Tag Archives: mortality

The Power of Dreams

My aunty forwarded one of those inspiring videos about life and happiness. One particular message struck me. It said something about having a dream then making it happen. Of course, it is easier said than done. It is not quite that easy to turn a dream into reality but those people who are the happiest are those who had a dream then put their all into making it a reality. I have many dreams. Through hard work and luck, many of my dreams are already a reality. I got into medical school, I graduated. I applied and got into speciality training and I am gaining experience as a paediatrician. I met a man with a big heart, fell in love and married him. We bought our lovely first home, a permanent abode after my many years of moving from flat to flat.  I fell pregnant when we were in good place and the baby has been growing well with the easiest pregnancy. I am getting ready to realise one of my biggest dreams – giving birth and being a mother. So yes, my bucket is overflowing.

This is about my professional dream.  I used to think I would be happy to graduate, specialise as a paediatrician, get a consultant post and settle down to a routine. With the recent political shenanigans and the more I work in the NHS, the more I realise I want more. I want more out of my life and I also want to contribute more than the daily grind. Don’t get me wrong, I know in my current role I do make a difference to lives. There is nothing more satisfying that when I have done a good job and I know that parent or child’s life has been changed for the better, no matter how small that change is. However, many days I look back after a busy day and think was that worth it? Those days which are all about paperwork and administrative tick-boxing exercises that contribute nothing except to some faceless manager’s satisfaction.

The part of the world where my life started (Yola) is lovely in a lot of ways but there is a significant poverty. In terms of economics but also in healthcare terms. Nigeria as a whole fails to cater to the healthcare needs of its population unless you have lots of money to go private. The North-East of Nigeria is one of the poorest when you look at health outcomes. In particular, looking at childhood. The statistics (where there are any) are shocking. Nigeria, for all its wealth, regularly features at the bottom of tables for health outcomes. We are in the bottom 5 for most outcomes including maternal and under 5 morbidity and mortality. For the non-medics reading this, morbidity refers to how much ill-health and disease (sickness there is) there is and mortality refers to how many are dying.

Mothers naturally should come in a low-risk group. Most should be healthy young women doing what is most natural – getting pregnant, growing a baby and then delivering the baby. Young children, although fragile because they are not mature yet biologically are despite all of that resilient on the whole and have bodies that are full of strong healthy organs with endless potential for healing. What we are failing to provide is basic care. Basic antenatal care, trained birthing assistants, hospitals to assist in difficult deliveries and facilities for emergency caesarean sections (surgery) for those women who cannot do it naturally. Infections, on the whole preventable and most totally treatable, cause a lot of the morbidity and mortality in Nigeria. Many of the other things we provide here in the NHS is simple supportive care, allowing patients own bodies to heal themselves in a secure environment.

So here is my dream. I would like to set up a women’s and children’s health centre. Big dream I hear you say. Yes, I am aware. It will be a huge task. I worked at the FMC in Yola for 4 months in 2012. I saw how much need there was and the things that were missing. I know a lot of the patients we couldn’t help were those who lived far away from town and did not come to us until their disease was too advanced for us to be able to do anything. Mothers died in childbirth because they did not have adequate antenatal care so predictable problems were not discovered until it was too late. Preterm babies died because they were born out of hospital in environments not hygienic enough and did not get simple breathing and feeding support and early treatment with antibiotics. Term babies were born too small because their mothers were undernourished and unwell with treatable conditions during pregnancy but were not diagnosed and treated. Very few of the patients we couldn’t help needed fancy expensive medicines or surgery. It was simply too little too late.

On the positive side, those that did come to us in time had better outcomes than those suggested by the statistics I read about on WHO and the likes. Those preterm babies born at FMC Yola thrived and majority survived until discharge. Sure, their progress was slower than here in the NHS because of a lack of basic equipment and provisions like oxygen and breathing support, working incubators, labs, fluid pumps, parenteral nutrition for those too young to feed by mouth or through the stomach. But survive they did because they are little fighters.

So what I dream is to provide all those basic things to the mothers, babies and children free of charge if I can manage to raise funds or at the very least at the smallest prices possible to give those with little the chance to quality healthcare. To go with that, I would like to provide an outreach service to those isolated villages. Run clinics, provide immunisations, antenatal vitamins and nutritional support, teach about prevention of infections and when it is vital to seek early medical help. Central to that idea is to train some of the villagers to provide safe simple birthing assistance, supportive care for new-borns and how to diagnose and treat the most common infections and provide first aid. All little things but added up should cut the numbers of mothers and children suffering unnecessarily and prevent the many preventable deaths.

