Letter 658: Waiting for Death

Yesterday, I watched a patient die-- slowly-- on the operating table, and I did nothing.

I sat in a chair, next to my intern, watching every single parameter that reflected signs of life (or the gradual lack thereof, in her case) on the monitor with painful solemnity. Her heart was progressively exhausting itself. The steadfast galloping sound on the monitor became slower: 120-- 103-- 97-- 78-- 63-- 59-- 47-- 36--... Signs of ischemia began to manifest on her primary ECG lead, and as her trace became more irregular, it eventually went into ventricular fibrillation before flatlining. She had no plethography trace, for she was peripherally shut down so extremely that her fingers were pale, blue, and ice cold. Her central venous pressure went from 5 to 3 to undetectable. The arterial line that I had put in earlier read a blood pressure of 11/3 (yes, eleven over three), and a trend downhill to a final reading of 0.

Harsh fluorescent lighting bounced off the cream-coloured walls of Theater 1, which had been reduced to a somber asylum of watchful waiting since the surgeons and my consultant anesthetists decided to call it quits on her half an hour ago. My intern and I sat side-by-side, in chairs dressed with green-and-white stripes, next to our patient who lay motionless on the operating table, each breath sustained by the ventilator that was connected to her lungs via an endotracheal tube. There were only the 3 of us in that theater, wordlessly waiting for death to approach. The surgeons have long gone to inform her family, and the nurses were sterilising instruments next door after cleaning up blood from the patient's face and body and covering her with a clean blanket. 

There was nothing anyone could have done to revive her. She was an extremely high risk patient who consented for surgery knowing very well that intra-operative death was a strikingly plausible outcome. Her family was aware that long-term ventilation and/or death were imminent possibilities, yet they wanted us to take the risk. Was it a blind leap of faith, or did they see us as her salvation? They wanted full resuscitation-- CPR and all that-- in a 77 year old lady who was on home oxygen, who was anemic and actively bleeding from her upper GIT, who had a 6.5cm abdominal aortic aneurysm waiting to burst, whose exercise tolerance was only 20 meters at best with a 4-wheel walker, and who was probably osteoporotic from long-term prednisolone use in which case if we were to perform CPR, there'd be no doubt we will break a few ribs.

A few hours before she was taken to theater, when the surgical registrar and I were explaining the risks of surgery and the bleak outcome of going through a full resuscitation, the patient's own words to me was "I've still got years to live, my dear, of course I'd wanna be resuscitated!"-- all the while ignoring the fact that she had to gasp for air following each syllable. She coded on us before we managed to take her to theater-- an ominous sign heralding a dire outcome.

She was scheduled for an emergency gastroscopy in order to locate the source of her hemetemesis. I intubated her for this, and while the surgeon was pushing the gastroscope down, fresh blood was gushing out. I suctioned her over and over again. Blood flowed ceaselessly from her gullet like a burst water pipe. My senses were strongly assaulted by the sight and smell of fresh blood around her mouth, on her neck, on her pillow, and on her sheets. In the end, I left the suction sitting in her oropharynx. 500mls of blood later, with no source of active bleeding found, the surgeons decided to open her abdomen. It was a risk we had to take: open her up and risk dying from blood loss and/or anesthetic complications, or call it a day and still risk dying from ongoing blood loss. 

Laparotomy revealed a fistulous connection between her aneurysm and her duodenum. In other words, she was bleeding from her aorta. Blood was spurting forth with each contraction of her heart. We kept transfusing her, unit after unit of blood products. Her initial hemoglobin was 70, and, after about 5 units of packed cells, was still sitting at 70. No matter how much we were transfusing, she was oozing it all out. According to the surgeons, the fistula was in a tricky spot, and the position of the aneurysm itself posed a challenge-- there was no way of clamping the aorta without risking renal shutdown. In the end, a decision was made to close her up. Just as they were doing so, her aneurysm ruptured.

She bowed out with a grand exit.

So this was how my intern and I found ourselves, after the surgeons have sutured her up, and after the nurses have cleaned and covered her, sitting next to our patient, watching her, watching the monitors, waiting for family members to come in to say their goodbyes. We had made plans pre-emptively for her to be retrieved to a tertiary centre post-operatively, but now, now she wasn't even stable enough to be transferred out of the operating room, let alone be retrieved. 

