember too well. i often wish i could forget. i was on call that night in icu, so it was up to me to get him through to the morning. he had been bleeding from the mouth and nose a bit all day. his blood pressure hovered just above the unacceptable level. his lungs were full of fluid and the ventilation was tricky to say the least. but as the night progressed things got worse. the first thing was the bleeding. quite soon blood was oozing from everywhere. he even had a trickle of blood running down his cheeks like bloody tears from both his eyes. and as he bled his blood pressure started falling. he became too unstable to dialyse so that was stopped. the inotropes were increased to industrial doses but that did little. i became desperate. i phoned the transplant consultant.

after i had verbalised all the parameters to the consultant over the phone it was like i had told them to myself. i knew what the consultant was going to say. if i were him i would say the same thing. the situation was beyond repair. the patient was going to die and nothing we could do would change this fact.

"he is going to die, bongi. you can't win them all."

i knew he was right. i hung the phone up and just sat for a while. i thought of the fact that this man, the sole breadwinner of his family, had walked into the hospital with hopes of a better life without dialysis and would be leaving on a cold morgue slate. it just seemed so unfair, so wrong. had we killed him? i didn't know but at the time i felt we had. my consultant had advised me to stop active treatment and see if i could get some sleep. i stopped active treatment but i refused to sleep. it just seemed to me that i was supposed to at least be with him to the end even if that was all that i was going to do.

i sat in the patient's cubicle and waited, like him, for the end. when it came it was horrible. blood was now streaming out everywhere. his breathing tube was bubbling with the pink frothy liquid seen in pulmonary edema and the ventilator strained against the pressures needed. the colour slowly seeped out of his face giving him the countenance of death before the fact. and then slowly his life force left him.

i turned off the ventilator and all the infusions and left. but even then sleep and the peace that could possibly come from it eluded me. to be honest i did not have that peace for some time thereafter.

stand back, i'm a doctor!!

surgeons are not stand back kind of people. they fall more comfortably into the category of charge in where angels fear to tread. i think the work tends to preferentially attract those type of people. but sometimes standing back can be the lesser of two very evil evils.

the call was a standard weekend consultation. the patient had hematemesis and his doctor was worried. nothing i hadn't seen many times before. but when he came in the patient's wife had a few more details to spice the story up a bit.

just about a year ago he had had a resection of his stomach for cancer. the surgeon had told his wife they couldn't get all the cancer out because it was growing into some big blood vessels behind the stomach. for some reason they both decided not to tell him this. so when he was referred for his chemotherapy (something that could not be described as awe-inspiringly effective in stomach cancer) he truly thought he was well on his way to full recovery. and now he lay before me, pale and restless.

he was a shadow of what he once must have been. his skin hung loosely as if in remembrance of the large man it once covered. i was not happy with the mass i clearly felt just under his left rib margin. the cancer was back and it seemed angry. i got the necessary drips running and ordered blood. i considered dropping to my knees but due to a back injury when i was still a student i wasn't sure i'd be able to get up onto my feet again.

the wife called me aside and told me the patient was not aware of the fact that the operation was not a roaring success and therefore that he was essentially living on borrowed time (which i grimly thought he is about to pay back with interest).
"you need to tell him." i said.
"no!! doctor!! i can't do that." she needed the truth.
"this man, your husband may die here in this hospital within a day or two. you need to speak to him." but she would hear none of it. she also didn't want me to tell him things were not so rose coloured (i suppose depending on what colour roses you're talking about of course).

the next day the patient was feeling much better. amazing what a bit of blood will do. we chatted a bit. you know, shared a moment. he even laughed at how bad he had felt the previous day in comparison to today. then it was back to business. in this case business meant i was going to take a long, not so thin pipe and stick it down his throat to take a quick look at the source of the bleeding in his stomach. i sort of lied to myself, telling myself that maybe i'd see something that could be fixed with a knife. in truth i knew what i would see. the palpable mass and the history dispelled almost all my doubt (or hope). but i knew i needed to look. i needed to know for sure how much or how little i would be able to do for him. maybe i needed evidence for one day after it all when i am called to account.

the cancer was a large fungating mass with a deep necrotic core. it was gently oozing blood but i could see it was capable of so much more. it seemed to me it had stopped its torrent of blood long enough to give me a glimpse as if to taunt me. as if to say you know me and you know you have no power here. it was right.

after the procedure the patient once again started spewing forth blood. i sat with him for quite some time. between his retching we spoke.
"this is not good doctor."
"i know." what more was there to say?
"what are we going to do?"
"we are going to hope the bleeding stops." what more was there to do?

then i went against the wishes of his wife. i told him this cancer was going to be the end of him. he looked at me with a calmness and a gentle smile.
"i know."

he probably had known for some time but i think he felt he had to go along with the charade and maintain the lie with his wife. he seemed relieved that the truth was out. he seemed to relax.

that night the sister called me to tell me he was bleeding massively. i explained the situation and asked her to push blood iv. if that didn't help nothing that i could do would. the next morning he was dead.

somehow when we sit behind our computers and in our nice expensive offices deciding about the futility of certain treatments and who should get what based on cost or whatever, the actual point is lost. the nice old man finally vanquished by the hideous monster called cancer or the old lady with heart disease or whatever who is forced to succumb to the dark inevitable is the point. it is the person, the individual. the one like me. and maybe like you.

i was just left with a sense of how difficult it is to stand back and let someone die when you know what that means. it, i assume, is much easier for the powers that be, snug in their artificial real worlds.

call it

i noticed my use of the phrase 'call it' a few times recently. it is something i saw on american tv and not at all something that is common in my neck of the woods. the sort of scene that you would get in gray's when the junior doctor is pumping the chest shouting 'i will not let you die, dammit!' while the senior doctors stand one side and instruct him to 'call it!' is pretty foreign to our way of doing things. i even got ragged a bit for using the phrase at all. i thought i'd relate a story from days gone by that illustrates this point.

