Dr Robin Youngson shares the inspiring lessons he takes from his patients, working in many small rural hospitals in New Zealand.
Some days, the emotional work of being a doctor overwhelms the capacity for making meaning of events. Too much happens to fit in one human mind and there’s a limit to how many times you can find the courage to stare death in the face and bring all of yourself to the battle, every ounce of your knowledge, skill, compassion and caring.
The first inkling of the drama to come was a phone call from the surgeon.
‘Sorry to disturb you on your day off but I wanted to let you know about a ‘train-wreck’ of a patient we’re taking to the OR tomorrow. I don’t think she has much likelihood of surviving surgery but she’s determined to take her chances. She says, she’s too young to die!‘
The patient, in her sixties, had terminal lung disease from a lifetime of smoking. Her lung capacity was less than 20% of normal and she was breathless at rest. During the simple transfer from the hospital bed to the operating table, she was left gasping and cyanosed. Prior to this illness, she just barely had enough strength in her breathing muscles to keep her alive. Now she presented with a colon cancer and bowel obstruction.
I knew there was a 50:50 chance that I wouldn’t be able to wake her up and get her breathing any time after surgery. It’s a terrible thing to take a patient to the OR and know that your injection of anaesthetic might signal the end of conscious life. What words do you use with a patient when you might be the last human being they ever talk to?
I know in such circumstance that the death or survival of the patient is largely out of my hands because there are larger forces at work. At the end of life, we witness mystery and awe; many things happen that medical science can’t explain. I asked the patient if she had a faith to sustain her? I sat with her, and held her hand, and told her I would be watching over her for every minute of the operation.
This patient had probably faced death many times already. In patients with severe chronic disease, when a final blow arrives such a cancer diagnosis, many patients are ready to give up on life. They don’t have the will to struggle any longer. Others find ways to transcend their limitations and hold onto life as something precious. I explained to my patient that her will to survive was probably more important than the medicines I could offer. She declared her determination to choose life over death.
I won’t deny the extraordinary medical knowledge, skill and experience we brought to the care of this patient. The surgeon and I have a combined total of seventy years of medical practice between us. We both spent many hours agonising over our treatment choices and plotting an unconventional approach to the anaesthesia and surgery. Our patient survived her surgery and was admitted to the intensive care unit. The next day, Friday, she was sitting up in bed, smiling, talking, pain free. We had pulled the rabbit out of the hat.
That Friday, already half-exhausted with the burdens of the last 24 hours, I looked forward to a simple list of routine cases in the OR. It was not to be. Owing to staff sickness, the hospital had no anesthesiologist to cover either the acute OR or the ICU, which was full of sick patients. I was pulled off my routine list and allocated to the emergency OR. A challenging case awaited me.
The patient was nearly 80 years old, had complex heart disease and insulin-dependent diabetes, and was now in septic shock with suspected gangrene of his small bowel. All his organs were failing. His kidneys had stopped making urine, his blood pressure was low, his blood chemistry was deranged, and he was so short of breath he could hardly talk. But like my patient of the day before, he wanted to live.
In anesthesia, we grade our patients on a scale of risk from 1 to 5. A score of 5 means that we expect the patient to die within 24 hours whether or not they have surgery. That was my score for this patient.
Such cases present us with a moral and ethical dilemma. What is the right course of action? If we submit the patient to what is probably futile surgery, are we just increasing his or her suffering? Is heroic treatment just an expensive waste of our limited health resources, when there is so little chance of the patient surviving? What is the truly humane and compassionate thing to do?
As the anesthesiologist, it falls to me to have this life-and-death conversation with the patient. Not only am I responsible for trying to keep the patient alive during surgery but, in this small hospital, I am the doctor that also has to manage the intensive care after surgery. I am duty-bound to explain the risk and benefits of proposed treatment, even when the prognosis is grim, and to compassionately elicit the patient’s concerns and wishes.
This sensitive and heartfelt conversation should preferably span hours and days. In the circumstance, the patient’s life is slipping away by the minute. There’s little time for words. I focus instead on bringing a compassionate presence and healing intention to my patient. The patient knew that he was dying but he begged us to take him to the OR and give him a small chance of life.
During surgery, our fears are confirmed. Half of his small bowel is gangrenous. An awful stench of death fills the OR when we open his belly. The surgeon makes a quick assessment. The rest of the bowel is healthy and is enough to sustain life. He works swiftly to resect the dead tissue and remove the source of sepsis.
The patient’s condition deteriorates rapidly during surgery. I administer almost no anaesthetic and have to give massive doses of adrenaline and nor-adrenaline to sustain the blood pressure. Arterial blood gas samples show severe acidosis; his cellular function is failing together with all his organs.
The surgeon completes his task but the patient is barely alive. We are still waiting for a bed to become available on the full ICU so I continue to care for my patient in the OR. Despite maximal therapy, about an hour after surgery his blood pressure falls to critical levels. I tell everyone in the OR that I think the patient is about to die on the table.
At that moment, something perplexing happens. Without any action on my part his blood pressure suddenly doubles and his face flushes pink. His kidneys start to make some urine. I am bewildered and astonished. This event reminds me of patients’ stories of near-death experience when they travel towards the light and then suddenly are pulled back into the body, at the same time that the doctors witness inexplicable improvement.
We’re able to transfer him to the ICU where he continues full life-support treatment including massive doses of ‘double-strength’ noradrenaline, required to sustain his blood pressure. Over the next fifteen hours, his condition steadily improves. His kidneys come to life and the lung function improves. We gradually reduce the blood pressure support.
