Confessions of a GP

Dying

Our frequent close proximity to death and dying is perhaps one of the features that sets doctors apart from people in other professions. For most people, death is fairly sanitised now. It is rarely seen in its gritty reality and many people of my generation will never have seen a corpse or even somebody very ill. The constant exposure to something that most people would find very shocking can’t help but take its toll on your personality and outlook on life. Of course, we don’t suddenly acquire these characteristics upon passing our final medical school exams. Death and dying become gradually normalised as we are processed through the system of medical school and our first hospital jobs as junior doctors. In our very first week at medical school, we were cutting up corpses in the dissecting room. This was partly to learn anatomy, but also an attempt to give us an early exposure to death and help us learn to distance ourselves from it emotionally. I know that I must have normalised dying in my head because, although I have seen hundreds of people die, I can only actually remember one or two of them. Perhaps I’m particularly callous or have an exceptionally bad memory, but as I’m sitting here now racking my brains, I can recall very few of the names or faces of patients whom I have watched breathe their last breath.

Although I now feel very unsentimental towards death, the first patient that I watched die is etched very strongly in my memory. I can picture her face very clearly and I can even remember her name but I’ll call her Mrs W. She was an ordinary 60-year-old woman who had woken up as normal that morning. She had felt fine and had been getting herself ready for what she had expected to be a fairly average day. Somewhere between breakfast and getting ready to pop to the post office, her aorta burst. The aorta is the main artery that runs from the heart, so as you can imagine having it spring a leak is bad news. It was my first hospital attachment as a medical student and I was hanging around A&E trying to learn something and not get in the way. As a third-year medical student, I was in a strange void between being a normal person and being a doctor. I’m fairly sure that no other nurse or doctor who was working that day will have any memory of Mrs W because it would have been just another day at work. But for me, it was all very new and shocking and I still remember the episode in distinct detail. I was seeing death in the way a non-medical person might see it and not from the perspective of the hardened doctor that I am now.

When Mrs W’s aorta ruptured, she had a sudden pain in her abdomen spreading to her back and began to feel faint. She called an ambulance and after the casualty doctor felt her tummy and saw her blood pressure dropping, it became fairly clear that she had burst her aorta (known as a ruptured AAA – abdominal aortic aneurism). She needed an emergency operation and there were all sorts of people flapping around organising scans and getting the operating theatre ready. As a medical student, I had the advantage of not having my own role or job to do. I could just sit with the patient and take it all in.

During the following ten minutes, several more doctors arrived, prodded her tummy and spoke among themselves. Despite being very unwell, Mrs X had been alert and conscious through the whole ordeal. Nobody had really had the chance to tell her what was going on, but from the commotion occurring around her it was obvious that things were serious. She lay in bed connected to drips and monitors, yet stayed calm and immensely dignified. Her husband and daughter were sitting on either side of the bed, each holding one of her hands. The consultant surgeon soon arrived on the scene. He was a big burly man and was already in his surgical blues as he barked instructions at the nurses and junior doctors. I felt a pang of fear just by being in his presence. He marched over to Mrs W, sat down at the side of the bed and took her hand.

‘I’m Mr Johnson and I’m going to be operating on you this morning. You have burst the main blood vessel that runs from your heart. If we don’t fix it, you’ll die. If we do an operation, there is a 50 per cent chance that you will survive.’

The words on paper look unbelievably harsh but Mr Johnson spoke them with an amazing air of calm and gentleness. He refused to be distracted by the surrounding mayhem but instead focused all his attention on Mrs W and her family. Sitting and watching, I was overcome with an amazing sense of how her life lay so tightly in the balance. She could sit up and talk and see and hear, but hidden beneath her skin, she was slowly bleeding into her abdominal cavity and ultimately dying.

‘It is a major operation and we will need to replace the part of the burst vessel with a synthetic tube. After the operation, you may be in intensive care for some time. We’re going to wheel you into surgery and start operating straight away. Do you have any questions?’

Mrs W and her family shook their heads. As the porter came to wheel her into surgery, she took back the hands of her daughter and husband. I assumed that she would say goodbye, tell them how much she loved them or at least leave them with some poignant words. Instead, she listed a series of instructions. ‘There’s some mushroom soup in the fridge that needs using up and your dad is running low on his athlete’s foot powder. I owe the window cleaner from last week and don’t forget to send a card to your auntie June on Tuesday, as it’s her birthday…’ The list of nonessential instructions continued right up until the anaesthetist put her to sleep. I wanted to shake her and say, ‘Don’t you realise what’s happening? This might be the last time you see your husband and daughter! Don’t you want to say goodbye?’ I guess we all deal with things differently and this was the way that Mrs W dealt with what must have been an overwhelming and bewildering experience.

I changed into surgical blues and went into theatre. About halfway through the operation, Mrs W’s heart stopped. It was bizarre watching them do CPR on her chest when her abdomen was lying wide open. Her heart never restarted. The surgeons changed out of their surgical clothes, told her family the bad news and then carried on with their day. I imagine they barely gave her death another thought.

I, on the other hand, was quite upset by Mrs W dying. It played on my mind for several weeks and I thought about her a lot. She was the first patient that I had watched die and although she was ultimately a stranger, I felt quite upset. I have never felt that way since about a patient dying. Sometimes I wish I could get that fresh and almost innocent compassion and emotion back. In some ways it would probably make me a more empathic and caring doctor, but at the same time if I felt like that about every patient who died, I would have had to give up the job years ago.