The Rude Visitor

"Death is like a rude visitor. It sometimes arrives unannounced. Other times, we see it coming. It does not care about our feelings. It takes no concern for the inconvenience it brings. It wants only to be served and to be answered. It takes who it wants and all we can do is sit helplessly by as it stomps through our lives making a mess of our emotions, wreaking havoc with those who are left to pick up the pieces. Death brings discomfort and inconvenience. It injures our hearts, robs us of joy, and takes from us our loved ones." (Matt Slick)

I am a messenger.

A bearer of good and bad news in equal measure.

A teller of tales. A harbinger of doom. A shining proclaimer of hope when all seems lost.

Life.

Death.

I’ve seen it all up close, down and dirty, and with all the nitty gritty in between.

Some of it I’ve laughed at. With some of it I’ve cried. At times I’ve barely held myself together when the hole that I had dug for someone else seemed to get deeper with every sob that arose from the depths of their soul.

Death – ever present; has stood gauntly beside me throughout my medical career. Peering over my shoulder. Watching my every move.

As an intern one of the more straight-forward jobs was to sign the death certificate for patients that had died on the hospital wards. When you had been around for a while you realised that this really was a very boring job. But, the first time was something altogether different. My first was a little old lady. I don’t remember the details of her demise but I do recall that she was very frail. I entered the room with a degree of trepidation. The curtains were drawn. The lighting was subdued. It was quiet. The monotonous sounds of the busy ward somehow faded into the background. Now, there was a procedure to be followed. There was no way that I was going to be one of those sad, sad bunnies that somehow managed to send a living creature to the morgue and have them wake up in the middle of the night in a body bag. Oh, no – not me. I went through the check list.

I calmly strode to the bedside. I reached down and held her wrist earnestly searching for a pulse – absent as predicted. I took out my stethoscope. Delicately I placed the earpieces into my ears and leaned over her cold, still body and placed the stethoscope on her chest. Heart sounds – absent. I paused, remembering my list, and listened to her lungs. Breath sounds - absent. By this time it was pretty much a done deal. She had not stirred. Her skin was cold to the touch. She had a very sickly complexion which conjured up memories of a B-grade vampire movie. But – I had a checklist. I needed to be complete. So, I proceeded to the final step – checking for a response to pain. I had been taught that the best way to check for this was with a sternal rub. With this technique one applies pressure to the breast bone with the knuckles of a closed fist. You can imagine someone doing this to you with enough firmness that you would instinctively push them away and possibly swear at them. I did that to this little old lady. Now, unfortunately she was a LITTLE old lady and the modicum of force that I used was enough to compress her chest a bit more than most people. When I released that compression, the negative pressure created in her chest cavity was enough to cause her to appear to breathe in. A gasp if you will. On that first occasion, in that darkened room, and by myself, this appeared to all intents and purposes to be a response from her wizened form which up until that point I had assumed to be as dead as a door knob. My response was immediate – I made pretty much the exact same noise as her and every sphincter in my body tightened. Time. Stood. Still. Just for a moment. I then realised what had happened, composed myself and left the room to fill out the paperwork. Foolishly I told the nurses what had happened and I didn’t hear the end of it for weeks.

Some deaths are just as memorable but not for the same reasons.

In the mid 90’s I worked many hours in the emergency department of the base hospital in Mackay. A lot of the work that came through the doors was your bog standard “I could have gone to the GP but it was more convenient for me to wait for hours at the local hospital and clog up the accident and emergency department”. There was the occasional more significant presentation of a heart attack, or broken limb, or welders flash burns to the eye etc. Very occasionally there was a true emergency – a major trauma – usually the result of a road accident. It would be all hands-on deck. One senior doctor would be in charge calling the shots. Drips, catheters, splints, X-rays, CT scans – all being done at the same time by many different nurses, doctors and orderlies. The patient’s clothes were cut off. Their face would often be obscured by tubes, masks or sometimes bandages. These patients would make a transition from individual person to generic patient as they went through the doors of the department and were loaded into one of the emergency bays.

I remember one such transition very clearly. He was young and male - as they often were. High speed motorcycle accident. Weaving around the narrow roads between the sugar cane fields surrounding Mackay, he had encountered a tractor towing a cane bin. These were massive metal cages into which the chopped sugar cane was loaded and then transported to the closest mill for processing. He whizzed past it and quickly realised that there was an oncoming car and so accelerated to get past the bin and zip back over to his side of the road. Unluckily for him there was another bin being towed just in front of the first one. He didn’t stand a chance. There was no time to brake and the impact was devastating. He would have been unconscious from that point on.

He was alive when they brought him in – just. Scans and X-rays showed that he’d suffered internal injuries. All four limbs were crumpled appendages. The brain injury was one of the worst the senior doctor had ever seen. Within a short time it became evident that nothing could be done except make him comfortable and call in the family. In a hurried but calm manner the team prepared him for the family’s arrival. The family were brought into the room where he lay and the head doctor explained his injuries and the futility of treatment. It was gut wrenching. I remember three things very clearly from that day and they were all sounds. The rise and fall of the ventilator. The steady beep of the heart monitor. The wailing of his mother.