it was the time of the taxi wars. now taxis in our country are nothing like you might be thinking. they are fleets of mini-buses, quite often owned by people of questionable legal character. occasionally rival groups try to take each other out (i mentioned this before here). but roughly at the turn of the millennium there was outright war. when the war came to pretoria we saw quite a few of the victims, but neurosurgery got the most. a friend of mine was rotating through neurosurgery and this story came from him.

there had been a contact between two different taxi organisations. the casualties were streaming in. the neurosurgeon and my friend, his trusty lackey, were overworked and i think it had affected their sense of humour. so while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. when the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. and this is what they did.

the neurosurgeon looked at each patient in turn. the first three he told them to send into casualties for his attention. but the fourth...he took one look at the fourth and exclaimed;
"vat hom weg! hierdie een is gefok!*"

my colleague laughed the next day when the newspapers reported;
"on arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty." fortunately they did not quote him verbatim.

*take him away! this one is f#@ked!

post traumatic stress

in a previous post one of the topics i touched on is the aftermath of losing a patient or rather the effect it can have on you as the doctor. a good post i read recently also touched on the desensitisation we tend to undergo. it is often forced on us, as was demonstrated by the sister's comment to me after the patient died in my post quagmire. there was no space for feelings. she didn't follow me out to speak to the family and be confronted with feelings. she just jabbed me a bit, maybe to help with the desensitisation process.

but sometimes the reality itself doesn't allow for the luxury of emotions. there are so many stories i could tell to illustrate this point like the time one of my patients crashed while i was resuscitating another one. when patient one died i didn't have time to even register emotion. i had to get to the other one who was in the hands of my medical officer whom i had sent ahead. when i got there to find him dead too i mustered up the troops to get back to the endless streams of impatient patients in casualties. they didn't care about our emotions. they didn't want to wait and they were willing to throw abuse at us if they did.

but the real reason i'm reminiscing about all this is a recent conversation with an anaesthetic friend. he was also talking about the effects these things have on you. it is quite sometiong to have someone die literally under your hands and wonder if there is something you missed that may have changed the outcome. to possibly be partially responsible for the death of another human being seems to leave quite a mark.

he was on call. a disaster was presented and the team got to work. he describes scenes quite similar to the fan fair i spoke about in the case presented in quagmire. anyway the details are not important. the point is there was high drama and it was traumatic and shocking to all involved and the patient died in great thespian style on the operating table despite all efforts by everyone concerned.

my anaesthetic friend was shaken, as can be expected. he wanted to go home, or even just sit and let the adrenaline work out. (home would no doubt have been better). the theater matron came in. he looked at her with a blank stare. maybe he felt empty and his face reflected that. the matron asked;
"so what case are we doing next?"

just like that! the dead patient, the devastation of the family (still to be faced), the blood all over the place, the shock to the team, specifically the anaesthetist and all the matron wanted to know was what case to do next! in a certain sense you can understand it. the list is there. there is not another anaesthetist on call, so if he is not up to helping with the next patient, the next patient would not be helped. also it could easily be that the next patient is just as critical, but it could also be that it is something quite mundane. the point is my friend had no time to recover. reality steam rollered him and he had to deal with it...later...in his own time...when he would be so tired post call he would probably not be able to deal with it. somehow that is the way it usually turns out.

when we fall off the horse, most of the time before we can even shake the dust out of our hair, we are shoved back on and the horse is given a hard thwack on its rump.

dignity

he was old. not so much in years, but old. his body had born the brunt of a full life. there was not much left. so when i saw him the first time with a rock hard abdomen and free air in the peritoneum i knew it would be a long shot.

in discussion with the patient and the family, we went ahead and took him to theater. if he had any chance whatsoever, it would include surgery. he did, however state his desire not to be kept on 'life support'. we informed him that he would be on a ventilator at least for some time post operatively. he accepted that and we went ahead.

the operation rendered a few surprises, but we got through it and delivered the patient to icu, intubated and on a ventilator. amazingly enough he did well and, was extubated on day two. the family (and surgeon) were elated.

then on day four he started slowly but surely deteriorating. he told us he was tired of life and just wanted to die. he also said he didn't want the tube down his throat again. then he slipped beneath the waters of consciousness. i was called.

he clearly wasn't getting enough gas exchange and needed to be intubated and ventilated. however i was more and more convinced he was destined to die no matter what we did. we could prolong his life but he would never leave icu. i called the family.

i laid out the medical facts and told them they must decide if we should be active or leave him to die. they discussed it. it was not an easy decision for them and i could see them struggling with the concept of just letting him go while he was still alive. medical facts weren't good enough. i told them what i thought.

i firstly explained that to intubate held little guarantee of ultimate survival in this case. i then went on to say that it was probably better to die without a tube than with a tube. also to delay the inevitable would prolong his suffering. i then reminded them of something they all knew, i.e. that he had said he didn't want to be kept alive by a ventilator and maybe it was time to respect his dying wishes. they reluctantly agreed. i left the family, together maybe for the last time.

maybe i swayed them. maybe i influenced them to decide what i felt was best rather that just giving them the facts and allowing them to decide themselves. but sometimes medicine is not about facts. we are working with people and relationships and human interactions as well as just physiological systems and these things will always play a role. i was content with my actions and went home.

but what they did not see, what no one saw, was the moment just after i spoke to them when i moved off alone and thought about that day so long ago. the day i held my grandmother's hand in another icu in another city as she breathed her last breath. she too had also declined intubation. she too was given the choice of a death with dignity. i cried.