Chapter 8: Crisis and death

‘What is myocardial infarction, Doctor?’

The receptionist told me a patient on the phone wished to speak to an independent doctor in our practice about an urgent problem. The distressed woman’s opening words were: ‘What is a myocardial infarction Doctor? I simply have to speak to you about it; I’m too embarrassed to speak to the doctors there that I know.’

The story unfolded. Her husband, aged 56, had been treated by Dr A for hypertension. Her doctor was Doctor B. Twelve months ago Dr C saw her husband at home early one morning because he had chest pain. Despite attempted resuscitation after a cardiac arrest in the ambulance, he was dead on arrival at the hospital.

Everything happened so suddenly that she did not have an opportunity to speak to a doctor at the time but assumed her husband died from a heart attack. However, a copy of the death certificate that stated death was caused by ‘myocardial infarction’ confused her. She had mulled over this for the past year. Her catharsis began: ‘How could he have died in this modern day of wonder medicine? Why didn’t Dr A warn us this could happen? If only I could have spoken to one of the doctors. If only I’d known exactly how he died. I have felt like killing myself, I’ve been so depressed. I feel so bad about the way I looked after him’.

An erroneous death certificate

A patient consulted me last year, distressed and angry about the death certificate issued after her husband’s death. She said, ‘This certificate is wrong. It’s an illegal document. It’s a lie—Ted did not die from septicaemia after bronchopneumonia—he had a heart attack’.

Ted, who had a history of ischaemic heart disease, was found semiconscious with a blood pressure of 80/40 and a temperature of 38 °C. When hospitalised, with a provisional diagnosis of septicaemia, he was treated with intravenous antibiotics. He developed heart failure and died 48 hours later; the resident doctor issued the death certificate. Later, a post mortem revealed an extensive myocardial infarction.

Her grief and hostility towards the doctors at the hospital were profound. ‘Doctor, the diagnosis is wrong. The treatment was wrong—you will have to change it.’

The unreal image of the great hospital

‘Doctor, would you please call on Mum? She is in a terrible state over Dad’s death, although it was four months ago.’

Dad was a 72-year-old farmer who developed pyloric stenosis after a long history of peptic ulceration. He was admitted to a major teaching hospital in the city, under the care of a surgeon. His postoperative course had been good until a tear developed in the lower oesophagus following an episode of vomiting. After a high spinal anaesthetic on his third visit to the theatre, he became hypotensive and was admitted to the intensive care unit, where he died 16 days later.

When I called to see his widow I was taken into the dining room. A mass of medical bills was spread out on the table and several relatives looked on solemnly. The sum of the accounts was astounding and made me aware of my ignorance of some aspects of the health system. Apart from the surgeon’s bill there were bills from the surgeon’s assistant, the anaesthetist and the director of intensive care (51 items), and five other consultant visits that totalled a substantial sum. The hospital services included haematology, biochemistry, radiology (including 28 chest X-rays); microbiology (80 items). With other services, including bed charges, the grand total was more than $35 000.

‘Doctor, how could he have possibly died after all this expert care, in this day and age? What went wrong? Why do they send all these bills?’ They were pensioners but, acting on my advice, had obtained private health insurance.

Counselling was almost impossible. Depression, grief and anger dominated the family’s emotions. The breakthrough was a special visit to the family in the country by the surgeon. He explained what had happened and why modern technology and skilled medical practitioners could not save their husband and father.

Neil was one of my first patients when I commenced general practice in the country. He was a tall, athletic, handsome man of 22 years, more than 190 cm tall, and already married with a baby son.

The problem with which he presented was a 10-month history of persistent headaches early in the morning, increasing in severity and now waking him. The headache was dull in nature and, although diffuse, was mainly occipital in site. It was aggravated by coughing, sneezing and straining at the toilet. It was relieved by aspirin and tended to abate during the day. Associated with this were problems of dizziness when arising, and vomiting during the week that preceded this initial consultation. He had visited two doctors several times and they believed that the problem was related to stress and possibly to a previous neck injury. During the past six months he had been receiving chiropractic treatment.

DIAGNOSIS

A provisional diagnosis of an intracerebral tumour was made and this was supported by the presence of papilloedema upon the ophthalmoscopic examination of his ocular fundus.

He was referred to a neurologist and investigations confirmed the presence of a space-occupying lesion in the left temporal lobe. During surgery a large inoperable astrocytoma was found. It was biopsied and as much as possible was excised. A course of radiotherapy began after the operation.

When Neil arrived home, the community was stunned to see the zombie-like man with his stark, shaven and scarred head bearing testimony to invasive and futile medical intervention. His young wife and his family were shattered by the death sentence coldly conveyed by the neurosurgeon: ‘There is nothing further we can do; he has about three months left—possibly six at the most’.

The week of his return I was called urgently to his home to find him still in the throes of a grand mal convulsion. Intravenous diazepam was necessary to terminate the problem and subsequently phenytoin sodium was prescribed.

