When the tender thread snaps unexpectedly…

…its devastating.

Siting through the morning death report was hard today. It felt like death, death, death. A 76 year old man with severe pneumonia, a 38 year old woman with end stage HIV, a 35 year old man with a snake bite, a 78year old lady with hypertensive stroke, a 70year old man who had had a laparotomy….what!....hang on!... what!... No!... It can’t be!?...But as this particular report continued my surprise turned into disbelief, turned into shock, turned into numbness….and a flicker of anger. The patient from yesterday is dead. Genuinely, I could not believe it. The operation had gone so well, he had entered theatre in a bad way, his abdomen so distended he could not breathe well. But he had left so much better. So much better in fact that I had felt pretty relaxed about his prospects (my main concern being how soon we could reverse his stoma). What on earth had happened here? For all I wanted this news to be a mistake, it was not. Devastating. Heart breaking really. That little bit of you that, as a surgeon, will always be invested in the patients you operate upon, snatched away. And what a way to find out. Completely unintentional, for that’s the way they do things here, but it felt almost cruel.

He died a little over two hours after the operation. I had seen him settled onto the ITU ward (see previous accounts of how this might be considered a misnomer), he had had three sets of apparently very reassuring observations the last one timed at 18:20. He was certified dead at 18:47. No-one could tell me why or what had happened. Whilst any number of things might have occurred, my strong suspicion is that he had a respiratory arrest. With no monitoring, its occurrence, and the warning signs, went unnoticed. Settled quickly into his ward bed, with less and less stimulus, the residual drugs (mainly repeated boluses of ketamine) from his long (for here) anaesthetic still floating around in his system, might have had just the opportunity to take hold. Enough to tip him over the fragile balance. Enough to allow him to drift into a sleep, a sleep so deep he would never awake. Tragic. Gutting. Words don’t really cover it.

The rest of the day just happened. Somehow (although of course as professionals we always will), I managed to do the ward round, go to clinic and even operate – we have a big list stacking up and some extra operating time was found today. A bilateral hernia. I even managed to teach.

And this is just the way it is. Nobody really questioned what happened. There was no outrage. Rather just calm acceptance that this is what happens here. He had his chance, and unfortunately, it just did not work out for him. All the staff involved were open with their sadness, but vocally, their main concern was how I was feeling. I had been quite honest in saying that I was feeling very sad about the case. In Africa, to express such feelings is unusual. Their acquaintance with Death, whilst no less difficult perhaps, is however that much more familiar.