First Encounter with Death

Is it taboo to talk about death and dying? Nobody seems to take an interest. You could almost hear the unspoke thoughts in the silence: 'He's fading' 'We can't offer anything else' 'It is awful, watching someone (die on us)'

It is awful, indeed.

I struggle with my guilty feelings. Sometimes it seems easier to think about someone dying, an endpoint, closure, rather than to think or witness them suffering in prolonged disability. All or nothing, no grey areas in between. My world is solid again.

The first time I saw death outside of the anatomy class, it was with the a senior doctor than I, though younger in years than I. His proper English upbringing gives a palpable air around him.

Today he was teaching me about death. We had been called to certify a man who has passed away due to his fulminant cancerous state. We went into his single room. It was quiet - no distracting machines beeping at irregular intervals. No accessory lines, probes, blood pressure cuffs that restrain his body to the physicality of the room. There were no wailing or distressed relatives. There were no get-well cards or flowers from the gift shop. There was just him, an empty husk of a man lying beneath the thin sheets that no longer gave him warmth, but only serve to offer a fleeting modesty.

The colour of his skin was a bright yellow, as if someone had painted food colouring on him, except it had a sickly tinge, beyond his obvious jaundice. His skin appeared waxy and taut, stretched tight over the normally animated eyes, nostrils and cheekbones. His mouth was shrunken, yet fixated in that ominous 'O' sign.

'They nearly always look like this,' my mentor said, in his usual detached tone, so that his emotions were not betrayed. 'Do you know what to look for?' He asked. I gave him an anxious glance and started to utter a few words that floated to me from fragments of my clinical experience, almost six years past. Without hesitating, he started to teach me systematically a way to fulfil the legal requirement of death certification.

Artificially, the first step was to call out the person's name. Then checking a response to pain. I rub my knuckles over the patch of tightly stretched skin on the centre of the chest that no longer shifted air. 'It's easier when they've had a bit of time,' my mentor said, encouraging my efforts.

I pry open the plasticine lids and shine the ungraceful Energiser torch at his pupils. No movement can be seen in the laxity of those eye balls. I made a mental note to myself to buy a penlight so that no person at the end of their life should have their dignity lessened by their signs of life being checked by a big red ungainly torch.

I place my fingers over the major arteries of the neck. I feel nothing apart from the fine tremor of my own fingers and the weak rapid pulse contained within it. I place my stethoscope over the area of his heart, and contrary to what I hear 99.9% of the other times it is used, I heard an emptiness. Not completely devoid of sound, but a hollowness, as if the rustling of the sheets and the brush of the stethoscope were transmitted inside the empty cavity of his chest. A loneliness of sound.

We listen to this loneliness for a few minutes together, then silently lift our stethoscopes off his body, readjusting it into the comfortable nooks on our shoulders. There is no dramatic flare as we walk out of the room and nod gravely at the nurse so that she may begin the preparations down to the morgue. We find the medical chart and write down those fateful words:

"ATSP (asked to see patient) re: signs of life
No response to voice or painful stimuli. Pupils fixed and dilated, unreactive to light. No breath sounds or heart sounds heard. I pronounce xxx deceased as of time/date. May him rest in peace."

Beggers and Choosers

I sit inside the "fishbowl" - the nursing station that has glass panes separating the healthy from the sick. I twiddle my thumbs mentally as I glance at the screens that show changing numbers and squiggles. Numbers that show the heart is beating: how fast, how slow, how hard, how irregular. Numbers that show the lungs are breathing: how fast, how slow, how deep, how shallow, how effective. Here, the human being is reduced to a series of numbers and lines.

I am in the Intensive Care unit.

Where patients are asleep, bound to their surrounding machines and monitors by tubes and lines. Watched over by their assigned nurse with a hovering pen, ready to record the new numbers. Ready to adjust another knob to crank up the breathing support, the blood pressure support.

I am in a living physiology lab.

Challengers earn their entry inside the arena with the failure of more than two organ systems. Armed with antibiotics, IV fluids, painkillers and pump pushers, they wrestle and tackle their nemesis: Sepsis, Kidney Failure, Lung Failure. Retreated into the ever-expanding fluid-filled physical body, the tug of war of life and death takes place in an unseen realm. Some are winners, and go on to battle smaller enemies, like boredom, anxiety, lethargy, adjusting to leglessness. Some are not so lucky, and run on borrowed time.

Like Mr D.

Everyday he seems more gaunt. His hollow, sallow cheeks and semi-closed eyelids over softened eyeballs speak louder than the surprisingly good numbers his machines generate. The moisture in his body does not rise and fill his skin but somehow fall dejectedly, surrendering to gravity, to the dependent areas of his body. It's not that he was in a great condition before the illness either, with decades of alcoholism and smoking eating away and ageing him beyond his years. But I feel he is leaving, even though nothing else seems to have changed.

A wise person once told me, that initially people noticeably age in the space of ten years, then five, then three, then one, then by the matter of months, weeks, and when they are towards the end, in the units of mere days, hours, minutes.

If that is the case, then I pray for you, Mr D. I pray that you go to a good place, a good life, and catch a glimpse of your true nature unrestricted by this physical shell. May you be well and happy, and free from suffering.

May you go in peace.

Holistic Medicine vs Quackery

Whilst habitually clearing out my inbox one day, during a post-waking pre-caffeinated state, I came across an forwarded email entitled "fringe medicine." I thought, odd, especially coming from a holistic doctor's mailing list.

Scrolling past the various replies, I read the first email, from someone I did not know, but was adamant about the public attack on the NZ medical council's newsletter. It went something like this:

"... the fear of death as a sequel to illness is a powerful and not always helpful emotion. In the cloud of serious illness, the unwell human believes any number of claims to 'cure'. Most patients simply do not have the training nor the knowledge to make valid judgements..."

