Tag Archives: alcohol

The Expiry Date

This morning I read drkategranger’s blog regarding her expiry date (she is a doctor with terminal cancer who talks about death so candidly, it inspires. I would absolutely recommend!!!). The blog and some of the responses to it got me to thinking about death. I have already written about dying and the fact that I fear it not so much. As a Muslim, I tend to see death as just one of those certainties of life so I treat it quite matter-of-factly. This blog is will be further musings about my experiences of death. I will start with a quote from Hadith (Islamic teachings) which summarises how I generally see life and death:

Al-Hasan Al-Basrî said:
‘The life of this world is made up of three days: yesterday has gone with all that was done; tomorrow, you may never reach; but today is for you so do what you should do today.’ Al-Bayhaqî, Al-Zuhd Al-Kabîr p197

I am generally an optimist or more accurately an optimistic realist so I try not to be morbid and I am generally not one to dwell on death. However, I have had times in my life where the thought of dying has crossed my mind. Last winter was a pretty bad time for me. I was working in the hospital that inspired me to become a paediatrician (which still inspires me) but I was in a job with a particularly toxic individual who succeeded in poisoning the atmosphere. I became depressed after 6 weeks of this. So much so that I hated waking up every morning I was scheduled to work. It got to a point that I would lie in bed, sleepless and think ‘would it be that bad if I didn’t wake up in the morning?’ As soon as the thought came to my mind, I would feel guilty and terrible. Guilty because I knew that my life really wasn’t that bad and that there was so much for me to be grateful for. Terrible because I knew my death, although insignificant in the grand scheme of things, would be horrible for my nearest and dearest. My mama especially. I got through those 4 months because my husband was there and would not let me sink into the depths of depression that kept pulling at me. Thank you George!

I am now back to my normal sunny self despite some current work horrors. As a newly-qualified doctor back in 2009, I dealt with death day in, day out especially on my first job on gastroenterology at a busy inner-city hospital. After the initial shock, I got used to it. Not that I didn’t care or it didn’t bother me but I dealt ok with it. There are 2 patient deaths from those days that have stayed with me. Both died of alcoholic liver disease. Both men in their 40s.

The first patient died slowly from hepatorenal syndrome (HRS). Basically with chronic liver failure, if your kidneys too fail, you will die soon because that means 2 of your 4 vital organs are dead or dying, unless you get brand new organs (i.e. transplants). As things currently stand, you cannot be put on the transplant list for a new liver if you are still abusing alcohol because the new liver will get damaged just the same and it is considered a waste of an organ that is in high demand but short in supply. So with my first patient, who I will call Patient A, when his kidney function tests declined rapidly and nothing we could do medically fixed it, we diagnosed HRS and my registrars and consultants had a meeting with his wife to inform her of the diagnosis and what that meant for the patient. He too was told in due time but because of his liver failure, he was confused and did not fully grasp the fact that his condition was terminal.

He deteriorated slowly over a few weeks but in the meantime, he would ask me daily when he could go home and travel to India to be blessed in the Ganges River. I would mutter something non-committal and beat a hasty retreat out of his side room. Initially, it was clear that his wife knew his death was near. But even she began to belief he would miraculously recover from his liver and kidney failure. Every week, she would say something that made us worry we hadn’t prepared her for the inevitable. Every week we would remind her gently that although she couldn’t see it, he was in actual fact deteriorating judging from his biochemistry lab results and worsening oliguria (he was weeing less and less).

In the week of his death, he suddenly looked well again. If I wasn’t the doctor patiently doing bloods on alternate days and chasing those results and noting the relentless rise in his urea and creatinine, I too would have started to believe in miracles. His wife upon seeing the light return to his eyes and his demeanour brighten plunged headlong into denial and joined him in planning their trip to India to the Holy Ganges River. Less than 24 hours before his eventual expiry date, it was devastating for me to watch her grief as the light in his eyes faded rapidly and he shrunk back into himself. Within 12 hours of his final illness beginning, his strength was gone and his mind with it. His utterings became incomprehensible and he became completely disorientated. The look on her face said it all when we came in to see him on our ward round that morning. We returned the look and she ran out of the room to sob in the corner. He was anuric by then (had stopped weeing completely) with a creatinine of over 400 (in other words, his kidneys had packed up). His liver function tests painted an equally damning picture. We completed his end of life paperwork that morning and when we left work that evening, he was hanging on by the tips of his fingers. We came in the next morning to the news that he had died before the end of the day before. The side room he had occupied for many weeks stood empty, awaiting its deep clean before the next customer.

