Wednesday, April 16, 2008

And Times I Didn’t (1)



There’s more to life than living and dying. Being alive isn’t necessarily a beautiful thing and death isn’t necessarily something horrible. As Mel Gibson as Braveheart proclaimed, all of us will die, but how many among us truly lived?

Jaunah was only 46 years old but had already developed a wide range of diabetic complications. The first time I saw her, she was lying motionless in an isolated bed in the orthopaedic ward. The mother of five and grandmother of two was a chubby lady. Catatonic and staring blankly towards the ceiling, she blinked occasionally in an apparent pensive and mellowed state of mind. Her left leg was no more, amputated below the knee for a severe infection involving her left foot. The remaining lower limb seemed destined to follow suit. The bandage around her right calf bore testimony to a recent surgery to remove a collection of intramuscular abscess.

A dirty catheter protruded from the right of her neck. It was an internal jugular catheter inserted weeks ago to enable hemodialysis for her failing kidneys. Years of uncontrolled diabetes and recurrent bouts of severe infections had damaged her kidneys to a seemingly irreversible state. A tracheostomy tube prevented her from verbalizing any sound, word or exclamation. As such, no one knew if she was depressed or angry, hungry or thirsty or in pain. Bad lungs, prolonged ventilation and repeated surgeries had made tracheostomy a crucial intervention.

A bed sore in her buttocks measuring the size of a human palm emitted a foul-smelling stench, revealing the muscles and bones that lie beneath. It was badly infected with a potent organism doctors name MRSA.

A young lady and a small girl waited by her side every morning. Her daughter-in-law had resigned from her work to care for Jaunah. With the reduction in her household income, a baby-sitter was beyond her means so the young child had no choice but to spend her days in the infectious environment of the hospital. By evening, Jaunah’s son assumed his rightful responsibility of caring for his mother. He traveled from Kota Belud every day after work. It was a daily journey of 180 kilometers.

I read through Jaunah’s case notes. They stacked up higher than a Britannica collection. In a patient with multiple issues, a sense of chronology will put things into a better perspective.

Jaunah was previously well, until she started developing multiple areas of abscesses. She had undergone repeated surgeries for infections in her cheek, buttocks and thighs. It was during this time that she was found to have a poor kidney function. When her condition stabilized, she was sent up to the ‘extension ward’ to recuperate. One night, she developed total blindness in both eyes. Further investigations suggested a stroke involving the area of the brain responsible for deciphering vision. She was blind since then with further deterioration of her general health and kidney function. Jaunah was started on regular dialysis thereafter.

In the morning rounds every day, the surgeons and consultants virtually passed her over. They had practically given up on her. She was referred for ICU care. The intensivists came and suggested a DNR instead – Do Not Resuscitate. To be fair, it was actually a reasonable option as ICU beds are always in a state of acute shortage. I was left with the unenviable responsibility of counseling the family regarding her resuscitation status.

Her husband arrived after a whole week of waiting. He was of tiny frame, had thinning silver hair and bore an uncanny resemblance to Abdullah Ahmad Badawi. Years of kerja kampung had taken its toll on him. His wrinkles and sun-scorched skin painted a man beyond his years. A devout Muslim, he was submissive to the will of God and any eventualities but was hopeful that the doctors would not just give up without trying.

I was practically left to handle the patient by myself since then – a house officer with no experience or formal training in intensive care. With the help of my colleagues especially Dr. Bee, we made major decisions in the daily management of Jaunah. It was unprecedented – two house officers left alone in charge of an ill patient with little chance of total recovery.

We decided to replace the dirty tracheostomy tube as well as the over-aged dialysis catheter.

I spent almost an hour securing an intravenous cannula for Jaunah to undergo surgery.

When Jaunah developed upper gastrointestinal bleeding, we referred her to the gastroenterology team for a life-saving scope.

We controlled her sugar tightly and stabilized her blood pressure.

When she developed yet another severe lung infection, we took the liberty to prescribe the most appropriate antibiotics. In times when the specialists give up and walk off, the bulk is passed onto the house officers who must step in and rise to the challenging occasion.

Jaunah began to show tremendous improvement. She was passing urine well without the need for dialysis. Her infections have settled except for her bedsores. Her tracheostomy was finally taken off and I heard her voice for the first time after a month. She spoke as someone who had never spoken before, telling me the terrible and crazy things that happened to her during her stay in hospital.

It was also the last I heard from her. A few days later, she was transferred out of the ward to recuperate in the ‘extension ward’.

I heard from Dr. Bee that she was the noisiest patient there.

Shrug…

Jaunah died about two months later. I never knew why.

One may look at her death as a cornucopia of wasted efforts after so much money and time and intervention.

I’m only glad she had the chance to say goodbye to her husband before she passed on.

Sometimes, that’s more than sufficient.

2 comments:

CK Tan said...

the uncertainties and unpredictable events really filled a life of a doc. kudos to you guys.

the cili padi doctor @ Lynette said...

Fren..

Do not give up on caring for the 'untouchables', the neglected and the unwanted ones in our society. All our efforts count.

Love your writing..tis great that your wit, sarcasm and intellect shines through even in cyberspace. Keep up the good job!! God bless...