My grandfather listened to me talking about my dream and was (rather unexpectedly) downbeat about it. He pointed out that it wasn’t as easy as I was making out. Actually, I know it will be difficult to do and as I have never done this before, it is a monumental task. There is so much to do to get this off the ground. However, here is my plan. I will start small and do this project in stages. I will deal with the complications as I get to them. A journey of a thousand miles has to start with that first step. I have taken my first step. I have dared to dream and I have written down my dream in black and white. Now onwards and upwards. Watch this space.

The Cycle of Life Part 3

I could write and write about the many lives I knew that were cut short in their prime but I will complete the cycle with this last blog about one of my oldest friends. His name was Nabil. We probably met as babies but the first meeting I remember was when I was 15 years old. We had moved to London the summer before and were getting settled in still. My mama came home one day and announced we had been invited to have dinner the Ibrahim’s on Saturday. Who were they? I asked. She explained that they were old family friends. The parents were my grandparents’ friends and although their children were younger than my mother and siblings, they knew them well as children. I am told one of the kids had even stayed periodically with my grandparents in Lagos when they were going to school there. She told me that the oldest daughter had 2 sons, one my age and I was going to meet them.

Although we both lived in North London, it was quite a trek as there was no direct tube route and we had to go on 2 (or was it 3?) buses. By the time we got there, my nose, fingers and toes were frozen and all I wanted to do was curl up into a ball and sleep by a fire. I needn’t have worried. As soon as we stepped into their house, I felt my frozen cells begin to stir. It was always tropical in that house. Mum and Baba (the grandparents) like it very warm so there was never any danger of being cold once you got in there. I was introduced to the many adults, face after smiling face. It was like a mini-Northern Nigeria. All the warmth, the noise, everyone speaking Hausa. The boys were called down, Nabil and his little brother. They were instructed to take me upstairs until it was time for dinner. Although Nabil was friendly, he was definitely the quiet one. His little brother made up for it. He was very chatty, still pre-adolescent and full of excitement about life. Back then, he was quite small too. Very cute!

Nabil played us some music and told me about how they had only been in London for a year so were new to town too. He explained who was who in the family and we made general chitchat with his little brother telling us his fantastical half made up tales. We were in the same year of school and I was older by 2 months. By the time we got called down to dinner, we were friends. Over the delicious dinner cooked by Mum (his grandmother) and his mum, we talked some more. We exchanged numbers when I left. We stayed good friends over the years. We went to visit every so often and they made the trip across North London a few times too. We text occasionally in between visits. The next year, we talked about finishing year 11 and applying for colleges. I told him I was doing all the sciences and Maths because I would be applying to do Medicine. He said he wasn’t sure yet what he wanted to be so he was still thinking about which subjects to choose. We talked about where to go and I must have been convincing because I suggested for him to join me in Barnet College and he promised to consider it. He wrote down his address on a teddy bear notepad I had so I could sent him information when I had a confirmed place.

Common sense prevailed and he went to a college more local whilst I went to Barnet College. We went to see movies together and we even ate out at this stage, being all grown up at the ripe old age of 17 and 18 years. Every time we went out, he would insist on paying for everything and I would argue him down so we went halves. His little brother had grown into pre-adolescence by then and would irritate Nabil endlessly. His patience was great and he would repeatedly ask him to butt out of our conversations. I didn’t mind. I had a sister too and as the younger sister, I knew what it was like to be the little one. When we applied through UCAS for universities, he finally had a plan. He was going to study Maths. I was shocked. I mean, I was a straight A student and I got my A in Mathematics, an A* even in AS. I was no slouch when it came to it but to do a whole degree in Maths? I was agog! Why would anyone in their right minds do such a thing? He took my teasing in his stride. He said he didn’t have a profession in mind like I did and he knew he could use his generic Maths degree to do a wide range of things. I accepted this but I still thought him mad. He gave me that calm smile of his. ‘You’ll see’, he said.