Patient B was a young alcoholic who had developed liver cirrhosis in the months before I started the job. He had just turned 40 and I don’t think had any idea how serious the consequences of regular alcohol binges could be. Reality hit when another patient who was his ‘neighbour’ on our ward developed HRS and died rather quickly. All of our words of warning had somehow not sunk but with this other patient’s death, his mortality was clear to him. He called me over urgently that afternoon and said ‘Doc, I am ready to change’. I was pleased and felt a sense of accomplishment when I referred him to the rehabilitation programme. His wife found me the next day before they were discharged home to thank me for getting through to him. I was honest to say it wasn’t anything I did.

Unfortunately, he came in a few weeks later unwell with an infection which caused his liver function to deteriorate badly. I was encouraged to hear that he had no touched a drop of alcohol since his last admission. He developed litres of fluid in his tummy and I had to put in a tube into the side of his tummy to drain out all that fluid. He was in a lot of discomfort and fearful for his life and he asked me ‘Doc, am I going to die?’ I hesitated over the words I used but in the end I made no promises. Just that I would do everything I could to help him get through this. At first, it looked like the drain and intravenous antibiotics were effectively doing the job and the next day, the fear was gone from his eyes. I was encouraged by his blood results and left having ordered some more routine bloods for the next morning. Coincidentally, at I was securing his abdominal drain, I carelessly dropped the needle I was using to suture and when I went to retrieve it, gave myself a needle-stick injury. I had to get a co-doctor to inform him and take blood samples off him to check that he didn’t have any blood borne infections I could catch. He apologised every day after the event like it was his fault I had stuck myself with a contaminated needle. He asked me about those results daily – he seemed genuinely to care for my welfare. This went on for over 2 weeks as he slowly improved.

I was doing the ward round alone one morning when I was called urgently to his side. He was in a great deal of pain and was writhing in his bed with his abdomen larger than before we drained him. He was pale and clammy and his eyes looked like a man staring down the barrel of a gun. I could barely make sense of his words and as I changed his prescriptions, called the blood bank for blood products and prepared to get a new drain inserted. I could see the life begin to ebb out of his eyes. In a panic, I called my registrars and told them I needed them on the ward ASAP because patient B had taken a turn for worse and nothing I was doing was making a difference. The registrar told me to leave the drain for the meantime and focus on reassuring the patient. After I asked the nurses to call his wife in, I went to him and I held his cold hand. I looked into those eyes and I knew in that instant that he was not long for this world. I remember saying a mental prayer that he could hang on for his wife to be by his side.

‘Doc!’ he cried. I squeezed his hand and responded ‘Yes B?’

‘I am dying aren’t I?’ he asked. I looked down and swallowed the lump in my throat. ‘I am here for you B and I will do everything I can to help you. Your Mrs is on her way in.’

‘Stay with me,’ he entreated fearfully. I nodded and again I had to look away because the fear in his eyes was too powerful for me to take in. The rest of it was a blur. His wife made it in before he died but not in time for him to know she was there. He was delirious by the time she got to the ward and as he was slipping away before our very eyes, there was little time to have ‘that conversation’ with his wife. The consultant whisked her away and broke the news to her. She could see that treatment was futile by then and knew that he was on maximal available medical treatment. We had no more to offer. She signed the DNAR (do not attempt resuscitation) forms and we set about making him less agitated. When we finally called it a day, he was less distressed, still mumbling incoherently and his eyes had started to take on that distant look I now associate with death. I came in the next morning to a request to come to the morgue to complete his death certificate and Crem forms so that his wife could lay him to rest. I got a call 3 days after his death to say his blood tests for blood borne infections had come back negative so I was in the clear. I cried in the staff toilets. He would have been relieved not to have put me at risk I think.

What did patients A and B teach me about death and dying? Firstly that when it is your time to go, it is your time to go. Life unfortunately doesn’t usually give you a clearly labelled package with an expiry date on it. Secondly, although death is scary for the person dying, it is actually worse for the person who loves them who has to watch them lose their battle to live and battle their fear of the unknown. Who has to go home and face life without them and rebuild their lives around the hole left by the dead loved one. Who for a very long time will think about their dear departed every morning when they wake up and every night before they fall asleep. Lastly, every human is unique. Despite having the same disease and modifying your risk factors, your body will do its own thing. We doctors can try to influence outcome but whether we succeed or not is not within our power to control. That is beyond science and medicine. That is life. That is God. That is reality. May we all depart this world in the easiest swiftest way possible. Amen

Tell Your Truth  

I quoted Clint Smith’s comment about fear in an earlier blog and this one here is inspired by the something else he said on the same YouTube video. He is an American who lectures in the States and he says in the video that the only thing he asks of his students when they are in his class is to tell their truth and that nothing leaves the room without their permission. This got me thinking about truth and its importance. I know everybody lies sometimes and actually sometimes a lie is the kinder thing to say. However, I do think these days too many people lie willy-nilly for no good reason and it baffles me why.