Then the author started to list the ways in which doctors practising alternative therapies were turning against their training in logical, scientific rationality and embracing financial gain and satisfaction in making diagnoses and inventing treatments for many conditions that conventional medicine do not treat.

And simply concluded:

"... Fringe medicine has been around for a very long time. There was hope that the modern scientific method would rid us of dodgy practices. This has not happened. None-the-less a doctor’s role is clear. That role is to protect the patient from false claims and from futile or harmful treatments."

And so, the sentence is clear, any non-conventional doctor is a shady character of questionable ethical standing. Thus, by encouraging segregating and rejecting these people, the author is ultimately protecting masses of innocent unsuspecting patients.

Or so it seemed.

I have to agree with the fact that there are a lot of charlatans about, and in my experience there are a lot of well-meaning but somewhat ignorant therapists, and that there are also a number of skilled but incredibly poverty-stricken healers... but what about doctors?

"First do no harm" - first principle of medical ethics

We are trained to be cautious, to give promises only when based on solid fact or evidence. Diagnoses are made when certain criteria are reached. And if not, "subclinical" or "prodromal" or "viral" or "nonspecific" terms are used and no treatment can be commenced. The diagnostic train grinds to a halt, and the patient is offered a reassurance that it is nothing significant. Yet.

Somehow, preaching healthy lifestyle is not popular. But, selling a health-promoting substance is. If we cannot take a drug for it, then why not a tonic, or hope? Why try to change the unhealthy habit that caused it in the first place?

What a strange world we live in.

My grandmother is admitted to hospital again, while I look after other grandmas on the other side of the world. She was found drowsy at home and brought in for treatment. She had high blood pressure and, alas, traces of amphetamines in her blood. She is now recovered and spritely following various IV infusions and nasogastric feeding, the tonics of the medical world.

Amphetamines?! I gasped when I heard on the phone. How on earth does an elderly house-bound conservative Christian woman get hold of a street drug? And then mum added nonchalantly, "she is always taking some herbal remedy."

My mind spins. No wonder any alternative therapy is guarded against. And this is in tranquil New Zealand, where so far I have not heard of any immoral tainting of "herbs" with synthetic toxins. But already so much animosity in such a public domain.

It will be interesting to be doing a practicum with my mentor during the next period of time, when the group of complementary medical practitioners will be formulating their reply, hopefully with more integrity than reactivity, so that the air can be cleared once and for all.

Another Day at the Orifice

It is almost 2am. The building is quiet and I can hear the soothing sound of soft persistent rain outside, and the occasional call of a gecko. I've lost track of how much sleep I've had in the last 48 hours, having finally finished the last night shift at the Emergency Department. I will finally be in a place to reset my biological clock, that is, if I can. All I know is, I am tired.

My mind still drifts back to the last patient I saw before emerging again into a world of bright glaring sunlight and steamy heat, from a world of variably fluoroscene-lit and variably air-conditioned environment permeated with various smells (human or otherwise) that you don't really want to know where it originates.

Somehow, everyone I see is in varying degrees of anxiety, and mostly out of proportion to their physical ailment. This particular gentleman is in his 60s, well-spoken and uses medical terminology to relay his symptoms. He is anxious, and keeps glancing at my name tag, scaring himself that I were a day 1 intern. He had woken up in the middle of the night with tingling in the left side of his body, which hadn't gone away after four hours. Obviously he is worried about having a stroke. And as it happens, he is a medical professional, which just makes the worrying so much worse. I sympathise, and at the same time trying to not let the intimidation get to me, and proceed with a mish-mash of physical examination at the end of the 10-hour shift with my already cotton-wooled brain.

He is a little reassured that there is nothing solid on my findings to indicate he's had a stroke, and that his plantar reflexes were downward pointing. He did not even have objective temperature sensation changes. But alas he is still anxious. I hand him over to the fresh day team doctor and organises his CAT scan to happen immediately (a rare feat in the public system) . And his parting words were: "Go home, Kiddo."

For the first time in a long time, I feel acutely powerless in being young, female, Asian.

I know I am still gathering experience and that my knowledge base of Neurology is limited. But I also know that the CAT scan will show very little, and he is unlikely to have bled into his head during the middle of the night. However, he will mostly likely end up being admitted to hospital and proceed to an expensive MRI scan, which is likely to be inconclusive anyway.

I think about the fear that is driving his anxiousness. The loss of control not knowing what is happening inside his brain - should he take more blood thinners, should he lower his blood pressure; could his longterm smoking have contributed to his stroke; would he lose his livelihood forcing an earlier retirement than he'd liked, due to his procedure-based medical practice. And to make things worse, he is being assessed by a glorified medical student in the relatively unsupervised early morning within a limited public hospital away from any Neurology or Neurosurgery service. He tried to protect me from the outlash of this, by being nice, by proactively giving me his history, by smiling reassuringly that I'm doing the right physical examinations, by apologising to me when he saw me being lectured by a nurse about letting him use the staff toilet, by attempting the friendliness in his farewell when I could almost see the snarl in his lips as the words came and his unlistening ears to my wellwishes.

I had felt a strange mixture of emotions since parting his bedside. The elation of having finished a long stretch of shift work and performed satisfactorily in my assessments. And the feeling of being a passive observer in another being's struggles with morbidity and mortality, unable to influence or alter the outcome. I hope he does not end up having had a bleed, or a stroke. I hope at some time in the future, he emerges from being confronted so directly with the bare essentials of life and death, and the interim hell of disability that would be for him, and rises to a new level of meaning and awareness to what life is, and what life could be.

As one of my bosses had said recently following a particularly harrowing shift during the Xmas and New Years period: "... another day at the orifice."