As is the norm, we saw each other less when we went off to different universities. I went to Birmingham and he stayed in London. We probably saw each other once a year but when we did, it was like no time had passed at all. Ours was a very easy friendship. He would tell me about his ‘crazy’ Maths course. He seemed happy. I would tell him about Medicine and how much of it there was. How I realised more and more that what I knew was only a small fraction of how much I needed to know. He was openly impressed by how well I coped with it. His support and belief in my abilities were unwavering. Just like his friendship. I knew he was there somewhere should I ever need a friend. We text and Facebooked more than we spoke face to face. I can count the number of times we spoke on the phone in all the years.

Over the years, I would tease him gently about his girlfriend, or lack of. As the Fulani girl, I should have been more embarrassed to talk about such things but he was so shy about it. It became part of our friendships. I would needle him about ‘her’ and he would counter by asking me about my many boyfriends. I wasn’t shy about it. I had very little in the way of boyfriends but I told him of every encounter and how I preferred not having a boyfriend. He never admitted to any love interests but his brother was a more open book and I know there was somebody special at some point. He graduated and started an online sales platform. Next thing, he was talking about going back to Nigeria for his NYSC (mandatory youth service). He settled in Lagos. I happened to go the Lagos route once in his time there so I got to see him. He looked way too skinny and I was worried. As a newly-qualified doctor, I saw ill-health everywhere and was concerned he wasn’t sharing. He reassured me that he was fine. I didn’t need to doctor him. I believed him because youth corpers do tend to look the worse for wear during their year’s tenure.

The last time I saw Nabil was in Life Camp, Abuja in 2011. He happened to be visiting Abuja whilst I was there on a 10-day holiday. He was staying with a friend who brought him over. Again, I thought he was too skinny and he laughed it off. ‘Maybe I was always meant to be skinny like you’, he said. We chatted for an hour and he had to go. As we hugged goodbye, I felt how bony he had become. Life in Lagos was a hard one for a young man trying to start a business. My parting words were ‘You need to eat more. You should look after yourself better.’ His reply was a laugh and a ‘Yes doc!’ I stood at the door and waved until the car was out of sight. Not for a second did I imagine I was saying goodbye for the last time. The fuel subsidy crisis in Nigeria was the last thing we ever chatted online about. He became very involved in the demonstrations. I worried about his safety and he sent photos of himself and his friends at Lagos marches, looking happy and less skinny. He had found a cause to believe in. I was proud he was making a stand for a cause.

News that he was ill came out of the blue. I was in Yola, having taken a year out from working in the NHS to see the world. My mama got a call from one of his relatives saying that he was in hospital with a bleeding illness, cause still unknown. It was pretty serious and they were considering transferring him abroad as the healthcare available in Lagos was deemed inadequate. When my mother related the facts, I wanted to know more. What sort of bleeding? Was it related to a fever? Was Lassa fever the suspected cause? When my spoke to them again later, she was given more details. He had woken up that morning and told the friend he was living with that he wasn’t feeling too well. I think there was mention of a headache. He had been well the night before going to bed. His friend had gone with him to hospital and he either vomited or peed blood. The exact sequence is hazy but the gist of the story was that he had become sick rather quickly and what started out as an isolated bleed was now bleeding from multiple sources. He had been given a transfusion, we were told. He was conscious but seemed to be deteriorating.

When my mama related all of that news, I immediately thought the worst. When I burst into tears, she was alarmed. ‘He is alive,’ she said to me. ‘Don’t write him off.’ I tried to explain what I was thinking. I didn’t want to be a pessimist but unexplained severe generalised bleeding had a poor prognosis even with the best medical care. And he was not getting that. Not yet anyway. I had 2 professional experiences to draw on, both rather negative. My first experience of a patient with uncontrollable bleeding was in Malaysia on my medical elective in the 4th year of medical school. He was brought in by his heavily pregnant wife and a male relative to the A&E where I was working. He was very quickly diagnosed with Dengue Haemorrhagic fever. However, before any real treatment could be commenced, he went into cardiac arrest. With the medical students and his wife watching, the doctors performed CPR. It was horrific. He began to bleed from every orifice imaginable. His ears, nostrils, mouth. The blood was coming up the tube he had inserted into his lungs to ventilate him. The only part visible with no blood streaming out of it were his closed eyes. It was over as quickly as it began. It was obvious to everyone that he was far too ill to be saved. His wife was led away with the news.

