Tuesday, 28 February 2017

Mortality


David Deanshaw 

champagne

There was an air of concern in Martin Sheldon’s mind when Doctor Roger Browning said “you may get dressed now, there will be a slight feeling of discomfort until the dye passes through.” 

Hospitals are such forbidding places, especially for ordinary non-medical people.  For a start, there is that persistent whiff of antiseptic, which pervades the air.  Then the blood pressure thing – it is always higher when taken by a doctor – it’s called the “white coat” effect.  So what would happen with a barium enema? 

Would he speak to the patient now, or just say he would report to the surgeon without giving the patient any indication of his findings?

“Well Mr. Sheldon,” said Dr Browning eventually in a matter of fact way, “I should take care to put your affairs in order. I shall write a full report to Mr. Amber-Hill your surgeon.  He will make his own decision on the basis of what I have seen and will suggest.”

“Well what action is to be taken?” Sheldon inquired tentatively.

“Diet, hopefully, but if not - then surgery,” was the bland response from Browning, - he did not seem to care what the patient thought. 

“Is there an in-between option?”
“Yes, grin and bear it.”

“Come on seriously – what is the prognosis with surgery?”

“That is something for you to discuss with Mr. Amber-Hill when he has read my report, so you must ask him.  Do excuse me, I have an urgent appointment.”


Sheldon’s wife was waiting in the hospital car park, ready to drive home, when he got in.  “He has told me to put my affairs in order!  What do think that means?”

“He’s probably got to the end of a busy day and thought he would spice his own day up a bit.”

“Do doctors do that?”

“Sometimes, but he has obviously got you worried.  But he should not have said it anyway.”

Nora Sheldon used to be radiographer.  It was her in depth knowledge of the health service that had kept his almost complete lack of knowledge of the human body and its functions on some form of even keel throughout their marriage. Indeed she regarded her husband as a bit of a standing joke in that he had occupied his frame for over 60 years and did not have a clue how it worked.  She loved him deeply and had provided him with the occasional lesson in biology, a subject not done at his northern grammar school.  His cold analytical cutting edge was reserved to marketing strategies or market research. 

Her touch with patients had always been sensitive without becoming emotionally involved, especially in life limited situations.  “Most of us recognise that a patient is a statistic of one as far as they are concerned, yet we see these things every day.  Anybody who is trained to recognise symptoms of danger needs to have a human side.”  She assured him that there were very few senior people in medicine who did not care about their patients. Her experience had run to seeing a wide variety of professionals, so she was able to assure her husband that most radiologists were very professional, even sympathetic people.  “We are all trained to develop empathy with patients, particularly since we may be the first to discover a delicate or tragic truth.”

However, Dr Roger Browning was not such as these.  Knowing he had the name of a great poet was his only connection with sensitivity.  He was a clinical professional who felt he should have climbed higher, but there had been just one blot from years ago.

Today was just another day of dealing with those who would soon die, unless some drastic action could be taken. Some years earlier his over-reaction to diverticulitis symptoms had caused a major expense for the NHS operating system. When the patient died on the table, the surgeon claimed that the operation should not have been necessary had Roger Browning read the data in another way. The subsequent internal Inquiry had supported the senior surgeon’s argument that the data could have been read differently.  However since Browning had already achieved his PhD having written a thesis on just that topic - the interpretation of data - the findings were therefore a whitewash.  Browning kept his job and the surgeon moved away in high dudgeon. A bedside manner was for nurses not a scientist.  He would just do it for the money now. 

Martin Sheldon had suffered the pain for some months, but it had been intermittent. Sometimes it was searing; sometimes just a grumble.  But he had had a life time of pain over his 61 years.  TB had cost him his right kidney, in-growing toe nails trampled on during his sporting life leaving him with deformed feet, and then in his 40s, asthma and gout had ended his playing career.  Cricket had been the only sport he had played to any representative standard.  All of this made him determined to enjoy what was left of his life. 

Such was Martin Sheldon’s luck.  

Now he had a new problem. 

The wait for the call for an appointment with the surgeon was not long in coming.  The real concern was that it arrived first thing on a Saturday morning.

“Mr Sheldon, could you come in first thing on Monday.  We have a full clinic but Mr Amber-Hill would like to see you before he starts, could you manage 8.00?”

Martin was not a man given to panic but the off-hand manner of Dr Browning and the urgency of the call suggested that there may be some cause for concern.  Nora, his wife, was less concerned – “”It could be that he is off on holiday soon and wants to get you over with.”  Martin thought that she did not really sound convinced herself.

The surgeon stood up to shake hands when they were ushered into his consulting room.  It was a bland place, with white walls, a modern desk and a couch in the corner.  It could have been any private hospital anywhere.

