The Things That Medical School Won't Teach You (6) - Don't be afraid to diagnose death

It has been one of those trying weeks at the office. Lately it just feels like I'm stuck in a rut and the job isn't fulfilling. Even worse is the loss of patients; seems likes it's more traumatizing in these past few days. Despite working at a hospital, it's still easy to take it for granted that these vulnerable souls could just up and expire on you at a moment's notice. Makes you think twice about that expression "Sleep is the cousin of Death!"

With all the death we encounter, you'd think that there would be some special training to help us steel our nerves and encourage us despite the amount of loss we witness; training that would keep our minds at peace, so that we could be able to impart some form of closure and finality to the grieving relatives that we interact with on a regular basis. The answer to this is, of course, a big resounding NO!

I honestly can't recall any of my med school classes that evenly remotely mentioned the concept of death (beyond the usual sterile "cessation of all bodily functions" package). In fact, it's only been earlier this year in a Counselling CME (Continuous Medical Education) seminar when this issue was really broached for the first time. However, as in all things medically-related, we just have to make do with on-the-job training, usually carried out on your own. So next time you get a doctor with a questionable bedside manner delivering bad news to you, it might not entirely be his/her fault. Blame the profession.

I'm reminded of one experience that occurred during my internship while I was in the middle of my surgical rotation. On that particular day, I was manning my casualty post when an ambulance pulled up to the adjacent parking area. Convinced that an ambulance pulling up most likely signified either an Obstetric/Gynecology (Obs/Gyne) or Surgical emergency, I silently prayed that this was one for the Obs/Gyne team. (...and of course when I was in my Obs/Gyne rotation, I prayed the opposite prayer).
In a departure from the norm, the ambulance just sat there parked without anything apparently meaningful happening. I took a walk down to the Nurse-in-Charge's office so I could get some idea of what was going down. Turns out that the EMTs/Paramedics had ferried a victim (elderly adult male) of a road traffic accident that occurred in an adjacent county to our facility. This irked us to no end for a couple of reasons:

1. There is a protocol in place to follow when referring/bringing patients to our facility, which usually involves communicating with the Nurse-in-charge so that proper preparations can be made. Many people tended to ignore this common courtesy.
2. More often than not, some counties are particularly notorious for off-loading their workload by referring patients that they could satisfactorily deal with within their own county facilities.
3. With the advent of devolution, multiple county heads had acquired ambulances at a rate incongruent to the money they had invested in medical facilities. What this meant was that (as mentioned above), it was easier to handle an emergency situation by just dumping a patient at another hospital's doorstep.

So what we had was an actual stalemate. The ambulance had ferried an accident victim who was in urgent need of an ICU, but all our ICU beds were occupied (which they would have found out if they had bothered to inquire first); they were, of course, unwilling to transport the patient to another hospital or return him back from whence he came; our Nurse-in-Charge was sticking to her guns, and as per protocol, was not going to take responsibility for the patient.

I figure the ambulance had been parked for 30 minutes while this whole scenario played out. Finally, I made the decision to examine the patient within the ambulance to find out exactly what we were dealing with. So I step into the ambulance and the patient is eerily quiet; all I get from him is seriously laboured breathing. He's neither responsive to my voice or painful stimuli of any sort, and his eyes are closed shut; once pried open, his pupils are slightly dilated and not responding to a light stimulus. On the plus side, he did have a steady pulse. Thus, on the Glasgow Coma Scale (GCS), this patient registers an all-time low of "3".

Now any medic knows that this patient's breathing is going to be the next thing to go; devoid of an ICU with ventilatory support when that happens, death will most definitely ensue.
I relayed my findings to the Nurse-in-Charge, and we shared an ominous silence between us. The patient had no relatives/guardians that could organize for him to be taken to another facility, so he was stuck either way. Seeing as we really had no good choices, we opted to keep him in our casualty area, providing supplemental oxygen and as much supportive management as we could muster under the circumstances.

He lasted a good 2 days in that state (longer than I had actually anticipated), but in the end he passed away.

Despite all my experiences with death, even I fail to see how I would prepare a lesson to adequately prepare fledgling colleagues for what awaits them in the field. Every death encountered is as diverse as every life lived. You will watch some lives snuffed out within the few minutes you encounter them, and yet with others it will be a "slow burn" where you will get to experience the patient's life and those of their relatives for a prolonged period. And in itself, this notion of time is certainly a fluid concept: you could live a lifetime in the few minutes that you spend trying to resuscitate a newborn child, or, as in my experience with Edna, the 5 hours you spend with a practical stranger.

In my experience, I have found that you shouldn't be afraid to diagnose death! I'm not talking about that morbid movie-type experience where a doctor says something along the lines of you having 6 months to live (nothing is ever really that clear-cut); rather, you need to develop an acumen for seeing it coming. After being around death for such a long time, you and your colleagues develop a knack for predicting it (especially the nurses); in my Paediatrics rotation, I discovered that mothers are very good at sensing minute changes in their children's state, so when a mother asks you to check up on her child, kindly do it.

Any well trained health worker knows that recognizing the GCS will steer you right (except maybe in the tricky case of career alcoholics!). Thus, as a matter of fact, impending death is easy to predict in most cases, but occasionally it just sneaks up on you; I've had cases where we've fought out the worst of the patients' battles, and just as it appeared they were on the road to recovery, the war ended. So, in essence, the work of medical staff truly is that arm-wrestling match immortalized in my intro illustration. And in the end, we always lose!(...it is appointed for all men to die once, and after that comes judgment...).

Morbid as that may sound, death is not always the grim experience we all imagine; if handled correctly, it can provide closure to those left behind, a culmination of a life well lived. Pair that with the belief that people have of the afterlife, and you end up understanding that death is not the "be all and end all" of everything; it's just a phase.

I remember that during my first few months in China, I struck up a friendship with a young practising doctor from Mauritius named Javed. In the course of mentoring me, he gave me one quote that's stuck with me till today:

We treat, but God provides the healing!

There's only so much that you can be expected to achieve by the instruments and measures of your time/era, and death is always an inevitability, so be humble in your practice. A 'God Complex' is a liability to any true health worker worth their salt; do not give people false hope, but neither should you aim to dash their hopes underfoot; always do your best for your patients, and rely on all members of your team to get you through all eventualities. None of us is perfect, but as I've mentioned before, working with this segment of society is a privilege (despite its taxing nature); therein lies a blessing and a daily perfecting grace.

God Bless