The second experience was indirect. I was working in FMC Yola (Federal Medical Centre) and although Yola was ‘free’ from Lassa fever at the time, there were new cases being reported further south of the country. In fact, about 6 months before I had started working at FMC, there had been a patient with Lassa fever there and 2 of the doctors had contracted it from him. Unfortunately, 1 had died and the second had got to the Lassa Centre down south in time to be treated. He was one of the registrars on the paediatric team I was working with. So although he was okay, it seemed that mortality was quite high and only those who were diagnosed early and treated before they started actively started to haemorrhage (to bleed) were salvageable. Nabil’s story didn’t quite fit the bill because he had not complained of a fever and indeed had no fever in hospital. But it was my best guess with the facts I had and I feared the worst.

I pulled myself together eventually and prayed and waited with my mama. Next time we got an update, it was to say he was worse still, I suspect barely conscious at this stage. He was still bleeding despite all efforts and his parents were with him (they don’t live in Lagos). An air ambulance had been organised and he would be transferred abroad as soon as possible. We even heard he was being placed in the ambulance and I thought maybe there is some hope after all. That hope was short-lived. We got a call a few hours later to say that although his parents were in a flight to London, his air ambulance had never taken off. There were complications and unfortunately, he had not made it. I was so upset! All I could think is how his parents had no idea he had died and how they would have to make the return trip with that news weighing on them. To be honest, I have not asked them what happened exactly but it could only have been a terrible day.

I think the initial reaction of tears had taken the edge of my grief. I had started my grieving process before he was gone. I sat around in disbelief as my mama asked if I would be okay. As we made arrangements to go and visit his family, I could not stop thinking about how final death was. That was it for him, in this life anyway. I have no brothers so I whilst growing up, I found a handful of boys/young men to be my shining examples of decency in the male sex, my torch bearers when I felt dark about men in general. Nabil was one of them. Here was a gentle, calm, positive young man who believed in doing what was right, what was decent. He was respectful of God, his parents and our culture. He was a great friend and it was clear from the few times that I spent with him in the company of his family and friends that he was an all-round good guy. Losing Nabil was losing a little of the light in the darkness that sometimes surround men for me. Nabil was a good guy. Now he is no more. It took just over 2 days for a healthy young man in his mid-20s to sicken and die. Muslims would say it was time to go. I accept that but did it have to be such a horrible death? What did he ever do to deserve such an end? Why him?

The Cycle of Life Part 1

As I said in the bit about me, I am a realist with a healthy dose of optimism. Apologies that I am again going to write about death. It may seem morbid to my blog followers but I do not always find talking about death negative. I dwell so much on it because it is my way of not forgetting those who have left footprints in my heart. Also because unfortunately, for someone who has been fortunate not to be from areas where death is a daily occurrence, I have seen more than my fair share. In the old and in the young. If you are squeamish, this may not be the blog for you.

I write this in the living room of my sister’s flat in Abuja and this was prompted by another blog I just read and also by a conversation I had with my sister. It was a long conversation but it ultimately lead us to discuss our mortality and how death can strike unexpectedly, about being a parent and planning for that eventuality to ensure your children are taken of and about writing wills etcetera. Despite the gravity of the conversation, it was quite an uplifting one. The words to follow are snippets of memories centred mainly around 3 deaths that have literally changed my life. These are young people who no one expected to die and their manner of death changed the way I think about death.

The first was of a classmate from Queen’s College, Lagos. It happened in 1999. She (I will call her Eve here) was not a girl I was particularly close to or even fond of. But I had known her for nearly 3 years when tragedy befell her. Eve was the daughter of a quiet unassuming teacher who I will call Mr Brown here. Mr Brown was the complete opposite of his daughter. Where he was quiet, she was loud. Where he was always serious, she was always laughing, finding the humour in things even when it wasn’t appropriate. She was tall for a 12-13 year old and he was a short man. She was fair where he was dark skinned. The comparisons were striking being that they were father and child. Anyway, Eve was the class joker. She was always loudly laughing or telling a joke. She was always planning the next prank or calling out funny witticisms from the back of the class. Sometimes, it was distracting so I wasn’t always laughing with her but I never thought her to be malicious.

We came back for the 3rd trimester of JSS3 and Eve didn’t. Soon rumours began to circulate about her being unwell. Then we heard that she was in fact really quite sick and was admitted in hospital. Then we heard that she had been victim of an acid burn. The extent was unclear but we did not expect how grave it was. Why we asked? And we kept asking. She was only a young girl. Why would anyone do this to her? I was pretty sheltered so I had never heard of acid attacks nor did I know the usual motives behind them. My more streetwise classmates told me that normally jilted or scorned (adult) men were the perpetrators were and the victims the poor unfortunate girls/women of their affections. It was mainly a Southern thing back then so I had never come across this despite my mother’s job.