Immediately after his next outpatients review the family clan appeared on my doorstep—Mum, Dad, brothers and sisters. They were very angry and desperate. They said that they would try everything in their power and stated that they had made tentative arrangements to send Neil to a special clinic in Mexico where he could receive the ‘wonder drug’, laetrile (vitamin B₁₇). They also discussed the possibility of sending him to a cancer specialist working in New Zealand. They had mentioned this plan to the doctors in the outpatients’ clinic and were berated angrily for contemplating ‘such nonsense’.

My inexperience was now apparent and I found this problem threatening; I asked them to give me two days and then I would contact them. The phone bill soared as I contacted experts around the country. I then informed the family that they should save their money because the results of treatment for cerebral tumours were poor. However, I told them that Neil could acquire the therapeutic dose of vitamin B₁₇ by ingesting 15–20 apricot kernels each day. They all seemed satisfied by this compromise and so poor Neil chewed the bitter kernels every day.

I agreed to make home visits each week to encourage him and his wife with positive thinking and support. To our amazement, instead of arranging a funeral six months later, we were arranging his driver’s licence, an easy job and even Australian rules football. In fact, we were wondering if the tumour had been cured, but eight years later he started to have convulsions again, deteriorated gradually and died at the age of 31, leaving a wife, three children and happy memories of at least seven years of good health after the operation.

Glimpses of a cruel world

The local Health Officer met me outside the house. ‘She’s a widow living alone … a recluse … she’s boarded up all the windows and locked herself in … hasn’t paid gas, electricity or water bills for months and so all those services have been stopped … the folk next door sell her water for 50 cents a bucket,’ he paused. ‘Bit of a health hazard now.’

He produced a key and a powerful torch and led the way. Inside it was as dark as the tomb. He forced the shutters open and suddenly daylight flooded into the living room, which presented an extraordinary sight. Furniture was piled and stacked so that you could barely move, with new bird cages and an ironing board propped against a grand piano. And everywhere giant black cobwebs. ‘She’s a compulsive spender … here she comes.’

A fantastic sight met our eyes. Two very white human legs wriggled in mid-air in the beam of his torch. Then the feet found their way to the floor. An adult torso now started to worm its way backwards out to the waist-high tunnel. Eventually a woman dressed in black stood up. ‘Good afternoon,’ she said, in an exquisitely modulated English voice.

‘Good afternoon, Mrs Digby’, said my companion. ‘She lives down there,’ he said. He shone the torch down the tunnel, which proved to be constructed of furniture and roughly floored with cushions. ‘There’s a kitchen at the far end,’ and I could see a mongrel-looking dog tethered to the gas stove.

‘But how …’ I began.

‘There’s a back door leading to the yard’, he said. ‘They both use it!’

‘And how are you, Mrs Digby?’

‘If I’d known you were coming I’d have had the kettle on,’ she said demurely.

‘She’s not pregnant, Doctor’

She lay back wanly against the pillows, a white-faced married woman aged 30. I was doing a short-term stint at a small town hospital. She admitted to few symptoms.

‘I just feel exhausted’, she murmured softly. She was breathing quickly, but heart and lungs seemed normal to my examination.

‘I’ll just check your tummy’, I said.

Some instinct made me lift the sheet. Between her legs was a severed umbilical cord.

‘You’ve just had a baby’, I announced naively.

‘Oh no, Doctor’, she replied. ‘I’m not pregnant.’ Further questioning elicited further denials.

Her husband would have been forty-ish, and looked grey and tired. ‘Oh no, Doctor, she’s not pregnant’, he maintained. And then added, by way of oblique explanation, ‘I work nights, you see, and she’s on days.’

‘Has she perhaps been in another hospital?’ My tone must have sounded dumbfounded.

‘No—she’s just been at home with me.’

The woman police constable seated at the bedside looked incongruous in the little hospital ward. At home, in a suitcase, the bodies of twin boys had been found, their heads showing signs of severe contusion where they had struck the tiled floor of the bathroom.

I attended the post-mortem on the babies, done by a well-known forensic pathologist. ‘One of the more heart-rending crimes, I always think’, he said. ‘Infanticide—and you wonder why it isn’t commoner than it is.’

Trying to catch the bus

I was on casualty duty in the same hospital. An elderly man had just walked in.

‘I was just trying to catch the bus’, he said forlornly. He held out a hand. At first glance the thumb appeared to have been almost severed. In fact some skin and, mercifully, a core of tendon and connective tissue were still holding it on. This was well before the days of microsurgery. As I bent over to infiltrate, I noticed that his pain responses seemed satisfactorily dulled. He had a bland, facile grin on his face, and it was the face of a man in his late 60s.

‘I was running behind and tried to jump on,’ he explained. As I worked on I noticed that he seemed insensitive to pain, even in areas where I had not injected local. I had been qualified for all of eight weeks, and my mind wrestled with a diagnosis. I finished my needle-work and stood up.

‘I want you to come back tomorrow for a fresh dressing,’ I said, putting what I hoped was a friendly reassuring hand on his left upper arm as I did so. To my dismay his left humerus ‘clunked’ with an extraordinary display of crepitus and was clearly broken. Yet he did not even wince!