"Do you find it weird?" I asked my intern.

"What's weird?"

"Waiting for death. Seeing it all as it occurs on the monitor. Doing nothing."

There was a pause, as if he was contemplating the subtext of my statement.

"Yeah... I guess. It's so surreal. I've never been in this situation before."

Another pause, before I confessed.

"Me neither."

We continued with our silent reveries. Her family came, they cried, they said their goodbyes, they left.

My intern and I, we remained mute throughout.

Letter 657: I am So Flying Home to Vote in the Next General Elections

Today, I believe Malaysians all over the world woke up to a sombre morning in the aftermath of the nation's 13th General Elections held on May 5th. I won't bore you with details of electoral fraud, because anyone with access to social media will have access to the truth. And the truth is that democracy was robbed, in broad daylight, from the hands of every eligible voter in the country.

Today, I believe many Malaysians are in mourning. We mourn for our loss of liberty, and the loss of integrity of our nation's so-called leaders. Facebook newsfeed streams like a funeral procession, with the majority of fellow Malaysians changing their profile pictures to a black canvas to reflect the doleful doldrums of the day.

Today, I was not in the mood to work. Fortunately, the nature of my current job does not require much interaction with patients. So I bitched about the whole saga of injustice to my boss as the orthopedic surgeon was hammering into a hip. As amused as he found the whole electoral situation in Malaysia to be farcical (blackouts?? Again??), he also asked why I did not go back to cast my vote.

So today got me thinking: I have never felt the strong urge to vote, why? Because I am an eternal pessimist. Historically, BN has always emerged the ruling party. And, judging by the foul play they allegedly employed last elections, I was pretty sure they were going to win again, however unfairly. I was so certain of this that sometime last year, I made a comment to The Other Half, saying that if the Opposition wins, I will quite my job in Australia and move back to Malaysia. That was how confident I was of the upper hand BN holds, and although it may have sounded a little imperious at that time, that confidence actually stemmed from a sense of lost hope. Some time between the last General Elections and the current one, I have grown even more detached and impartial to the socio-political goings-on in the country. Corruption and crime seem like recycled news. Racial sentiments continue to command seemingly great importance in policy making. What hope have we got for the country? My one vote will count, sure, but my one vote also probably wouldn't change the outcome, just like everyone else's one vote. Ultimately, the dirtiest party will emerge triumphant. 

Therefore, I settled into my little cocoon of peaceful indifference until yesterday, when I started following live feeds of the 13th General Elections while attempting to study. My heart swelled with pride when I saw Malaysians coming together in this election. It was close to what I felt when the Bersih rally started in 2007, when I was filled with optimism that perhaps change might happen. Obviously, I was disappointed with the 2008 elections outcome. So when Bersih 2.0 and 3.0 occured, I was distant and disinterested. So what if there was a record number of people rallying for a free and fair election? This is Malaysia we're talking about-- nothing is ever going to be fair when you have a country run by people who believe in elitism, not pluralism.

Change occurs gradually, as we all know. It is a silent force that seeps its way into an individual's consciousness, as well as the collective consciousness of a nation, and takes shape insidiously, for better or for worse. Today, I certainly felt a change in me. I looked back at the last 24 hours and realised I have spent the entire time scrutinising the elections closely, hoping for a miracle. When my parents got home from their trip to the polling booths, I immediately Facetimed them, wanting to hear about their experience and how likely the Opposition was going to win this time because it seemed as if everyone I know was eager for the same changes that I wanted but dared not hope for. I was in despair when photos of foreign voters started to flood my feed. It was then that I realised, once again, BN would be in power for at least another 5 years. 

And I was right. Despite the statistics, when I went to bed last night as the votes were still being tallied, BN had won 20 parliamentary seats to the Opposition's 8. So I was not surprised that when I woke up this morning, my newsfeed was a sea of black.

But I was wrong about something. I thought I would've given up all hope in the wake of GE13 just like how it was after Bersih and GE12. I thought I would've become more apathetic about the country that I once knew and loved. I thought I was going to go back and hibernate in my little cocoon of ignorance till the next miracle descended upon us. But I was wrong. A little voice in me urged me to do something without making up any more lame excuses. I believe it was my conscience. Enough is enough. Malaysians have suffered enough deception from a fraudulent system run by power-hungry, corruption-driven politicians who cared about their own position and pockets more so than the well-being of the rakyat. I was wrong to have doubted myself, and to have diminished any hopes for my country, because I am now driven-- with righteous indignation-- to vote. Better still, I plan to fly home to vote in the next General Elections. I know, my one vote probably still won't make a difference, but at least I would have tried. I would have tried my very best to make Malaysia a better country for posterity. 

