I recently lost a patient to complications from cancer surgery. He was in his fifties. A decent man with a cheerful spirit. He was a farmer who had interests in pumpkin husbandry! Having learnt new tricks to their value addition, he was often invited by the high and mighty in his location to give some advice to their farm hands.

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He presented to a county referral hospital with acute bowel obstruction. He was vomiting and could not pass stool. His belly distended under his watch, scaring him! By the time of presentation, he was almost bursting like an overinflated balloon. My colleagues assessed him and quickly prepared him for emergency surgery. They found cancer blocking his large intestines; which they resected and nicely stitched back the intestines. He had a stormy recovery, and by the end of a week, he needed another surgery to address a small leak that had developed where the intestines had been joined. The joinery was dismembered and an outlet created through the skin where the stool would now pour out. This would control infection and allow him to heal before it could be rerouted to its normal position. After this second surgery he got sicker, all his tissues swelling, making the stool outlet to sink under a ballooning sick potbelly. He was taken back to theatre for a third operation, to reposition the outlet. This was a difficult surgery, with all loops of intestines matted to one another and plastered to adjacent belly under wall. The surgery ended well. And the doctors were hopeful he could now recover. But he developed leakage of stool from his surgical scar. We call this a fistula, a condition where a hole develops in the intestines and faeces leak out and pour into the belly, eventually finding an outlet through the scar in the skin. Read More Noticing this, he was advised that he would not feed by mouth. He required all his nourishment through a vein. This would ensure there was nothing going into the intestines, hence reducing the pressure and volume inside of the bowel and allowing the fistula to heal. He requested transfer to the hospital where I work.
‘This is a difficult scenario. It will be resource and labour intensive. It will be slow and frustrating. People might give up. But we have to keep the fight. As long as we are moving forward, we shall accept even baby steps’, I made it clear when called to review him the morning of admission. The condition has a high mortality rate even in the best of centres. My colleague from a nearby county referral hospital tells me the institution’s mortality rate is 100%. The patient cannot eat, and even if they do, the food pours out of the intestines before it can be digested and absorbed. They waste away under your watch. Despite all your efforts.
So, for over a month we struggled with him, changing his dressing nearly three times a day. We ensured he did not take anything by mouth, preferring to give all the nutrients required by a drip, calculating his energy, protein, fat, vitamins, water etcetera. Balancing the urine he produced and whatever he leaked out to make sure we balanced the accounts of his body machinery. Sometimes connecting a powered suction tubing to suck away all the leak just so the dressing and bedding could remain dry; and he could walk. We even got a drug to slow down the amount of secretions coming from his intestines, to allow him to dry up and give a chance for the fistula to heal. Some days he would be bright and we would move him around in a wheelchair. Other days he would be so forlorn. He always had one constant question every time I saw him at his bed.
‘For how long’?
To which I would give the innocent answer, that I did not know.
It was a relief for me when the family sought the second opinion of a senior colleague. I sighed in anticipation of signing off from his care and handing him over to another surgeon. But the colleague looked at him, heard what we had done so far and informed the family that there was not much he was going to add. He opined that we could continue with care.
The fistula output started reducing. We gave him clear water gaggles and ice cubes to moisten his mouth when he complained of dryness. We thought we could see some light at the end of the long and tortuous tunnel. But then he just died.
After some experience, you can tell a patient during his last day. All tests are normal, all observations are better than those of other patients beside him. No fever, no racing heart. But the face just says this is the last day. I saw him in the morning and asked my team to move him to the high dependency unit where we could observe him closely. I asked for the relatives, just to tell them this could be the last day. To prepare them for the inevitable.
I was in theatre evacuating a blood clot from the brain of an old ‘msee’ who had come convulsing weeks after a boda boda accident when the phone rang.
‘He is dead doc. We could not revive him’, I had seen it coming.
For two months and more, he had survived on food through the vein.
After theatre I went online, just in time to read of a lady patient who had sued a doctor because she remained without eating for a whole day, in preparation for a procedure. I was full of angst! But what caught my attention was the disregard for the explanation that the surgeon who was meant to carry out the procedure delayed because he was caught in an emergency! The emergency could have been anyone of us. The lady should be proud that thanks to her one day of fasting, someone else’s life may have been saved.
But lo and behold, she won’t hear any of this. It is her constitutional right to eat! Well, my message to her is this: I am really sorry that your procedure was delayed. I am sure your doctor apologised and explained when he came to see you. Every doctor I know will apologize to a patient when such happens. Sometimes procedures projected to take short may take double the time, because the body structure is different, and we have to restart steps trying to figure out how differently your creator made you, different from those others we have seen and read about. Would you imagine the doctor abandoning you at this moment just to be in time for the next scheduled appointment?
We live in an interesting society where someone thinks they need a court of law to justify that they need to eat. Eating is such an instinctual reflex; even brainless creatures know when to eat. And from the look of things, perhaps she does not require the test anyway, we already know her personality might be the reason she was bleeding from her gut. So, much as the rest of the world joins in cheering her to sue the useless Kenya doctor while awaiting the magic worker from Cuba, I would like to tell her that we have patients who just wish they could swallow saliva, or suckle on an ice cube block to moisten their tongue.
Legalistically she is a star to her ilk, but moralistically she and all her cheer squad stink like a skunk. There are societies where countries are governed with no written constitutions. In ours, we need to invoke the supreme law to argue out common sense. I wish her success in her pursuit of her constitutional right to eat.
I would like to take this opportunity to publicly recuse myself from ever taking care of her in my lifetime. If you know her, kindly alert her to advise her next of kin as appropriate. I am already conflicted. For, faced with an emergency, I would prioritize it over carrying out a public relations gesture with a stable patient just because they are starving, in a hospital capable of taking care of patients for months without feeding them by mouth.