‘I think you’d better sit down again,’ I said. I wrote a letter referring him to the nearest public hospital. An ambulance could take him at once.

A further emergency had just come in, and Sister was tugging at my arm. I ended my letter with the words ‘… I have not checked his femurs’.

You’ve guessed it. He had a fractured femur as well. And the cause of his anaesthesia? I never discovered.

VISIT 1

‘For God’s sake, Doctor, can you come immediately to Jack’s place? It’s Bert calling. Please come quick—it’s a matter of life and death’, was the dramatic phone call that interrupted my morning surgery. The urgency and drama from Jack’s brother was so compelling that I excused myself with apologies to the patients in the waiting room (a common event in a country practice) and sped towards Jack’s humble shack in the bush some 18 km away. Jack was a 58-year-old bachelor, who led a virtual hermit’s existence tending his considerable variety of animals.

My heart sank as my speeding car momentarily lost control, when I rounded a sharp bend with poor camber on the winding road to his shack in the hills. I then recalled my father’s advice that ‘a smashed-up doctor would be more than useless to a dying patient’ and travelled at a more realistic speed.

When I pulled up by the shack in a cloud of dust I was greeted by a pack of excited dogs and Bert, who said, ‘It’s not pretty, Doc’. I then realised that I had been monumentally misled. Poor old Jack’s corpse was beyond resuscitation. He had been dead at least 10 days and his decaying flesh was being eaten by his starving dogs.

VISIT 2

‘Doctor, could you come down and help us. There’s an elderly lady who’s really sick and can’t wake up or something. She’s with an elderly citizens group from Melbourne’. This was the urgent call from the ranger in charge of a recreational park, which was a popular day picnic spot for city people. ‘Hypoglycaemic’, I thought.

It took me 20 minutes to reach the park where the scene that greeted me was quite extraordinary. An elderly lady sat alone in a folding chair as though asleep in the middle of an area with about three hundred people standing back in a circle at least 30 m from her (Figure 8.1). I wondered if an explosive device was on her person, but the poor dear was sleeping peacefully and permanently. As I approached her the mass closely followed me, ‘We don’t know her—she has no friends or relatives with her. Is she going to be all right?’ Guess who knew she was dead but was denying it? And guess who spent the next two hours of his precious time organising the unhappy formalities? I often reflect that in real life I would have loved to have known her and spoken with her.

VISIT 3

On another occasion I received an urgent call from a farmhouse by the local dam, a huge expanse of water that provided water for part of the metropolitan area and also for local consumption. The caller said that there was a fisherman who was extremely sick and unable to be moved, and that his friend needed a doctor urgently. As there was no local ambulance stationed in our town I travelled to the area, whereupon I was led on a long and arduous snake-infested trek that only fisherfolk seemed prepared to undertake. Ninety minutes later I reached a very dead person, who had died suddenly from a myocardial infarction doing what he loved best. His companion said, ‘I feared the worst but you never know’.

VISIT 4

Sweet gentle old Mrs C rang me at 6.15 am to request a home visit because her husband George seemed so cold in bed and would not rouse. Sensing the worst, I sped to the neat homely abode where a rather composed and matter-of-fact lady led me to George, who had obviously been dead for several hours. I asked her to wait in the kitchen as I went through the motions of resuscitation for five minutes and then went out to solemnly inform her that ‘I couldn’t save him—I think he must have stopped breathing just as you noticed him cold’. ‘I thought it was too late’, came the reply.

The saddest and most haunting memories of my professional career are the deaths of children, which seem to be like beautiful buds of a flower snapped off so prematurely and cruelly. The following experiences encountered while working in the accident and emergency department of the Royal Children’s Hospital are self-explanatory.

• The 18-month-old daughter of a busy medical family arrived one evening with severe burns to 80 per cent of her body, caused by being placed in a bath of piping hot water by her 9-year-old sister who had the task of bathing her. Her agony was eventually ended by her death in hospital.

• DOAs of 2-year-olds found floating in the backyard swimming pool and others crushed by their parents’ car in the driveways of their homes were so distressing, especially for the parents. I can never forget the case of a 3-week-old baby in a carrying basket who was run over by the mother in a car park as she reversed the car over the basket, after absent mindedly forgetting to place the basket in the car when she loaded shopping items into the car boot.

• A 3-year-old died from injuries received from falling off the roof of a house after climbing a ladder left against the house.

• Epiglottitis (thankfully rare now with Hib immunisation), croup, asthma: deaths from these lethal respiratory problems seemed commonplace. In one month I encountered four DOAs from epiglottitis, with one child arriving with a piece of tubing from a Litmann’s stethoscope acting as a tracheostomy, which was bravely inserted by a general practitioner who accompanied the child in the ambulance.

• Acute gastroenteritis in infants: now there’s a problem that is real and often underestimated. In some instances death or severe illness occurred from inappropriate advice, including giving saltwater or copious amounts of lemonade to the infants to drink.