Thanatology: Death and the Doctor. . . . .My Perspective.

It was supposed to be a free weekend; one that I'd been aching for since weeks. You never expect a post double-emergency weekend to be free for a Trauma Registrar..... but, yeah, I did manage that feat in the middle of the week, thanks to people not drink-driving, falling, stabbing, hanging precariously outside locals, etc. etc. on Sunday or Monday (surprising!!!).
Anyways, today I got a call from my colleague in the wee hours of the morning that one of my patients in the Trauma ward had expired. To the best of my knowledge, I had no patient admitted under my care in the ward. So this statement raised a few eyebrows! On further probing, she was the trauma patient who I had shifted to the General ward around 2 months ago after stabilisation and had to be shifted back in view of poor general condition. Despite our best resuscitative efforts, the patient could not be revived and was declared dead.

I remember the situation around 3 months ago when this patient presented to our casualty as a case of Road Traffic Accident (RTA) with head injury. She was referred from a private hospital, intubated and on AMBU support. She definitely required a ventilator. I was the Trauma Registrar on call that day. We had no free ventilator in our Trauma Ward and I was forced to refuse the patient and asked them to take her to another public hospital where they most likely would have a ventilator available. The husband begged me to admit the patient. In such cases, we take an AMBU consent from the patient's relatives stating that they are willing to perform AMBU ventilation on their patient till the time a ventilator frees up (yes, considering it's a public hospital and with our limited resources and high volume of patients, we have to!!!). The husband appeared desperate. Apparently he had spent lakhs of rupees on her treatment in a private hospital and had run out of money and could see no results in his patient. Hence, the referral to a public hospital (a very common scenario at our hospital and hence the portrayed high "mortality-rate" despite the optimum care given).
This patient was under my care in the trauma ward for almost a month. I will not go into details of how she was resuscitated, stabilized and shifted to the ward after almost a month of being on a ventilator, being tracheostomised and then being weaned off the ventilator, undergoing a PEG (feeding procedure) etc. etc. All I can say is that I put in my best efforts to save this patient!
Shifting her to the ward after stabilisation was one of my biggest personal achievements given her co-morbid conditions as well (morbid obesity, Diabetes Mellitus, borderline hypothyroid).
To hear of her death got me thinking for a while.....

Back to this morning.......... After I heard the news, I cut the call, pondered for a while wondering what could have gone wrong and went back to sleep. Yes, that was my reaction. And, this similar non-sympathetic behaviour HAS become my reaction to the death of any of my patients! Am I heartless??? Think not.....
Death is an irreversible cessation of life- that state of the body that shows complete loss of sensibility and the ability to move..... the complete cessation of the functions of the brain, the heart and the lungs, the so-called "tripod of life" which maintain life and health. Death is a part of life and a part of my JOB. That is an unwanted reality that we as doctors have to face on a regular basis (especially in a trauma set-up). Initially, I'd be quite taken aback and found myself being emotionally involved. as a student in my MBBS days. After graduation, when I was authorised to declare death, I really couldn't bring myself to shed a few tears over someone else's loss, even if I wanted to. I gradually began to realise how and why this happened and why it mattered. As a doctor, I cannot let death take an emotional toll on my life. Yes, you may call me stone-hearted, heartless or whatever. But, I guess this is in the best interest of all the future patients that I will be treating. If I had to shed tears over every death that I have witnessed and had I let each of them shake me up emotionally, I would have given up being a doctor long ago! All I'd be thinking of were dead people! I wouldn't be able to work, to eat, to drink, to sleep..... just imagine!
Yes, I'm heartless during such situations and I have to be. I can empathise with the relatives but that's that....... I CANNOT let my emotions overcome me. And that is what my profession teaches me.......
There have been a lot many occasions like these, where I have given my all to save a patient, to see them eventually die. Frustrated, check.....Angry, check......Sad, check...... Unhappy, check. And a whole gamut of emotions- check, check and check again! Do I portray those emotions......NO! Can't get myself to either. It just dies down till I witness another death!
I can just imagine what you must be thinking but unless you're a doctor, I don't really expect you to understand.
So far, in my short surgical career (many years to go.....still), working in one of the best Trauma centres in our country, I feel as if I've seen it all. Victims of railway accidents with dismembered limbs, some carrying their own leg in their hands (YES!!!), electrocution injuries, stab victims, gun shot victims, burns with trauma, road traffic accidents with their wide gamut of presentations, month old babies falling off God-knows-what-not. (image alongside says it all, I guess. A concrete slab impacted into this young boy's skull with damage to the underlying brain matter successfully extirpated by our neurosurgery team. He was discharged, with just a scar at this site!). Lots more to see, I guess....
All I know is that those who have the strength and the love to sit with a dying patient in the silence that goes beyond words will know that this moment is neither frightening nor painful, but a peaceful cessation of the functioning of the body.
That's some food for thought, I guess. . . . . .
 