This was the perplexing issue to us, her classmates. Why would a girl so young attract such affection? Soon, we again heard that the attack was aimed at her older sister (also in our school but nearer 16 or maybe 17 year old). We were told that Eve opened the door to their home unsuspectingly and she had acid thrown in her face. We were told that she was badly burnt and had been admitted to the hospital weeks before we were hearing of it and was in a serious condition. We talked about her non-stop for a week. There was a sombre mood in the class. It was as if no one felt right to take over her role. So there was no joking or pranking in those days. We all feared the worst as the news we heard was comprised solely of rumours. Like Chinese whispers, we were unsure who to believe.

One morning, the Day students (as opposed to us Boarders) came in talking about the 9 o’clock news on NTA (Nigerian Television Authority channel, national news broadcast). Eve had been mentioned as there was an appeal for funds. The attack on her and the resulting serious injuries were so serious that the doctors in Lagos could do no more and I think the thrust of the news was that her family was appealing for donations to take her abroad. This was when we realised just how bad things were. We sat around in silence, praying for some news. Mr Brown turned up in our class that morning. For once, no one needed to ask for silence. We all sat in our seats and looked at him expectantly. He spoke to us in his quiet voice. His eyes were red…from exhaustion or from tears – it was hard to tell which. He confirmed the rumours. Eve had been the unintended victim of an acid attack. She had been home alone when the men called and as she was so sick, she could not identify her attackers. She was in hospital in a stable but critical condition. He left. For the next few weeks, we continued to whisper about Eve. What did critical mean exactly? More rumours about who the intended victim was and the suspected attackers. About the extent of her injuries. Some adults had been to visit and they all agreed it didn’t look good. Despite all our fears, she remained alive but in a ‘stable condition’.

End of term for us JSS3 students came early and on our last day, some kind soul had organised a bus for those of us who felt up to visiting to go and see Eve. Most of the Northern girls declined to come. I was the only Northerner to get on the bus. In total, out of 90+ classmates, the bus held less than a dozen of us plus a couple of adults. The bus ride was made in total silence. You could smell our fear and the tension was palpable. I mouthed prayers, praying that I could handle whatever condition she was in. I don’t remember much of the usual Friday traffic and the heat. I remember walking off the bus in a single file and how much I was dreading what I was about to see. The smell hit me first and I felt my gut roll. My nostrils curled inwards, as if to block off my nose and the smell with it. I thought I would faint. It was the smell of decaying human flesh reaching the corridor outside her room. I could hear someone whimper and start to sob within our group. We all marched on following the adult leading us in. We stopped by the door as she announced our entrance. When she opened the door, the smell hit us harder followed closely by the sound of Eve taking breath after painful breath. My knees locked and a part of me wanted to bolt. I remember telling myself sternly that I could face anything. If she had to be here, I could visit her. Even if only for a minute.

On wobbly legs, I followed. I inhaled and held my breath. The bedside cabinet was groaning under the weight of medication. Mostly topical and oral stuff with cotton wool and forceps in a metal tray. She was barely visible. Her head was uncovered and there was a lady (her mother?) whispering in her ear. Asking her to be brave, not to scream in pain as she had begun to do. ‘Your classmates have come to visit’ the lady whispered into the hole where her outer air should have been. She seemed to hear her and she lapsed into her painful breathing again. The rest of her body was covered. It was beneath a metal cage over which a sheet was draped. I could not see underneath but I was certain she had burns all over her body, which was why she was lying so. To prevent clothing coming in contact with her skin. We all took turns to step up next to her and tell her who we were. Her eyes were covered, she clearly could not see. The hair on her head was badly singed and what was left of it was in a clump, stuck to her skull. All of her skin was badly damaged. You could see bits of colour imbedded in the skin of her face and neck, clothes melted into her skin. Her nose was gone…there were holes for breathing but no nostrils. Her ears like I already mentioned were missing too. All that was left were holes leading to her middle ears. Her lips were also damaged and her mouth was hanging upon as she struggled to get air in. Through her open mouth, you could see her blackened shrivelled tongue.