Letter 656: Solo

Never one to splurge on body-and-bath products, I bought a 200ml bottle of Evodia body lotion after much deliberation. The tropical scent of mango and pink grapefruit reminded me so much of how we were-- of our carefree days in school where the subject that mattered most was if the chee cheong fun in the canteen was better than the chee cheong fun outside our main gates that everybody would queue up to buy after the final bell rang; of seeking shelter at bus stops and LRT stations during unexpected afternoon downpours, and then taking unexpected rides to explore unexpected places of interest; of sweet fuzzy nights drenched in the humidity of the cool tropical breeze while sipping on teh O ais limau and sharing a plate of Maggi goreng at midnight; and of curling up in bed, lying next to you while the sound of the ceiling fan droned on as we held hands and tumbled into dreamland together.

For tonight, as I listen to the rain, I will have no one to wrap my arms around as I drift off to sleep.

Letter 655: Balnaves

It is Anzac Day today. I have the day off. My grand plans to study is, once again, thwarted by my extreme levels of fatigue. I had one of my wisdom teeth extracted at the dentist's yesterday evening, and for the remainder of the evening, I couldn't eat anything. I tried sipping on some soup, but that just made the wound ooze again even though I had cooled the soup down to what I thought was a reasonable temperature. There was no gauze in the house, and in hindsight, I should've requested a packet from my dentist or at least grabbed a few from the hospital before I left work for my appointment. In a fit of desperation, I shoved a tampon into my mouth and bit on it for the next 2 hours. It stopped the bleeding effectively, just as it would with a nose bleed, but I was wary to put any food into my mouth after that, so from the time of my last meal to when I woke up this morning, it was an average of 18 hours before I would start eating again. My stomach was in knots, and I was cranky. Rummaging through the pantry, the only food that seemed palatable was a packet of dried apricots. What the hell. I tore the packet open like a hungry wolf attacking its prey, and munched my way through its plump juiciness. I made myself a mug of coffee, and that instantly made me feel 100% perkier. I still feel tired, tired of everything that I've done and have not. Tired of poring through all those journal articles and making sense of it then but not remembering any of it after. Tired of paying all these bills and seeing more piling up like dirty laundry. Tired of making plans and not following them through. Maybe I need more sleep, because no matter how many hours I've slept, it just doesn't feel quite enough. 

Letter 654: Blood and Tears

For the first time in my career, I actually thought my patient would die on the operating table. He was bleeding so profusely from his abdomen that his blood pressure was almost unimaginable-- 40/20. We were transfusing red blood cells into him, pack after pack, and pushing fresh frozen plasma, cryoprecipitate, and almost every other blood product that our regional, secondary hospital had in stock. I have never needed to give anyone 11 units of packed red blood cells until tonight. I was terrified, scared shitless that he couldn't make it till the retrieval team came. He had a high grade liver laceration after a motor vehicle accident, and it was a miracle that he didn't sustain a head injury, a splenic laceration, nor any long bone fractures. The surgeons managed to contain his bleeding eventually, and, after a 6-hour long procedure, he was finally stable enough to be retrieved. He lost about 7 litres of blood, at best guess. His sheets were soaked with blood, and there was blood all over the floor and on my gloves and on my scrubs. The operating room looked like a war zone. We fought a hard battle to keep him alive, but we won't know if he would be left with any hypoxic brain injury from all the hemorrhage. I guess life still goes on, whether he recovers well or not. Tomorrow's another day.

**Note to anyone out there who is reading this: Motor vehicle accidents are ugly. We all know this. But until you're actually involved in the care of a motor vehicle accident victim, you won't even know what to expect. As doctors, we have been trained to manage trauma, but even then, when the enormity of the situation actually hits you, all you can give is your best effort at attempts to resuscitate and save lives. So the key message here is-- and I'm sure you're sick of hearing this already but I've just got to say it again-- DRIVE CAREFULLY.