My mama and I (in case you haven’t realised it yet from the number of times I mention her in every blog) are very close and I think one of the biggest reasons why that is with each other, we tell our truths. My sister and I never went through ‘teenage rebellion’. We didn’t have anything to rebel about because everything in my home was out in the open. My mama has always been truthful when asked anything directly. Of course, there are things she held back from us when we were too young to understand but as long as she thought we would understand the answers and that it would teach us something, we were told. I knew about the birds and the bees from very early on and so it was never a big deal talking about sex in our home. Because my mama is a feminist and part of her NGO work is empowering women and girls, I attended a workshop she organised in the early 90s back when HIV and AIDS were in the headlines. So before I was 10 years old, I knew about safe sex, condoms, how to put them on and dispose of them safely. Even before that, I knew all about periods and puberty and everything else that was necessary to face growing up.

In the same vein, whenever I made friends with anybody, I would invite them to our home at the earliest opportunity so that my mama could meet them. I knew that if my mama was okay with such a friend, then they were good enough to keep as friends. I could rely on my mama to be truthful. So over the years, we have talked about friends, boys, men, sex, drugs, alcohol, travel, homosexuality, religion, war, the potential for an apocalypse, death and anything else I was ever curious about. We are so comfortable and open that people often get surprised by how much my mama knows about the exact things people would try to hide from their parents. It is only as I have got older that I have started to edit what I tell my mama. This is mainly to do with my significant other relationship and I keep things from her not to withhold my truth but so as not to sour the relationship between my husband and his mother-in-law. After all, ‘they’ say that if you tell your parents about the ‘bad things’ that your spouse does to you, they will harbour it for aeons whereas you might forget it the very next day or week. I am a very lucky girl because in my home telling my truth was not only actively encouraged, it was expected. I am now trying to teach my husband the same and I hope to emulate the same culture with my future children.

In my profession, telling your truth is a GMC requirement and it is set out as part of the duties of doctors which we are sent in paper copy periodically to remind us of our oath. I am a paediatrician and definitely not a surgeon. However as the cookie crumbles, I happen to be doing a surgical rotation (which is ending today. Hoorah!) currently and I have had major issues because of a lack of truth and the surgical culture of aggressive competitiveness and subtle bullying. I particularly had a problem when my father-in-law was taken ill and I was delayed going in for a shift. Long story short, I couldn’t leave him until he was safe and so I was going to be late for handover. The doctor that was meant to handover offered to swap shifts. I thought how lovely, swapped shifts and thought nothing more of it. Then rumours started to fly after I was late for another shift about how I was so late I didn’t turn up for my shift. After a couple of weeks of ignoring the immaturity of it all, I found the senior doctors involved and asked if they had a problem with me particularly if swapping that shift was a problem. They all denied having any issues but I had heard enough to take it to the top consultant and my supervising consultant. They were both lovely and reassured me. I thought ‘Great. All sorted and I’ll put it all behind me’. The rumours continued and I eventually found the source of it all. Disappointingly, it was a registrar senior to me who always made out we were cool. So I had it out with him and asked him to be professional. I am pleased to say once I confronted him, he has behaved in a more professional manner but I must say I will be glad not to have to work so closely with him anymore. I just think that there is no place in a professional setting for lies – everyone is there to do a job and if you are not interested and focussed in the job, maybe you should quit and go do something else.

I have a confession to make. I am rather feisty and not afraid to speak out in most situations. Even as a child, the worst thing you could do to me was lie about me. I remember way back in primary school, someone jealous of me for something or the other said to one of my friends that I had said something about her behind her back. My friend promptly told me because she didn’t believe I would do such a thing but I was so mad that the girl had accused me wrongly that I cried. Unfortunately, in these situations, I still get so angry that I often end up crying because I feel helpless to do anything else. I am getting better at dealing with the anger though so hopefully by the time the kids come along, their mummy won’t go round embarrassing them with her tears. As far back as I remember, I made a vow to myself. Unless there is an absolute need to hide the truth, I shall always tell my truth. And honestly, it feels great!