Antibiotics cannot fix an extensive bowel perforation, and the effects of sepsis on blood pressure and heart rate in a setting with minimal ICU support are difficult and sometimes impossible to treat. In the end, I had to remove a section of his small bowel and colon. Joining bowel together in an abdomen full of infection is dangerous because the risk of that sewn joint leaking is high. "How is he doing?” I asked our anesthetist. “Sort of stable," came the reply. Surgeons often will protect a sewn bowel joint with an ileostomy. An ileostomy is a piece of bowel brought up through the abdominal wall proximal to the new joint so that the patient stools out the side of the abdomen rather than the normal way. This diverts stool away from the fresh bowel joint and reduces the risk of further leak/infection.
"I hate ileostomies," I thought to myself as I weighed the risk of a leak while sewing the new joint. Patients that come to our hospital cannot afford the appliance and bag that protects the skin. Living without these appliances in Canada or the US would be unheard of, but my patients often just collect the fluid/stool in a piece of fabric. The fluid is caustic and eventually will erode away at the skin it touches, not to mention there is no capacity for continence with an ileostomy. But, this surgical procedures saves lives and when compared with death, its the lesser of the two evils.
I quickly made the ileostomy and washed the rest of the contamination out of his abdomen. I sewed his abdomen shut. It was a race against infection and I feared we were already behind given his diagnosis. Night came and I finished my other cases for the day. The boy went to our ICU where we can provide more extensive monitoring. He was transfused during the night, and I checked his labs trying to correct the abnormalities that present with a raging infection.
I couldn’t help but think that this boy is the same age as my son as I laid in bed awake that night. Between the heat, the mosquito I couldn’t kill, the noise of the ceiling fan, and checking on his status every 4 hours, I didn’t get much sleep. "I must sleep a bit," I thought, given that my colleague and I are on call every other day and every other weekend for 2 months.
I couldn’t help but think that this boy is the same age as my son as I laid in bed awake that night. Between the heat, the mosquito I couldn’t kill, the noise of the ceiling fan, and checking on his status every 4 hours, I didn’t get much sleep. "I must sleep a bit," I thought, given that my colleague and I are on call every other day and every other weekend for 2 months.
Morning arrived and he was still alive. Somewhat reassured with his condition, I tweaked a few things and continued to see my other patients when I got the dreaded call.
"Doctor come quickly!" His heart had suddenly stopped.
People quickly gathered at the side of this little body and started CPR and various other things. When doing CPR, 30 minutes can seem like just a few, and despite correcting everything we could, we could not get him back. Time of death 11:07am.
The father watched the events unfold looking helplessly. I felt helpless. This was the third patient this week I had in hospital with a similar infection. My other 11 year old patient has undergone 3 operations but is now in the clear. Another lady, my age, is struggling to learn to live with the dreaded ileostomy but she is also doing well.
The father watched the events unfold looking helplessly. I felt helpless. This was the third patient this week I had in hospital with a similar infection. My other 11 year old patient has undergone 3 operations but is now in the clear. Another lady, my age, is struggling to learn to live with the dreaded ileostomy but she is also doing well.
It is cases like the story of this boy that divide my being. The logical part of me can’t help but recount his clinical course and try to figure out what could have changed his outcome. The emotional part of me grieves with the family. Sometimes it is just easier to try and forget as the next patient will be arriving any minute. Maybe a trauma patient with a mangled leg, or another child with some horrible infection. It's not that surgeons want to be apathetic, but each patient is a series of mission critical decisions and steps. There often isn’t time for emotion.
Death forces me to review those mission critical decisions. I suspect one way to deal with recurrent death and suffering is to just not think about it at all and move on to the next emergency. I find this hard because at the end of the day, I genuinely care about every life in front of me. I hate death.
This post is a glimpse of the deaths that haunt me. It is one of many gravestones of a life lost that is etched in my mind.
I am sure you are thinking, wow, this is a super depressing post!
But by understanding a low like this, you can begin to understand the pure highs I experience when seeing a patient totally healed after their life-threatening surgery, or one unable to walk now able to move again.
You can appreciate with me the joy of averting the course of someone spiralling towards death. When you see me smiling on my facebook posts, it’s real! It's the reason I practice surgery in Africa. I love and I hate what I do. It’s the blessing and the curse of being a surgeon.
You can appreciate with me the joy of averting the course of someone spiralling towards death. When you see me smiling on my facebook posts, it’s real! It's the reason I practice surgery in Africa. I love and I hate what I do. It’s the blessing and the curse of being a surgeon.
Today I joked with my OR staff that I look forward to being unemployed in heaven. Even my muslim colleagues laughed. As I reflected more on this case, I was reminded that
I serve a God who cares about kids.
In fact, he reprimanded his disciples for hindering kids. He cares about life, He hates death and He understands what it feels like to suffer and die as a human. It makes going through situations like this a bit easier and it’s what gives me strength for each new day and each new case.
By Jesh
By Jesh
