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Sunday journal: A truce in the battle to conquer the night

By AMANDA LUCHSINGER
Published May 7, 2006


By AMANDA LUCHSINGER

Sometimes the truth is heard only in the dead of night, when the ebb of life is at its clinical nadir, a time when the very ill, or the very old, let go and die.

In a teaching hospital, the dead of night belongs to the lowest level of the medical staff: the bemused medical student and the weary intern, who answer the endless pages, pad softly to the side of the struggling patient, run frantically to a code blue, and sleepily fulfill the urgent requests of the better acclimated night nursing staff. The fledgling doctors survive by dreaming of the end of their 36-hour shifts, and of fresh air, buoyed idealism, or simply shuffle around numbly, clutching a foam cup of third-shift coffee.

I still see Mr. B as if lit upon a stage, lying motionless in his intensive care air-bed, his dark skin illuminated in an eerie blue glow by his overhead night lights, and his chest undulating gently to the command of his ventilator. Around him, in the shadows of the intensive care unit, lights blink and pumps hum and beep, while plastic tubes twine about his wiring, and each other, like vines that suck at the recumbent patient, their ends trailing off into the technojungle of the ICU. There is a distant mutter and occasional harsh cackle of night nurses chattering.

Mr. B was far from his native jungle. He was African, the victim of a liver-chewing virus, and now the recipient of one of the early liver transplants, a life exchanged for a life, a miracle of modern medical technique. All had not gone well with his surgery; his postoperative course had become legend throughout the transplant unit. We whispered of the record-breaking 142 units of blood that had kept him alive when his new liver had abruptly and inexplicably clotted off its arteries at the end of his 12-hour surgery and had to be removed. We cheered the supreme hunting ability of his surgeons, who, with only 72 hours allotted them, triumphantly flew in with a second organ match, a liver freshly sliced from the bowels of a hapless motorcycle accident victim, and sewed it into Mr. B's gaping abdominal cavity - a second life exchanged for a life. We shuddered at the aftermath of the surgical delay: the swollen organs and tissues now preventing closure of the massive abdominal wound, so that his belly had to stay open, nylon mesh covering the pulpy, quivering red mass of his intestines, as we waited for the swelling to subside.

Day after day, I stood at his bedside, dutifully transferring columns of laboratory results onto his wall chart. We monitored every molecule of his sodium and potassium and carefully tended his magnesium level, smiling with relief when his liver-function tests improved. I breezed in on my daily rounds, asking the rhetorical "How are you today?" expecting and receiving no answer but the sigh of his ventilator. I patted his arm, or such portion of it as I could reach without disturbing his tubing, and spoke encouraging words to his quiet wife as she sat there, draped in her traditional African garb, often accompanied by their two young sons. She clutched her shama anxiously when he left his room every two or three days, called by the surgeons to the operating room, where they tugged the frayed edges of his abdomen closer together, re-igniting his pain, so that his restlessness had to be quelled with increasing doses of the merciful narcotics.

Weeks passed, and Mr. B had inched his way toward an intact abdominal wall. Only a few patches of nylon mesh remained visible in the war zone that had been his belly. The surgeons deemed it time to remove his ventilator, and we watched him cough and hack his way to independent breathing. Mostly, he slept deeply under the influence of the narcotics that cooled the slow burn of his wound. At times, I would enter his room at night and see him staring vacantly at the ceiling. He said nothing, voice and vocal cords weakened by the trauma of intubation, we assumed. We still asked the rhetorical "How are you?" question, and went about our business, determinedly saving his life.

We fought on together, medical team and patient. We poured vast quantities of antibiotics down his intravenous tubing, battling the attack of bacteria, while he lay racked with fever and chills the bacteria induced. We checked and rechecked every rejection parameter and every drop of medicine. He turned his head and looked expressionlessly at his visiting family, while his wife sobbed softly into her head scarf. The patient seemed to stabilize, and the legend of his and our fight for his survival grew and grew; he had to make it.

Finally, it was in the dead of night, as I shuffled my weary way across his room at 2 a.m., that Mr. B told me how he really was. I stood entering the day's last tally of bewildering laboratory numbers into his chart, when restless movement behind me caused me to turn and look at the bed. He was straining to lift his head, at last struggling to speak.

"What is it?" I asked, "do you need more pain medicine?"

"Please," he wheezed, his voice fading away to a croak.

I swabbed out his dry, cracked mouth with a handy oral sponge, and bent my ear closer, thrilled to be the recipient of his first communication.

"Please," he wheezed again, succeeding at last in forcing out the words, "please, kill me."

-- Amanda Luchsinger practices internal medicine in Dunedin.