“Good morning Mr Sheldon, Mrs Sheldon.  I am pleased that you were able to get here so early.”  Briskly, he opened an ordinary looking brown file which contained the X-Ray films of the barium enema.

“I would like to show you the x-ray films as well as this picture. Mrs Sheldon, I gather you used to be radiographer, so you will be familiar with what we have here.”

His manner was calm and knowledgeable.

The picture appeared to be a photograph of what looked like a large grapefruit, only its colour was pink with orange tinges.

“What is this?”  Sheldon asked nervously.

“I don't know yet.  But it is in a difficult area to reach.  It is near the junction of the large and small intestine.  Your wife will know it as the ileocecal valve. This is a sphincter muscle of some significant importance.”
“Is that what you have found inside me?”  Sheldon’s voice became very hoarse. 

“I do not wish to frighten you into thinking that it is really the size of a grapefruit. I have magnified it 100 times so that you will be able to understand.  Not every patient has a wife or husband who would know these terms; you are a very fortunate man.”

“But what does it mean?  How long have I had this?  How will you deal with it?  Why did Dr. Browning suggest I put my affairs in order?”  The questions started to flow. 

The surgeon raised his hand to call for calm and then asked for it:  - “I want you to be very calm whilst I explain what the options are – is that ok?”

Sheldon nodded and sought his wife’s hand for consolation. He felt her grip and realised that she too was concerned.  She squeezed his hand gently more than once to soothe him.

“Because it is where it is, I cannot reach it easily. Many cases of intestinal surgery can be resolved either by approaches from either end or sometimes with key-hole surgery. Sadly not in your case.”

“Well what are you going to suggest?”

“At its simplest, that I cut it out.”
“Is that a simple operation?”  The words croaked out of Sheldon’s mouth.

“No operation is simple, but it is really is quite routine these days.  Bowel cancer has been known for some time and the procedure is quite straight forward?”

“But in view of the location, is this not a little more complex?”  Nora asked tentatively.  The very mention of the word cancer was a shock to both of them.

“Yes it means that I will need to cut quite a length of bowel to be able to ensure that there is no peripheral damage and hope to be able to do a simple plumbing repair.  It is the location which is the cause of the major surgery.  If you like to take off your shirt and lie on the couch I will point out where the incision would need to be.”

Sheldon did as he was asked. “What about this suggestion about putting my affairs in order?”  Lying there he felt vulnerable and slightly helpless.

“Well it was perhaps a bit early for him to have said that, but he is very clear in his view that although we do not know whether this polyp is malignant, nor do we know how old it is, it is necessary to remove it.”

“So he was being alarmist?” the question was urgent.

“No.  And I am also going to suggest that you put your affairs in order. I must just tell you that nobody has died on my table for over ten years, but that does not mean that it would never happen.  I am sure that all will be well.  But, please, please, be under no illusion, this is a complex operation by virtue of the difficult location.  It means major surgery and a lengthy recuperation. I will not minimise the danger. Looking at these notes, I see that your heart is strong that is a major boost to the process. And I have done it before – many, many times.”

“Is there an alternative to surgery?”  Sheldon croaked his question with real difficulty.

“Simple – you will carry a colostomy bag for the rest of your life – no major exercise, no sudden excitement and above all, no sex. This is not like replacing part of an exhaust pipe – the intestine is a sensitive tube.  I can cut out the infected part easily, but cannot guarantee to join the ends successfully. If the join fails, there will bodily sewage sloshing around your inside with the potential of infection, without any chance of scientific monitoring.  Is that a risk you are willing to take?”

The devastated couple were dumbstruck. Silence reigned.

“You need to recognise that at your age there are things you can no longer do, so using one’s imagination is a good substitute. I had a similar experience with another patient some time ago and since he started to use his imagination, he can be an Olympic swimmer, score 100 goals a season and write best sellers.”

Martin Sheldon pondered on these words, part in shock, part in anger and perhaps most of all in resignation.

“I can do the operation three weeks on Monday. Will you have sorted family matters by then?”


The journey home was depressing.  The turmoil of so much still to achieve and now the prospect of an early death initiated a major headache.  He had overcome migraine years before, but this shock brought on a major throbbing in his temple.  Sheldon’s knowledge of logistics came to his rescue.  He sat quietly in his study and started a series of lists.

Wills, family trusts, finance, shares and investments were all suddenly major priorities.  The farewell letters would really take some thinking and writing.  Then, the impact on his business; short term whilst he was hors de combat; longer term, the business would close.

Then the more difficult issue – what if... he did not survive?