MEDICINE AS A LEARNED AND HUMANE PROFESSION

People have always asked me what it feels like to be a doctor. That "oh-so-noble" profession that everyone keeps referring to. When you introduce yourself as a doctor, people's perception about you automatically changes. It's like..... you are someone to be revered and respected; the adulation and at times, awe are all part of the package. But is this what being a doctor means??? I think not....... Read on.

Becoming a physician has meaning far beyond completing medical college. It is the entry to a way of life, the one characteristic common to every true profession. It may sound old-fashioned, but the learned professions are really "callings" from which the members cannot separate their lives. There are no "part-time professionals", at least in this profession, having accepted such a calling, one is bound to live it or leave it. A physician can also be a good spouse, a good parent and a good citizen of the community; however, the role of a spouse, parent and citizen, is inextricably intertwined with the calling of being a physician.
Medicine is not just a science, but a profession that encompasses medical science as well as personal, humanistic and professional attributes. The process of becoming a physician and being committed to lifelong learning requires that an individual possess the scientific base not only to acquire and appreciate new knowledge but also to see new ways for applying it to patient care. Every physician must delight in learning the new, correcting the old and perfecting the future. Much of what medicine now accomplishes depends on large-scale testing of procedures, interventions, vaccines and new drugs.

Being both professional and caring is an acquired skill. A physician can diagnose and prescribe in a technically correct and scientific, but insensitive way. The patient may be made better, even cured, but still feel unsatisfied with the interaction. In these cases, patients are likely to ask the questions:
1. Does my physician really care?
2. Does what happens to me matter to the physician?
3. Does my doctor show sensitivity and compassion beyond mere technical ability?
Patients want and deserve compassion and understanding. They want their doctors to be interested in them as individuals who seek advice, as well as relief from pain, disease and suffering. They want to sense that they can safely share their deepest thoughts and their most heartfelt confidences with their doctors. In short, they want to value their physician as a trusted friend. My own experiences during my rural internship have shown that a kind word is all that is needed in allaying part of the fear and anxiety associated with visiting a doctor.

Patients also expect to be kept informed while they are receiving competent professional service. As a caregiver, it is the sharing of oneself that is so very important. To some, it may seem odd to talk about caring as a learned skill, but it is just that. In studying to be a physician, one must learn both compassion and caring. Easy, supportive interaction with patients and others less fortunate, is a skill that comes readily for some and with great difficulty for others. In learning how to demonstrate compassion, Kahlil Gibran taught us: "You give but little when you give of your possessions.....it is when you give of yourself that you truly give". The giving of oneself with ease, with grace and with meaning is, for most persons, an acquired skill. Sometimes a deep sense of awakening within is required to release the innate sensitivity and compassion that perhaps have not been expressed since childhood. Nevertheless, these traits remain imperatives if the aim is to become a "complete physician".
When patients seek medical attention, they entrust their doctors with their very lives. The physician must earn such complete trust. Technical abilities and skilled treatment of disease alone do not suffice. Patients must believe that their physicians care about them as people, not just as patients. Physicians, in turn, must understand that they do far better as professionals if they err on the side of being human with their patients
A particularly difficult time comes as physicians deal with patients who become old, frail, dependent, crippled or cognitively impaired. These are circumstances from which the most sensitive among us truly learn what it means to give of ourselves. Sometimes we may find once again that our patients are the "best teachers".

On second thought, I really can't define what being a doctor encompasses..... because it is something that goes way beyond mere "definitions"..... for me, I guess, it's a way of life...... as said before, something that is inextricably intertwined with my very being.....

Adapted from: Cecil's Textbook of Medicine