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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

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Neglect Has A Lasting Legacy

I was 5 years old when my sister and I went on a road trip with Baba, our Grandad, up North in Nigeria. It was not normal for just the two of us to go with him. There was usually my grandma too or maybe my mama. However, this time we got to go solo with him. I suspect it is because we begged and it was the holidays and my mother was busy at work with no better plans to entertain us. Whatever the case, we got to go and I remember my sister and I getting bored quite quickly (probably an hour into the 6.5 hour journey). Plus my grandad had taken to listening to boring traditional Hausa music (Mamman Shata and the like). So we sang every nursery rhyme and Disney song we knew. We sang for hours until our throats were sore. Must have driven my grandad and the driver mad but they bore with us.

When we got to the town we were staying the night in, my grandad took us straight to my ‘aunt’s’ home. I say ‘aunt’ because this is not my mother’s sister, my favourite aunty in the whole world aunty Bilky. No, this is someone who grew up with my mum and her siblings and is therefore considered a ‘sister’. I will call this aunty ‘Auntie’ henceforth for easy reference. Now, we had spent quite a few holidays with Auntie and her many daughters in the past so we knew them well enough and were quite happy to be taken to hers. One of her daughters is very close in age to my sister and the youngest was a year older than I was but we usually got on pretty well. I couldn’t tell you if there were any special circumstances at the time we visited but I think not because we would have known. My mama was always upfront if anything major was going on especially if she was going to let us visit. Anyway, out of the car we tumbled, tired and excited. It was well after lunch but not dinner time yet but we were already feeling the first pangs of hunger having had a late breakfast on the road but not stopped for lunch. We were all shown into a living room in their sprawling home and someone showed us to the ‘bedroom’. I use the term ‘bedroom’ loosely because although the large room had beds (I think it was 3 single beds), most of it was clearly a dumping ground for dirty laundry and other clutter and it looked like no one had slept in there for a long time. My grandad left whilst we checked out our lodgings.

My sister and I waited for what seemed like ages for someone to come and tell us what to do with all the mess if we were actually going to be staying in that room. We also waited in vain for someone to offer us a drink or give us a snack. Nothing happened so we eventually picked one bed and cleared it and the area around it. We lay on the bed listening to the noises of muted conversation until all we could hear was our tummies rumbling. The sun began to set and we were soon left in darkness. One of us hunted for the light switch and we resumed our waiting game. We might have dozed off or maybe just lay around in a hungry tired trance but eventually I remember saying to my sister that I needed something to drink. That spurred her into action and she led me hesitantly out of the room and we wandered down the corridors of the seemingly empty house, most of the lights off. We found a kitchen but our hunt turned up nothing to eat. We had some water and sadly found our way back to the bedroom and eventually slept on empty stomachs.

We awoke to the sound of voices outside, going about their morning chores. We could smell breakfast frying…I am not sure now what it was (because we didn’t get any) whether it was fried yam, potatoes or bean cakes (kosei) but the smell was right under our noses and we were so famished we looked at each other in hope. No one came to get us and being nice Fulani girls, we stayed put. I remember asking my sister if she thought they had forgotten we were there. ‘How is that possible?’ She replied so we waited and waited. We waited some more as all the noise died down and the house fell silent again. Had they all gone out without so much as a word to us? Were we home alone in this house we didn’t know, in a town we had maybe visited a couple of times before? We finally ventured out and explored the section of the house we were in. No one was there. We returned to the kitchen, probably assuming that they might have saved us some breakfast. We found evidence of breakfast in the dirty dishes in the sink but not a bite left for us.

At this stage, I thought I was going to die of hunger. It was getting close to 24 hours since we had breakfast on the road with Baba and there was no adult to be seen. We went back to the room and my sister rummaged desperately in the backpack we had brought with us. ‘Look’ she cried excitedly after searching for a while. She brandished a N5 note. N5 (five naira) in those days (around 1990) was actually worth something. We could certainly have breakfast on the street with that. Remember this was a town we were not very familiar with so it was with trepidation that we ventured out of Auntie’s house and into the busy street. Thankfully there was no one out to cause mischief and we were left alone. We followed the smell of kosei to a street corner nearby and found a lady frying the delicious bean cakes seated on a stool by the fire over which she was frying. We gave her the N5 and asked for kosei. ‘All of it?’ she asked and we nodded hungrily. She scooped the freshly fried kosei out into the traditional newspaper wrap, sprinkled on a generous helping of the chilli powder that comes with it and handed it to us. We walked a few metres away before we gave in to the hunger in our bellies and we tucked in. After a few mouthfuls, we felt good enough to continue walking and we ate as we walked back to the house. The portion was decent and we gobbled it all up within minutes. Finally satiated, we chucked the paper in the bin and went in to have a quick wash and get dressed.