“Sorry to hear about this Mr. Sheldon, but I can see you and your wife on Wednesday.  If you could let me have some details in advance by email, I will have some thoughts to present to you. Shall I prepare a Power of Attorney as well?”  Bernard Bridges had acted for the family in the amendment to their wills five years earlier.  He was a kindly man, despite his relative youth.

“Yes whatever you advise, thanks, we will be with you at 10.30 Wednesday.”  A solemn response from Sheldon.


“Look darling, these operations are routine now.  When the Almighty is ready for you, He will decide.  In the meantime we must tell the kids and they should be made to understand how serious this is.  It would be helpful for them if you could be strong and not become morose.”  Nora, practical as usual, tried to hide her own anxiety.

“Can we arrange to have dinner together on the Sunday before?”  The request had a pathetic ring to it.

“Why don’t you choose the menu?  Remember that after breakfast on Monday there will be nothing until about Friday!”

“I will lose some weight then?”

“That’s good – keep being positive darling!  Remember only last month we were talking about how you would toast your beloved daughter at her wedding next year.  Then there is your season ticket at Aston Villa when you and our son would bond even more. What are you planning for this evening?”

“I will sit down at my desk and set out where you should look for various papers if it all goes wrong.  Then I suppose I will try and write some letters.”


“My darling, if you are reading this, the operation will have failed.  Please remember that I loved you more as the years unfolded.  It just got better and better.  Thank you for the children and all the care you have lavished on me and above all for being my best friend.  All my love.  Martin.”

The tears had poured as he typed, knowing the same would happen when he penned some thoughts for his daughter, the apple of his eye; and his son – the only one to carry on the family name.

Sheldon ended each day on his knees.  He was not sure just how much faith, if any, he really had.  At this stage, perhaps it was not worth taking any unnecessary risk.  How well would he sleep was uppermost in his mind.


Monday morning dawned with golden sunshine just after six as usual in August.  He was not required to report to the hospital until after lunch, having had breakfast and then nothing from nine o’clock. Why not try and sleep?  It was a hopeless thought for a man who believed that this day may be his last.

Promptly at one thirty, Mr Amber-Hill bustled into Sheldon’s room, armed with a file accompanied by a nurse wheeling a blood pressure machine. “I hope you have settled in and are comfortable.” It was not a question, merely a statement of fact. “I cannot predict how long I will need for your procedure, so you are at the end of my list – probably five thirty-ish. Do try and get some sleep. I would like you full of strength – the anaesthetist will be here to discuss some practical issues with you and so on. Have you anything you wish to ask me?”

“Yes, I suppose I have – for the sake of my family, how confident are you?”

“I did say that I have done this sort of procedure many times. Unless this lump is malignant and more importantly soft, I do not expect any problems at all.”

“And if it is either or both?”

“Please stop worrying.  I know my business!”  With that he left.

The nurse moved closer and brought the machine alongside the bed.  “Let’s take your blood pressure,” she said gently. “You know he really does know his business, it’s just that he has a long list and two of the patients may not last the week unless he removes some malignant growths.” She said assuredly.

“Is that what they still called – growths?  That’s how they were referred to years ago.”

“I just used that term because I was not sure how much you understood.”

Sheldon knew she was obviously trying hard. “Just breathe normally now whilst I measure your blood pressure.” She wrapped the pressure bandage around his bicep. “That’s good – it’s a bit high but only to be expected.  Let me find a vein now, so that we can put you to sleep when the time comes.” She did so easily and placed her hand on his sweating forehead. “He really is the best. You are really lucky to have him.  Now see if you can get some sleep.”


At 1.45 a man in a white coat appeared. “Hello Mr Sheldon, my name is Dr. Graves; I am going to put you to sleep later on.  Tell me, are you allergic to anything?”

“Just bossy women,” he offered trying to be brave.

“Good, just let me give you a little shot now to relax you.  Then I will see you later on.  Sleep well.”  Then he was gone.


5.30 came and went.

6.00 came and went.

At 6.15 another man opened the door, this time wearing a green coat, carrying to clip board.  “Mr Sheldon?  Just confirm your full name and date of birth.” He ticked some boxes on his clip board. “Right – it’s your turn now. Just relax.”

The bed was wheeled through the door, along the corridor at a pace faster than expected; they reached the lift, the door opened immediately.  The lift doors closed and then went down two floors.  The lift doors opened.  A blast of cold air met the trolley on which he was lying.

“Right Mr Sheldon,” Dr Graves lifted Sheldon’s left hand and said, “This will bring a chilly feeling for a moment.  Just give me a nod as you feel the cold along travel your arm.”

Martin Sheldon nodded slowly and his eyes closed, perhaps for the last time.

Twelve hours later, in intensive care, he realised that the Almighty still had work for him to do.

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