The next morning, a Saturday, we take him back to the OR to see what’s happening in the belly. All is well. The surgeon is able to complete his operation, joining the ends of the bowel together and closing the abdomen. The patient’s condition is so miraculously improved that at the end of the operation, I am able to wake him up and take him off the ventilator. A few hours later he’s sitting up in bed talking with his wife. By some miracle, he too has survived.
This Saturday morning is just the second day of my long weekend shift as the duty anesthesiologist. My joy at his survival is tempered by the awful tragedy of the young patient in the adjacent bed on ICU. This is my next task, to support the parents and sisters of a young boy who is now brain dead, following an accident that is so senseless that we are all left speechless.
The family has agreed to organ donation and a massive organisation has sprung into action to coordinate the complex steps of time-critical organ retrieval and donation in different cities across the land. At least four recipients are being prepared for surgery in different locations and teams of doctors are jetting across the country.
I have not been involved in the initial intensive care of this patient, nor in the agonising process of testing for brain death and approaching the family about the possibility for organ donation. All this has been completed before my involvement in the case. My only task is to meet with the family, to stay with them around the bedside in the final hour before their son goes to the operating room, and to introduce them to the transplant team that have flown in by Lear jet.
My first step is to apologise for being yet another strange face before them. The family have met countless doctors and nurses in the two days and nights over which the tragedy unfolded. Present at the bedside are the boy’s mother and father, and two teenage sisters. Being with the family at that time was an extraordinary privilege.
They tell me stories and show photographs, we laugh and cry, we hug and share tears. There is so much love around the bedside. The girls tell me about their little brother, how he was so mischievous and funny, his love of bad jokes, his big heart, his compassion and generosity, and about the special bond he had with his new pet dog. They tell me that he would have been so thrilled and proud that his sacrifice could mean new life for others.
I recognise in this family qualities I have been writing about in my new book, ‘From HERO to HEALER’. The book is about the lessons I have learned in more than a decade of campaigning to bring more humanity and compassion to healthcare. I learned that being angry, blaming others, trying to persuade people to change, being the expert, and focusing on problems were all counter-productive. The world began to listen and I became more effective when I adopted non-judgment, non-persuasion, a willingness to be vulnerable, to listen and learn, to be generous, and to always seek stories of what works best.
In the face of catastrophic tragedy and loss, this family shined with all these qualities. There was no blame, no anger, and they were deeply appreciative of the care and kindness of so many health professionals. In agreeing to organ donation they were making a huge and courageous sacrifice. They explained to me that they understood things might go wrong, that organs might not survive, but they appreciated that every single person was doing their best. In the midst of their sorrow and suffering it was some comfort to know that the death of their loved one was not meaningless, that other lives might be saved. They instructed us to take every organ that could be used.
This inspiring family demonstrated one other quality that wasn’t in my book: the healing power of humour and laughter. The girls told me with the greatest affection how father and son shared the same love of bad jokes and irreverent humour. They used this bond of humour, laughter and smiles to paint a vivid picture for me of the boy they had lost and to show me how much love and affection bound this family together. We shared tears of grief and laughter in equal measure.
My job on that day was to bear witness to the nobility of this family, who inspired us all with their love, their generosity, their compassion and their humanity. My brief time with them was unforgettable. I felt renewed in my belief about the innate goodness and courage of the human spirit.
The qualities I write about in my book are intended as lessons for those who are leaders, social and environmental activists, and for all those trying to build a better world. Latterly I realised that these values – compassion, non-judgment, non-persuasion, vulnerability, curiosity and a willingness to learn, generosity of spirit, and always looking for the best – are a foundation for healing medical practice. It was these qualities that allowed me to step aside from my technical role as an anesthesiologist and intensive care doctor and to be fully present to this family with compassion and humanity.
Without really knowing what I might have offered, it seemed to be what they needed at that time. We parted with hugs and tears as their boy was taken away to the OR. I felt incredibly privileged.
Healthcare is in crisis. The system is overwhelmed with too many sick patients and the health professionals are frantically busy, exhausted and burning out. Although we are all part of the caring professions, too often the workplace is a harsh place full of stress and ill-temper. Modern healthcare with all its technology and frantic pace of work somehow loses sight of the person in the patient and we neglect the care and compassion so important to healing.
In my thoughts about reforming healthcare, I write in my book about the power of being the ‘inner activist‘, not railing against the system but just showing up each day with kindness, compassion and generosity. When we bring our humanity to work alongside our technical knowledge and skills, we too achieve a nobility of purpose. In my own work, any day that I struggle to be fully present and compassionate I will try to remember this family and be inspired again. There seems no problem in the world that could not be overcome with such nobility of human spirit.
By Sunday, the hospital had quietened down; all the crises were resolved. I had the opportunity to visit my elderly patient, the one who survived septic shock. We held hands as we talked and I noticed his strong grip. I told him about the miracle of his survival and asked him what he was looking forward to. His one-word answer surprised and delighted me.
“Retirement!” he said. He’d apparently started a new and physically demanding job at age seventy-seven!
I lay awake for hours in the night, unable to fully process all that had happened in two short days, and wondering when my phone would ring to call me to another crisis. One thing seems evident to me. When it comes to life and death struggles there’s only so much that medical technology and skill can achieve. The miraculous survival of my two elderly patients is as much owing to the human qualities I bring to my work. In turn, my patients and their families had lessons for me in the noble qualities of the human spirit that have left me enriched and grateful.
In these dark days of political turmoil, nationalism, insecurity and greed it is these precious human quality of compassion, openness, curiosity, generosity and optimism that will carry us through. The darkness only shows us how precious is the light.
If you would like to reflect more on these ideas, my book ‘From HERO to HEALER – Awakening the inner activist‘ is available to you as a free gift. I just want to share with you lessons that might help you make the world a better place.