I See People Die In My Dreams

The date and time are irrelevant. Whilst the days are neither the shortest nor the coldest I have experienced, the winter month of June in Pietermaritzburg has been marred by so much death, depression and hopelessness. I am dictating this from my bed physically exhausted, but too unsettled to fall asleep just yet. People die everyday of course, but it is unusual experience for a person (or for me at least) to see people dying everyday as I have done for the past two weeks. I am working diligently as I can, the hours are brutal, and I leave every call with a terrible sleep deprivation headache, but it all feels pretty futile.

Not For Resuscitation

I was in the middle of seeing one of my patients when a nurse walked over slowly, in the particular unhurried way that ironically seems to accompany most emergencies in this department.

"Doctor, can you come and help me, please?"

"Is it urgent?"

"Doctor, please come and help me."

I have noticed that this lack of outlining the basic details of the problem with the patient seems to be a cultural euphemism amongst the nurses in KZN for when a patient has died.

I followed her across the aisle that divides the ward in two.

"This patient is not breathing."

I called out to the woman whose eyes were rolled back and mouth open and unmoving. There was no response, and no pulse. I remember asking, uselessly, how long she'd been like this, if she was 'for resus', was I actually meant to start CPR now? Two seconds pass and there is no answer so I climb onto a step adjacent to the bed and start chest compressions. Two inches deep, at a rate of 120 per minute (I tend to go a bit fast) with adequate recoil between each thrust. She was old and frail and I felt her ribs break as I pressed down, a sensation I haven't got used to despite it happening several times already. I call for help. It was chaotic in the way these things always are: too many hands and everyone seemingly shell shocked and unmoving before then all moving and getting in each other's way until someone (often me when there aren't senior doctors around) starts giving orders and responsibilities to individuals.

Fortunately one of the doctors was quickly on the phone to the consultant of the firm that the patient belonged to. Without much ado the message was relayed that the patient was not for resuscitation.

So I stopped. I washed my hands. I went back to the patient I had actually been seeing before all this started. I'm irritated that I had to waste three minutes doing that, but grateful it wasn't 20 minutes. I am briefly ashamed that those are my immediate feelings, before I remind myself that there is no time for feelings and I must push on with my ward round.

The Unmoveable Patient

This next patient is on my firm. She had recently undergone an above-knee amputation for diabetic foot sepsis. She weighed somewhere between 140 and 160 kilograms and had a body mass index of about 60. She is completely bed-bound, and her left thigh terminated in massive stump with wider than the diameter of a football.

According to the notes, she had been vomiting profuse amounts of blood the night before. This had fortunately stabilised on its own. The night team to stop her low molecular weight heparin and plan for an upper endoscopy in the morning. But to stop her blood thinners meant inviting another killer to the table: a massive pulmonary embolism, a near certainty for a morbidly obese, completely immobile patient post major surgery. She will almost certainly get a a pulmonary embolism, and if she has a major GI bleed, we have no Sengstaken-Blakemore tubes with which to tamponade the bleed. Which cliff are we going to push her off?

Endoscopy revealed the damage: extensive oesophageal candidiasis, pangastritis, and a prepyloric ulcer. But when I examined her, the systemic problems were not limited her gut. Her previous notes had nothing remarkable written down; just a brief mention of pus on her wound. But looking at her, you could tell she was profoundly toxic.

I found a central line in the femoral vein of unknown age. When I pressed around it, pus leaked from the insertion site. I pulled the line and sent the tip for culture. Then I put my stethoscope to her chest, so I could justify the standard surgeons' cardiovascular examination notation, "S1, S2, no murmurs".

But no, she has a gallop rhythm. A quick dig into her old internal medicine charts revealed why: she had a history of congestive heart failure.

As I stood at the foot of her bed, looking at this massive, septic, immobile woman, struggling to breathe and in my mind I know the end is near. She cannot leave the hospital. She will stay in this bed until she dies. What exactly were we trying to achieve by hacking off a limb, only to leave the rest of her to fail?

She died two days later.

In the bed next to her was another long-term resident whom I had actually admitted 6 weeks ago when I was rotating through Greys Hospital. She had been here for two, maybe three months, suffering from an enterocutaneous fistula; a communication from the intestines directly to the atmosphere on the abdomen. Additionally, she was newly diagnosed with both TB and HIV.

Because of resource constraints, there was no wound manager, no specialised advanced dressings. Bowel content was pouring directly out of the high-volume fistula onto her skin. The defect was too large for a standard stoma bag. The suction tube was gone. I was asked to if I could "patch" the dressing.

Without a wound manager or some sort of vac dressing to suck out the spillage, this is quite a pointless thing to do. Bowel content, essentially poo, is aggressively bubbling out of a patient's abdomen. She was literally lying in her own waste. The smell was terrible. I feel so sorry for this lady whose index problem was a bowel injury at at exploratory laparotomy for an ectopic pregnancy more than a year ago. The surgeons had to resect bowel and bring out a stoma which she had for about a year. Stoma reversal was done a few months previously but was complicated by the fistula.

Yesterday the consultant decided he was going to try to perform a heroic and high risk surgery to repair the bowel and remove the fistula. This would take several hours and there was a high chance she would die on the table. She was extensively counselled on the risks and advised to speak with her family perhaps for the last time. She was keen for the surgery, happy that there was a small glimmer of hope. I also liked the idea of this surgery, it seemed difficult to imagine how her life could be worse. This surgery promised either marked improvement or the freedom from a life not worth living. Unfortunately, she developed sepsis overnight and was not fit to withstand anaesthetic or surgery. A new plan had to be made and she is now in limbo again.

All Vitals Normal

Meanwhile, the acute surgical conveyor belt doesn't slow down. My calls on Tuesday (a public holiday) and Saturday brought the usual influx of trauma numerous gunshot wounds to the abdomen, all requiring emergency laparotomies.

During our intern weekend ward rounds where we are tasked with seeing every surgical patient in the hospital, we found a burns patient tucked away in the back of a ward meant for "stable" outliers.

She was essentially unresponsive. Her Glasgow Coma Scale (GCS) was sitting around a six or seven. On her chart, the routinely recorded vital signs showed she was fine. The reality at the bedside told a completely different story.

I counted her respiratory rate myself; it was in the high thirties. Her heart was racing at 138 beats per minute. When I listened to her lungs, I heard loud, coarse crackles and bilateral bronchial breathing. She had a severe, multilobar pneumonia alongside infected, foul-smelling burns across her abdomen.

Obtaining intravenous access and taking blood from her was very difficult. We started antibiotics, and the next morning’s X-ray was in keeping with the clinical findings: dense consolidation in both lungs with air bronchograms.

Despite our best efforts, moving her into high care area, antibiotics, correcting electrolytes, blood transfusion, she died on my next call a few days later.

The Whole Patient

These aren't isolated incidents; they are the daily rhythm of our service. Just yesterday, I saw another gentleman who had undergone a below-knee amputation, while his chest vibrated with the harsh, ejection systolic murmur of undiagnosed aortic stenosis.

As junior doctors in a surgical department, it is incredibly easy to develop tunnel vision. We focus on the stump, the fistula, the burns, the bullet hole. We tick the surgical box and move on. But these patients are not just a collection of surgical specimens; they are human beings with fragile, failing medical ecosystems.

If we don't adopt a holistic approach to the people in these beds, if we don't look past the scalpel incisions to see the heart failure, the advanced immunosuppression, and the broken social realities then we aren't practising medicine. We are just managing logistics until they die. Of course even if we do all these things right, they may well die anyway.