Dealing with Death

"Some wish to live within the sound of church and chapel bell;

I want to run a rescue shop, within a yard of hell." 

― C.T. Studd 

I wrote the following while operating in West Africa:

I recently experienced what I have titled "The Hour of Death." It was not an actual hour, but the events unfolded quickly. It started after I finished an operative case. I had 20 minutes before my next case started. Often surgeons take that time to see new patients they were asked to see. I saw two in-patients before my next case started.  

The first in-patient consult was a 21-day-old child. The exhausted infant was tachycardic and breathing fast. There were skin changes, an ominous finding. The x-ray showed that some of the small bowel was dying or dead. This child was very ill. I wanted to think about it and talk with my surgical partner. I do not deal with this diagnosis, necrotizing enterocolitis, often. Antibiotics and IV fluids would be a good start.

The next in-patient consult I went to see was a 30-year-old man. He had a necrotizing soft tissue infection (flesh-eating bacteria), meaning the condition was killing his muscle, skin, and other soft tissue. The disease was circumferential and extended from his foot to two-thirds up his thigh. There was a terrible smell. People do not complain in that area of West Africa, but it was apparent he had exquisite pain. I explained in English, which the translator translated to French, and then to Hausa, that the man needed an amputation. Without intervention, he would die. The patient was not interested in a surgical solution, but the problem had no other answer. He needed the source of his infection controlled. The patient refused. His brother was in tears; his father wanted the surgery done. The patient was unmoved. I went to the OR to see if the next patient was ready and returned again to beg the patient to let us save his life. Nothing would convince him.  

My next case was starting, and I found these two in-patient consults weighing heavily upon me. The patient on the table was asleep now. Our working diagnosis was perforated typhoid with a moderate amount of pus in his abdomen - 2 liters. He was 18 years old and otherwise healthy. I would do an efficient operation: resect the bowel segment with the three perforations, pull up an ostomy, wash him out, and close the skin. I would be done in under an hour. He would get another operation in 2 days per the hospital protocol. As I started the procedure, a surgical resident told me the young child had just died. That was quick. I thanked the resident for letting me know. I needed to stay focused. Five minutes later, another resident informed me the patient with the necrotizing infection refused amputation and had left the hospital. I thought to myself, at least one patient I am touching this hour will live. I completed the case, and they took the patient to the ICU while I sat down to write the operative note. Before finishing the documentation, I was urgently summoned to the ICU. My fresh post-operative patient was in cardiac arrest and did not survive. I suspect he was prematurely removed from close anesthesia monitoring and unable to breathe sufficiently, becoming hypoxic. I believe this was a preventable death.

After those events, a surgeon can struggle. A person wonders how to control so many factors that seem beyond one's control. These events sit heavily on one's shoulders and in one's mind. I was not wrestling with the sovereignty of God but grateful for it. I do not know how expatriate and local families manage the reality and magnitude of death and morbidity daily.  

As a surgeon going to desperate places, I can see that a missionary or humanitarian surgeon must make solid decisions, optimize limited resources and time, overcome individual and cultural barriers to progress, and accept loss when it comes. There must be grace and mercy for others, the system, and oneself.

I suppose we tend to forget about all the patients that live. I will say that austere surgery is not for the faint of heart or those that only like cheerful stories and happy endings. I believe that the patients and their families know we are trying to love them. We are a place of last resort, which for some of them is unfortunate. The spiritual alone is left when the physical and the emotional fail. To take from the C.T. Studd quote above, there are not a lot of church bells here. This hospital may be a yard from hell.

This is a picture one of many patients with typhoid peritonitis.