Over the next hour or two he deteriorated and died right there in the emergency department. As his brain swelled massively it pushed down on the area which controlled his heart and slowly but surely his pulse rate dropped and dropped until it eventually stopped. All through this process the family stayed at his bedside. They would occasionally go outside to smoke and rail at the injustice of it all, then return sobbing to be at his side again. Once the ventilator was turned off they left together, into the darkness. I had trouble sleeping that night.

Some deaths are noble visions of the strength of the human spirit. Idealistic demonstrations of how we can approach our own ultimate demise with a mixture of thankfulness and courage. Unfortunately, we can’t all have a sense of a “life complete” when staring into the abyss. Often this awareness is reserved for those that are more senior in years. The young often have much to be thankful for but sometimes lack the judgement to appreciate.

One thankful patient stands out for me – Mary. I met Mary when I was working as a GP in an outback town. She had a thriving local business that she had been a pivotal part in building from the ground up. She’d been treated for breast cancer years previously and when I first met her she was a cheerful soul who brightened my day whenever she came to get her blood pressure checked and her regular prescriptions. On one occasion however she was quite unwell and not her usual self. She couldn’t put her finger on it, but she wasn’t quite right. I was no closer to the cause of her illness after I examined her and I took some blood and sent it off for basic checks. When the results returned the next morning, I was surprised to discover that she had severe kidney failure. After consultation with specialists in the closest referral hospital 5 hours drive away she was sent for an ultrasound scan. The news was bad. The tubes which transported the urine from her kidneys to the bladder were blocked on both sides. The cause was unclear. The outlook was bleak. She was rushed to the referral hospital and further scans were organised. The picture became clearer but darker. Her breast cancer had returned, spread and was now encasing both tubes. The prognosis was dire. Any treatment was temporary and even with the best of care she only had weeks at best to live. The specialists were able to insert a thin, flimsy tube into each kidney to drain her urine but even these in time would fail. They sent her home, to her family, to await the end. When she arrived back at our hospital she was tired. Tired of tests. Tired of being poked and prodded. Tired of being alone. Just tired. Despite all this she still managed a chirpy greeting and a wry smile when she arrived. Her laugh brightened the darkness of the room and the spirits of those around her. As the disease progressed her pain increased and soon she was on strong medications to control the constant ache. One of the tubes draining her urine stopped working and then one afternoon the other came out when she was given a sponge bath. The nurse looking after her was inconsolable. Distraught that she had killed this woman who had suffered so much. I comforted her – you can’t kill a dead woman walking. The family were understanding. Mary was…. well, Mary was Mary, and she took it all in her stride. She had known the end was nigh for some time and weeks had now been converted to days. In some ways, I think she saw it as a relief. It was now time, quite literally, to go home. There was nothing that we were doing for her at the hospital that couldn’t be done at home and so plans were made. She was fitted with a tiny needle under her skin into which her pain medication was injected using a special pump. As she left the hospital on her last physical journey she profusely thanked us for our help. Once home, her family took control and we guided from the sidelines. The director of nursing at the hospital visited regularly, changed the pump, gave advice, held hands. I was there at the end. It was only on that last night that I ever heard her call out. By that time, the effects of her failing kidneys had dulled her senses and confused her mind. Then, thankfully, she was gone.

I don’t remember the funeral. I don’t remember most of the grief. What I do remember is a vision of a proud thankful woman. She was thankful to see her kids grow up into adults. She was proud to have made a business with her own two hands. She was thankful that she had a chance to say goodbye and in some small way went out on her own terms surrounded by those who loved her.

I was recently told about a speech by Winston Churchill, made after the death of King George. It struck a chord in me and reminded me of many patients that I have had the honour to care for over the course of my medical career so far.

“During these last months the King walked with death as if death were a companion, an acquaintance whom he recognized and did not fear. In the end death came as a friend, and after a happy day of sunshine and sport, and after "good night" to those who loved him best, he fell asleep as every man or woman who strives to fear God and nothing else in the world may hope to do.”

Some will succumb with acceptance as Mary and King George did. Some will fight to the end as in Dylan Thomas’ “Do not go gentle into that good night”.

“Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light.”

All of us though will meet our end and see others around us meet theirs. Sometimes we can control how that end will come. A lot of the time we can’t. What’s really important is what we do in the here and now – before the end. Once they’re gone – they’re gone forever. So, make that effort with family and friends!

For some that effort will be having to forgive perceived past slights. For some it will be something as simple as clearing a space in the calendar. For some it will be making that phone call that should have been made years ago. Do it! – make that time, swallow that pride, go that extra yard, try and ignore the superfluous bullshit, and make that connection.