He presented to a county referral hospital with acute bowel obstruction. He was vomiting and could not pass stool. His belly distended under his watch, scaring him! By the time of presentation, he was almost bursting like an overinflated balloon. My colleagues assessed him and quickly prepared him for emergency surgery. They found cancer blocking his large intestines; which they resected and nicely stitched back the intestines. He had a stormy recovery, and by the end of a week, he needed another surgery to address a small leak that had developed where the intestines had been joined. The joinery was dismembered and an outlet created through the skin where the stool would now pour out. This would control infection and allow him to heal before it could be rerouted to its normal position. After this second surgery he got sicker, all his tissues swelling, making the stool outlet to sink under a ballooning sick potbelly. He was taken back to theatre for a third operation, to reposition the outlet. This was a difficult surgery, with all loops of intestines matted to one another and plastered to adjacent belly under wall. The surgery ended well. And the doctors were hopeful he could now recover. But he developed leakage of stool from his surgical scar. We call this a fistula, a condition where a hole develops in the intestines and faeces leak out and pour into the belly, eventually finding an outlet through the scar in the skin. Read More Noticing this, he was advised that he would not feed by mouth. He required all his nourishment through a vein. This would ensure there was nothing going into the intestines, hence reducing the pressure and volume inside of the bowel and allowing the fistula to heal. He requested transfer to the hospital where I work.
‘This is a difficult scenario. It will be resource and labour intensive. It will be slow and frustrating. People might give up. But we have to keep the fight. As long as we are moving forward, we shall accept even baby steps’, I made it clear when called to review him the morning of admission. The condition has a high mortality rate even in the best of centres. My colleague from a nearby county referral hospital tells me the institution’s mortality rate is 100%. The patient cannot eat, and even if they do, the food pours out of the intestines before it can be digested and absorbed. They waste away under your watch. Despite all your efforts.
So, for over a month we struggled with him, changing his dressing nearly three times a day. We ensured he did not take anything by mouth, preferring to give all the nutrients required by a drip, calculating his energy, protein, fat, vitamins, water etcetera. Balancing the urine he produced and whatever he leaked out to make sure we balanced the accounts of his body machinery. Sometimes connecting a powered suction tubing to suck away all the leak just so the dressing and bedding could remain dry; and he could walk. We even got a drug to slow down the amount of secretions coming from his intestines, to allow him to dry up and give a chance for the fistula to heal. Some days he would be bright and we would move him around in a wheelchair. Other days he would be so forlorn. He always had one constant question every time I saw him at his bed.
‘For how long’?
To which I would give the innocent answer, that I did not know.
It was a relief for me when the family sought the second opinion of a senior colleague. I sighed in anticipation of signing off from his care and handing him over to another surgeon. But the colleague looked at him, heard what we had done so far and informed the family that there was not much he was going to add. He opined that we could continue with care.
The fistula output started reducing. We gave him clear water gaggles and ice cubes to moisten his mouth when he complained of dryness. We thought we could see some light at the end of the long and tortuous tunnel. But then he just died.
After some experience, you can tell a patient during his last day. All tests are normal, all observations are better than those of other patients beside him. No fever, no racing heart. But the face just says this is the last day. I saw him in the morning and asked my team to move him to the high dependency unit where we could observe him closely. I asked for the relatives, just to tell them this could be the last day. To prepare them for the inevitable.
I was in theatre evacuating a blood clot from the brain of an old ‘msee’ who had come convulsing weeks after a boda boda accident when the phone rang.
‘He is dead doc. We could not revive him’, I had seen it coming.
For two months and more, he had survived on food through the vein.
After theatre I went online, just in time to read of a lady patient who had sued a doctor because she remained without eating for a whole day, in preparation for a procedure. I was full of angst! But what caught my attention was the disregard for the explanation that the surgeon who was meant to carry out the procedure delayed because he was caught in an emergency! The emergency could have been anyone of us. The lady should be proud that thanks to her one day of fasting, someone else’s life may have been saved.
But lo and behold, she won’t hear any of this. It is her constitutional right to eat! Well, my message to her is this: I am really sorry that your procedure was delayed. I am sure your doctor apologised and explained when he came to see you. Every doctor I know will apologize to a patient when such happens. Sometimes procedures projected to take short may take double the time, because the body structure is different, and we have to restart steps trying to figure out how differently your creator made you, different from those others we have seen and read about. Would you imagine the doctor abandoning you at this moment just to be in time for the next scheduled appointment?
We live in an interesting society where someone thinks they need a court of law to justify that they need to eat. Eating is such an instinctual reflex; even brainless creatures know when to eat. And from the look of things, perhaps she does not require the test anyway, we already know her personality might be the reason she was bleeding from her gut. So, much as the rest of the world joins in cheering her to sue the useless Kenya doctor while awaiting the magic worker from Cuba, I would like to tell her that we have patients who just wish they could swallow saliva, or suckle on an ice cube block to moisten their tongue.
Legalistically she is a star to her ilk, but moralistically she and all her cheer squad stink like a skunk. There are societies where countries are governed with no written constitutions. In ours, we need to invoke the supreme law to argue out common sense. I wish her success in her pursuit of her constitutional right to eat.
I would like to take this opportunity to publicly recuse myself from ever taking care of her in my lifetime. If you know her, kindly alert her to advise her next of kin as appropriate. I am already conflicted. For, faced with an emergency, I would prioritize it over carrying out a public relations gesture with a stable patient just because they are starving, in a hospital capable of taking care of patients for months without feeding them by mouth.