When my grandad came for us around lunchtime, we were happy again. Still left to our own devices but happy because my sister had fed us. We looked clean and my grandad was none the wiser. Lunch was served with my grandad so of course we got fed. I remember picking at the food because I was still stuffed from our late breakfast and also because I was so disappointed my Auntie had been so mean. But we said nothing. Just very happily jumped back into the car for the 3 hour trip to Kaduna where we knew we would be treated by my aunty Nafisa like princesses. I was not disappointed!

For many years after that, I did not forget or forgive that episode. The daughters I didn’t blame so much because half of them were young like us. But the 2 older girls were certainly old enough to know that young children visiting should at the very least be given a drink and food. Auntie should certainly have known better. I made up my mind that she was no longer my auntie but only my sister knew this for the next decade or so. I found every excuse not to go back there and mostly, I didn’t.

The next time I went was unavoidable. My mama and I were on the way to Kaduna and from there were to catch a flight back to Lagos where I went to boarding school. I wasn’t really given a choice of itinerary because she wanted to say hi to her ‘sister’. I knew anyway that I would be treated well because my mama was there but the hypocrisy grated. I clenched my teeth and said not a word. The visit was ok-ish. It turned out her daughter was getting married and we had been invited but my mother neglected to mention it. I had nothing to wear for any occasion as I was on my way back to boarding school and being a teenager, it mattered to me. Bearing that in mind, the youngest daughter and her cousin/half-sister on night 2 were in the same room as I was but I was lying on the bed, my head buried in a book as I was usually found in those days. They were whispering loudly about the pre-wedding party they were going to the next night and how much fun it was going to be etc. Being close in age to them, I would have expected them to have the courtesy either to invite me or not to talk about it in front of me. They did not have the courtesy to extend an invitation to me. Party night came and they snuck out when it was time despite being chummy with me all day. What sort of a fool did they think I was? The morning after, they were giggling over events at the party but would fall silent if I walked in a room or turned in their general direction. What grated wasn’t that I didn’t go because to be honest, I wasn’t one for parties at that age and I certainly did not have anything to wear. What sucked was their meanness of spirit and being treated like a fool.

Since that visit, I have stayed well away from most of that family. Although I have forgiven them their neglect and meanness, I doubt I will ever forget. That amongst other things are major character flaws I really wish not to be associated with. I have not considered Auntie my aunty for very many years to my mama’s consternation. I have since told my mama about that episode and several other incidents not talked about in this blog. I know she was dismayed and even sad but perhaps a small part of her is hoping that me and my sister’s account of that incident is overly-dramatized as remembered by our young immature brains. Regardless, I sincerely believe that if we had been her actual nieces, she would not have treated us so carelessly when we were so young. And she would not have allowed that mean spirit to rub off on her daughters.

When I think of her, I think of two quotes:

“When someone would mistreat, misinform, misuse, misguide, mishandle, mislead… or any other “mis”… to others, they’re obviously missing something from their lives.”
― Donald L. HicksLook into the stillness

“I know it’s painful growing,
I bet the changes was painful too.
But nothing is as painful as being somewhere you don’t belong.
Obviously.”
― Touaxia Vang

Black Sisterhood

I am black. I love being black. I celebrate being black. Earlier this week, I had an incident that to me highlighted what is so amazing about being black and being included in the black brotherhood. Or sisterhood when it comes to us ladies.

My husband borrowed my nice 100% electric eco-loving car on that day because his work car was in for repairs and I was stuck with his super-sexy sporty German turbo-charged something or the other. Honestly, I am a bit of a speed fiend so I wasn’t complaining too loudly and he did custom-order the interior leather colours to suit my taste. So here I was in his sexy car running down to the nearest Charity shop to drop off some bits and bobs. On my way back after another diversion for road works, the fuel low indicator began to flash furiously at me and I thought this was the normal husband thing where the fuel is always a little too low for comfort and I get teased mercilessly for preferring the comfort of a few extra litres, just in case. Anyway, to cut the long story short, as I debated where the nearest fuel station was, the car started to slow down and then cut out shortly afterwards and then I was broken down.

