30 Hours of Humility

Giving Mr H a big smile and a wave, I stepped away from the last of 30 patients on the two hour long rounds. I was glad that Mr H was finally being discharged home, he was one of the more popular patients in the team, due to his motivated and good-natured demeanour. Heading into OT, I quickly refreshed my memory of femoral triangle anatomy on my trusty phone app. We had a high ligation and stripping of long saphenous vein that day, a rarity in a world where minimally invasive techniques of mechano-pharmacological ablation of varicose veins reign. Despite the advances in medical technology, it was still a wonder, and a consolation, that surgeons still relied on the good ole’ techniques of yesteryears, the gold-standard standbys sometimes referred to as ‘Plan B’, for situations where anatomy bewildered our scalpels. As trainees, we are encouraged to have both traditional and new techniques in our repertoires. 

Scrubbing up, I held back a little frisson of excitement; I was given the chance at starting an AVF creation under LA. Applying gentle pressure on the scalpel downwards on skin, a little blossom of blood flowered, and was gently dabbed away. The operation started and the thudding of my heart slowed to a lull. The therapeutic motions of identifying and dissecting whisked me away to this meditative state that was equally humbling and calming. But, as soon as it started, it ended. Suddenly, my dissecting scissors hit a roadblock; the artery was too scarred and too small. Try as I might, I could not free it. My registrar gently took over and murmured that I did a great job thus far, acknowledging that this was a difficult case. I swallowed my disappointment and my inner self-criticism. ‘Yet another one bites the dust.’ But another one would come my way and I would nail it, I’m sure. I had to be gentle with myself. There is yet a long winding road to go.

Palpating the groin wound of a Mr A, I tried to keep my face unreadable. Mr A, a seasoned intravenous drug user, had left behind a fragment of his needle after his nightly session, and had a groin exploration to remove the foreign body with drainage of local abscess just one day ago. And now at 10pm, he was complaining of intolerable pain at the wound site post operatively. I could taste that sour feeling at the back of my tongue, that feeling that I was possibly being capitalised for a quick opioid fix, that feeling of irritation, escalating to anger, and almost abhorrence. I caught myself then, reeled in my emotions, and decided to give him the benefit of the doubt. I may be wide-eyed or gullible at that moment, but a patient is a patient, regardless of breed or creed, and I would not be callous and hardened.

Frowning at the continuous vitals monitor of Mr L, I tried to shake off this ominous feeling that gnawed at me. Mr L just had a partial hepatectomy a few days ago, but unfortunately spiralled into hepatic decompensation. His primary team decided that he was breathing too fast and too hard for their liking, and requested that I keep an eye on him overnight. His vitals were somewhat reassuring, but he had the lethargic ashen look of an exhausted man treading water in the deep end. I quickly inserted an IA line, rushed off bloods, dialled up the oxygen, and instructed the on call HO to keep a very close eye on Mr L, just as I was called to attend to a neurosurgical patient.

Patting the hand of Mrs B in reassurance, I told her that I would be the doctor transferring her to NNI for her scans and follow up care. Mrs B had a temporal lobe lesion that laid dormant until it announced its uninviting presence with a full-blown seizure. She repeatedly told me she did everything right in life, ate the right food, abstained from the right vices, exercised the right amount, so why did this lesion choose her cranium as its dwelling? I braced myself for this oft-asked question of desperate patients, silently acknowledged my own fallibility, and murmured gently that I truly had no idea, but she will be in good hands soon. She returned my gaze uncertainly, gave a sigh and closed her eyes as if to burrow herself away from this clinical world of needles, beeping monitors and the omnipresent possibility of ‘cancer’. I steadied myself against the wave of guilt of not being able to console her, of not being able to give her an answer, an antidote, an elixir, anything to fortify her spirit against the onslaught of what might be and will be. 

Stepping out of the ambulance after the transfer, I hurried to Mr L’s side and the ominous penny finally dropped. He was delirious with Kussmaul breathing. Thankfully, the SICU registrar was by the bedside and making arrangements to admit Mr L to SICU. But the grim look on the usually cheerful SICU registrar’s face confirmed everything. Mr L’s acute deterioration in just a few hours was alarming and portentous.

Picking up my phone, I received the much-dreaded news of extensive bowel ischaemia on Mr L’s CTMA. My consultant was alerted and a family conference was called.