She grunted when each girl said her name. We retreated to the back of the room and stood silently for some time. Her carer took a bottle from the cabinet and dropped it onto some part of her face when she started to complain of pain again. Soon, her bravery was unable to contain her pain any longer and she began to whimper. This very quickly turned into screams of anguish. She was clearly in unbearable pain. We all had tears in our eyes as we were ushered out. Her carer came to us and said ‘thank you so much for coming. I know Eve appreciates it’. None of us replied, we were too busy crying. We got back on the bus and gave way to emotion. I remember staring unseeingly out of my window as tears coursed down my cheeks. I wept for nearly an hour, until we got back to school. When I got off the bus, my face was dry. It was obvious I had been crying but the tears stopped. I had to be brave. I got my things and I went home. I did not speak much of it over the next few days except my family would ask how I was doing whenever the appeal for help with medical costs was broadcast. Her death was announced on the Tuesday after we visited. Although I didn’t say it out, I sent a word of thanks to God for answering my prayer. My prayers on the bus after we left was that He put her out of her misery. I was sad but life went on.

About a month later, 2 of my older male cousins, my foster sister, my sister and I had one of our late nights of playing cards by the light of a lantern on the veranda whilst most of Yola slept. It was around midnight and Yola was definitely in bed by then. We were suddenly famished and we rooted around in the kitchen to no avail. We decided to go out and buy some food. We walked in the quiet to the night market (‘kasuwan dare’), fearless in those days of anything untoward happening. Yola was that kind of town. Despite the fact that 3 of us were young girls, we felt safe enough in the company of 2 older boys. We bought food and came home, had a merry little feast and were in the middle of telling jokes and laughing when it suddenly dawned on me that Eve was dead. Just like that. She would have no more holidays, no more jokes, no more laughs. She was gone. Forever. The enormity of it hit me. The pain she was in, the senselessness of her death (her murder come to think of it) and the grief her family must be going through. How had she felt just before the attack happened and when she had the acid thrown at her? How had she borne the pain for so long? Could she smell her own flesh decaying? Did she realise how badly she had been hurt? Did she know she was dying?

From laughter, I dissolved into tears and I could not stop. The more I thought about her, the more I wept. The others were concerned. I told them through my tears not to worry. I was just remembering Eve. They were worried I could see but also understanding. This carried on for maybe half an hour. Eventually, my sister suggested that the boys go home. My sisters would look after me. I smiled through my hysteria and tried desperately to compose myself. I remember rocking as I sat on the ground, hugging my knees and trying not to hyperventilate. I was sobbing out loud, my eyes closed as I got flashbacks of Eve in her eventual death bed.

My sisters asked what the matter was when I did not show signs of stopping. I said ‘I will be fine. I don’t know why I can’t stop crying.’ Actually I did know. I could not stop imagining myself as her. Going through that ordeal, surviving for over 3 months with all the pain. Unable to talk, unable to move, unable to ask why. I thought mostly of her mother, who had to watch her daughter go through this. I thought about the inadequacy of treatment, how she was clearly in pain but there were no painkillers strong enough to control her pain. I thought of her sister, who was rumoured to be the intended victim. How did she feel? Did she feel bad her little sister had taken her place? Did she feel guilty by association? I thought of Mr Brown and his wife. I knew they would be devastated. I had seen it in their eyes. How were they carrying on? How could they bear the pain? If the pain I was feeling was so deep and I wasn’t even that close to her, how must they feel? How could they bear to be alive?

It took over an hour for me to calm down and stop the sobbing. I still cried. Until dawn that day but silently as my sisters lay next to me and went to sleep. I got it all out then and not once since have I shed a tear over Eve but I remember her whenever I think about life and death. The details are unclear to me now but I think her attackers were caught. Her sister was a witness in the case. I don’t know if they were convicted and what happened to them afterwards. We never got to go to the funeral because it happened over the summer holidays.

Life moved on when we returned to SS1. Without Eve. She had never made it out of her pinafore and into the skirt we were now wearing as senior students. Whenever someone said someone funny, we would refer back to what Eve would say. Mr Brown, bless him, looked devastated whenever we saw him, which wasn’t often. He did come to say thank you to all of us for our prayers and our parents’ donations. He especially wanted to say thank you to those of us who visited. He said we helped Eve. I hoped so. As the days turned into weeks and weeks into months, we gradually moved onto other topics. Other girls soon took up the mantle of class clown and the laughter returned. Still, I never forgot and I know at least within my circle of friends at least, none of us will forget her. She lives on in our hearts. What a senseless loss!

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