OMG! I managed to steer the car into the inside lane before it cut out completely then called the recovery people. I popped my hazards on and settled down to wait for the lovely recovery people to come save me after a few choice words to my husband which clearly displayed my displeasure at the predicament I found myself in. The first bus that came up to me stopped and pretended a whole lane was not wide enough for him to use and he wanted me out of the way. I pretended not to see him but I was looking as he gestured something rude. A really fat white man.

I got onto my phone and started doing phone things to stave off the boredom that was already overwhelming me 3 minutes into the wait (in a promised less than 1 hour wait). I was engrossed in my phone when I perceived a vehicle slowing down to a halt beside my car. I reluctantly pulled my eyes away from my device when I heard an incredulous voice say ‘oh no, she is on her phone’. My already bad mood immediately worsened and before I could engage the brakes on my mouth, I said ‘Well I am broken down. Is there a law against using my phone when I am stationary?’ It was a white police woman in a police van. She blushed in embarrassment because her jumping to that conclusion was completely prejudiced having seen that here was a young black woman in an expensive car stopped in an unusual position. She apologised immediately and after suggesting that I might perhaps be safer standing out on the pavement, she drove off swiftly. Smh!

As I stood by my car and waited, I had several dirty looks from passing drivers, all white and seemingly hostile because I had the audacity to break down in their path. Never mind that they could all drive past in the unobstructed outer lane. I stared them all down and waited. A black guy driving a delivery van stopped 2 car lengths behind me and offered his assistance. With his help, I managed to reverse back into a better position leaving more space for the outer lane to flow nicely. When he was satisfied I was in a better position, he left with a kind word. My mood much improved, I hummed a song as I paced the pavement. I was broken down in a spot near the Royal Orthopaedic Hospital so I had a few patients stop by to offer their kind help too.

There was a very elderly very English gentleman who tottered over in his tweed jacket to ask if there was anything he could do to assist me. My smile firmly restored, I was able to say no but thank you and watched as he made his slow progress away from me. Next a pair of fellow elderly Africans stopped. I joked that I just needed a parking space and was waiting for them to leave. After they had unsuccessfully tried to guess that I was Nigerian, they commiserated with my situation and offered to let me sit in their car to shelter from the light drizzle. I declined their offer and instead had a debate about the Ebola outbreak and what it would do potentially to us ‘poor’ Africans. I had to reassure the ‘dad’ that I was definitely okay and that the recovery van man had called to say he would be there in the next 15 minutes or so before they reluctantly drove off.

I have been reflecting about this little incident for the past couple of days and my conclusions are as follows. There is definitely a lot of work to be done in inter-racial relations and the negative stereotyping we all do especially when it comes to colour. Britain might like to pretend it is PC and all that but actually there is an undercurrent of racism in a lot of their institutions, the Police being a prime example. The neighbourhood I broke down in was inconveniently the ‘most racist’ one in Birmingham. Northfield – the stronghold of BNP in Birmingham where many EDL supporters live. Allegedly. I am sure many of those white drivers who jumped to conclusions about why my car was stopped on the main road going through Northfield were of the BNP/EDL-persuasion. But who knows?

Most importantly, that incident was a very positive experience for me. First that the lovely old gentleman saw a woman in need and was gentleman enough to offer help that he physically would not have been up to. Second that the black delivery guy took time out of his busy schedule to stop to help a sister and indeed succeeded in making me and my car safer. Lastly that the African pair kept me company and offered to shelter me from the rain. I am thankful that kindness and neighbourly concern are still quality traits on display and that there are still men out there who would go out of their way to offer their assistance to a complete stranger. Despite her gender or colour. I am thankful to be part of a race that believes still in brother- and sister-hood of everyone black and that where we are a minority, there is a code of this black-hood that means they automatically consider us part of one large family. It is such a lovely feeling and it is part of the reason why I love being in Birmingham because I see evidence of such goodness often as I go about my business. Long may these feelings and attitudes continue to prosper!