Facing Mr L’s wife and daughter, I sat mutely next to my consultant as he explained the critically ill condition of Mr L, and the options of surgical management of bowel ischaemia versus palliation. The wails gave way to soundless sobs, as the anaesthetic consultant gave his input on the dismal post surgical outcomes. The daughter was stoic and stalwart, the wife was inconsolable and despairing. The choice was difficult, the deterioration too sudden, but the time was nigh, a decision had to be made. After what seemed like aeons, they chose to give it one last bid for life, they chose surgery.

Preparing a coagulopathic acidotic patient for surgery was no mean feat, but with the help of an accommodating intensive care team, Mr L was ready to be wheeled in. But, when the operative consent was reconfirmed with the daughter, I caught a whiff of hesitation, as her eyes darted around indecisively. I immediately sat her down with a box of tissues, and the floodgates opened. She didn’t want her father to suffer the horrible but certain fate of multiple relook laparotomies, to struggle to speak with an ETT tube and later a tracheotomy tube, to be confined to the sunless SICU for weeks on end, to be poked and prodded with dialysis catheters, and to finally face the possible iatrogenic destruction of what is left of her father’s humanness. This little whip of a girl, no, woman, wise beyond her years, was able to discern that quality of life trumps quantity. She knew medicine was not infallible, and doctors were not miracle workers. And she loved her father too much for those almost certain eventualities. But she was only human and a daughter. She, who for the past few hours shed little tears and remained strong for her shattered mother, finally was able to release bottled up feelings, and was able to come to peace with her decision. I discretely signalled to the SICU registrar that the surgery was called off, and sat with her until her tears dried up and she was ready to face her dying father again.

Watching Mr L slip off from the SICU doctors’ station, I let loose a breath that I did not know I was holding, relieved in the fact that to the very end, Mr L was comfortable. He had moments of lucidity where he ruffled his daughter’s hair and held his wife’s hand. But most of the time, he was calm and pain-free and an air of peace prevailed in his room. It was a dignified death.

1pm

Finishing up the last of my ward chores and making sure the HOs were alright, I trudged to the cab stand. I was finally able to go post call.

In the cab, I closed my eyes, it was a physically exhausting, emotionally draining 30 hours. But I considered myself lucky, I survived it with my spirit and motivation intact.

When I turned 12, my father pulled out a well-worn frame from his desk that framed a prose poem from Max Ehrmann called “Desiderata”. Until this very day, I have kept it near and dear to my heart in everything that I do. The last lines of it read, “And whatever your labours and aspirations, in the noisy confusion of life, keep peace in your soul. With all its sham, drudgery and dreams, it is still a beautiful world. Be cheerful. Strive to be happy.”

Well, I am happy. 

 

By Max Ehrmann

Go placidly amid the noise and the haste, and remember what peace there may be in silence. As far as possible, without surrender, be on good terms with all persons.

Speak your truth quietly and clearly; and listen to others, even to the dull and ignorant; they too have their story.

Avoid loud and aggressive persons; they are vexations to the spirit. If you compare yourself with others, you may become vain or bitter, for always there will be greater and lesser persons than yourself.

Enjoy your achievements as well as your plans. Keep interested in your own career, however humble; it is a real possession in the changing fortunes of time.

Exercise caution in your business affairs, for the world is full of trickery. But let this not blind you to what virtue there is; many persons strive for high ideals, and everywhere life is full of heroism.

Be yourself. Especially, do not feign affection. Neither be cynical about love; for in the face of all aridity and disenchantment it is as perennial as the grass.

Take kindly the counsel of the years, gracefully surrendering the things of youth.

Nurture strength of spirit to shield you in sudden misfortune. But do not distress yourself with dark imaginings. Many fears are born of fatigue and loneliness.

Beyond a wholesome discipline, be gentle with yourself. You are a child of the universe, no less than the trees and the stars; you have a right to be here,

And whether or not it is clear to you, no doubt the universe is as unfolding as it should. Therefore be at peace with God, whatever you conceive Him to be. And whatever your labours and aspirations, in the noisy confusion of life, keep peace in your soul. With all its sham, drudgery and broken dreams, it is still a beautiful world. Be cheerful. Strive to be happy.