Developing clinical detachment isn’t easy. Doctors experience pain and grief in equal measure when a patient is long gone.
A few months ago, I had operated on an elderly lady for a behemoth tumour arising from her pituitary gland. We take down these tumours through the nose using an endoscope. Surgery went off immaculately. Her vision, which had been expeditiously deteriorating, improved almost instantly after the operation and she returned home within a few days of surgery. Her two sons, who worked as servers in a restaurant, were delighted with the outcome and grateful to us for doing it at a nominal cost.
A week later, I got a phone call at 7 AM from the son, indicating that the mother was refusing to wake up. “She’s breathing but appears to be semiconscious,” he said tersely, not able to make sense of the situation. I quickly ran a laundry list of possibilities in my mind for delayed deterioration after an operation of this nature: infection, sodium-water imbalance, hormonal disturbance, hydrocephalus, hypoglycaemia, stroke… the list went on. “Get her to the emergency department of the hospital immediately,” I bounced back, charging to reach there myself, making innumerable phone calls on the way to get the team geared to deal with the myriad possibilities I was considering. We put the scheduled cases for surgery on stand-by in case she needed to be taken back to the operating room.
When I saw her, she was gasping. I grabbed a breathing tube and shoved it down her throat to secure her airway and connected her to a ventilator while the others fixed an intravenous access to collect blood samples and run some fluids. A nurse put in a urinary catheter and a litre filled the bag in a whiff. I tugged on her neck to see if it was stiff. It was log-like. “Shit,” I winced, diagnosing, “She’s got meningitis.” My assistant looked at me with raised eyebrows and the unspoken question of “How the hell did this happen?”
We ran her through the CT scan machine and noted that her ventricles or fluid-filled cavities of the brain had blown up. We paced her to the operating room and placed a drain in the ventricle to release pressure as well as to test the fluid for infection. Cerebrospinal fluid, which is often chaste, was dirty and turbid in her case. The results of the analysis were ominous. The highest doses of antibiotics were administered as we shifted her to the ICU to place some more lines and tubes as she lay there tethered to a tower of infusions.
After two hours of commotion, I finally sat down with the family. “Did she have any fever or leakage of fluid from the nose?” I inquired. “No,” they said, “she was absolutely fine until she went to sleep,” they lamented. “It’s very unusual for such a dramatic presentation,” I told them, but convinced that brain fluid had been leaking from somewhere that had been infected, perhaps not coming out through the nose but probably trickling down the throat. Their eyes welled with silent tears trying to make sense of this unexpected turn of events.
Over the next few days, their mother made a steadfast recovery, her eyes opening to mild pain, her limbs making random purposeful movements. Sighting a window of opportunity, we took her back to the operating room to seal the suspicious leak. We found it and packed it with fat, sealing it with glue and a little prayer. We changed the drain in the head on two occasions over the next two weeks; leaving it long enough inside the brain risks infection as well. I spoke to the family for an hour each day, sometimes 2–3 times a day. I answered phone calls from several other relatives and from other doctors they were known to, appraising everyone involved.
After about 3 weeks and noticing only a marginal improvement, they were running out of money and hope. I helped arrange for some social workers to aid them. I organized a GoFundMe campaign through some charities. The hospital too benevolently deducted whatever they could. Later that week, her level of consciousness dropped again. An MRI showed multiple tiny strokes in the areas responsible for her consciousness. The infection had gnawed away at the tiny arteries supplying these areas. The blood pressure was labile, the urine output began to drop, the liver started giving up – all signs of a malevolent sepsis.
One month had passed since she had been admitted. The sons had exhausted their mind, spirit, and sinew. I answered every question and replied to every text message at odd hours of the day and night, surrendering my time at home to alleviate their anxiety. I offered to shift her to the public hospital where I worked so that further treatment would be cost effective. She passed on within a few days of transfer after battling for 36 days. The body was wrapped in a shroud and cremated within a few hours.
I didn’t hear from either son after that. Their names no longer showed up in my most frequently contacted section on WhatsApp. It was as if I didn’t exist for them anymore, while in my head and heart, I had felt as though I’d become a member of their family, fighting for a common cause.
Their names no longer showed up in my most frequently contacted section on WhatsApp. It was as if I didn’t exist for them anymore, while in my head and heart, I had felt as though I’d become a member of their family, fighting for a common cause.
“It’s hard for me to fathom how people can be so ungrateful for the things you do for them,” I despondently said to a colleague one day, wondering why they could not even say “thank you” – not at the time of death, of course, but a few months later.
“Their mother died. You have no right to be upset with them,” he pounced.
“But I do,” I said, without any guilt.
Dr. Mazda Turel
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