Examining the Deceased Person

Two weeks into my medicine rotation, and I’m really starting to enjoy it. It’s a refreshing change from the mundane stuff I was doing in orthopaedics anyway.

Finding out that I would start medicine as the night ward call RMO on the last week of orthopaedics made me a tad bit apprehensive though. My apprehension was unfounded however, as the nights had seemed to be going well. I’ve got a very friendly and reliable registrar, and the tasks I’m asked to deal with are manageable at my current level of knowledge.

Perhaps one of the amusing things I’ve done so far, had been examining a deceased person. Prior to this, in the one and a half years of working, I’ve only come across one deceased person as an intern. And that wasn’t the greatest experience. But that’s another story for another day.

Anyway, I got phoned by one of the nurses asking me to confirm the death of one of the patients.It was an expected death with the daughter present there. I made my way to the ward, and carefully read the patient’s history. I looked at my watch. 12:40 am. As I got to the patient’s room, it was illuminated by a very dim light, throwing sharp menancing shadows over the patient’s face. Her lips were sunken in, and she had an open mouth, with eyes closed. Protruding cheek bones, and a pale face alerted me to the fact this woman would have been very frail and in poor health prior to presentation.

I introduce myself to the daughter, and explain that I’m going to be examining her mother. I call out the patient’s name, and start giving some tactile stimulation over the sternum. No response. I feel her radial pulse. No pulse. I try the carotid pulses. No pulse. I listen over her chest for breath sounds and heart sounds. Neither of those are present after 30 seconds of auscultation. Finally, I open her eyes to find big dilated pupils that don’t react to a torch light. The eyes looked out, almost as if they were made of glass. I contemplated doing the “rag doll eyes” test, but given the way the patient’s head was angled, and how the daughter was there, I decided against it. I calmly turn around to the daughter and say “I’m sorry to inform you, but your mother has died.” I glance at my watch; 1.04 am. The daughter sobs quietly. I ask her if there is anything I can offer her for the time being, like a cup of water. She politely declines.

I walk out of the room to document my findings. I am surprised that I wasn’t freaked out this time by a deceased person. I know I shouldn’t be saying this, but it felt different in a way (in my mind, kind of cool), seeing and examining someone who’s life ceases to exist. I felt detached in a way examining the patient. I felt emotionless, felt like I was just going about doing my job. I think what helped was that I hadn’t been involved in this patient’s care. Perhaps that’s why I didn’t feel so emotional. But then, I’m not so sure how I am supposed to feel after something so sad like this. Was I supposed to feel this detached, or was I supposed to feel at least a little something about a person passing away?

I’m certain that there are many more deaths I’ll be asked to confirm. So far, I have confirmed 3 deaths, which for my stage of training is probably considered quite low (thanks to me being in a more regional hospital with less patients). I am lucky so far in that the deaths of all the patients I have had to confirm have been expected deaths. I fear the unexpected death, and having to explain and answer difficult questions they may have, as well as dealing with reactions of family members like anger and denial. I hope I’ll have the experience and skills to deal with that in the future.

The Issue of Brain Dead

I think perhaps one of the most horrible things that could happen to someone would be to be ‘brain dead’. Now I’m sorry to anyone if my use of the term ‘brain dead’ is offensive, but I simply don’t know any other way to convey a more concise meaning, without being too wordy. The alternative is something like “loss of higher cerebral functioning secondary to brain hypoperfusion”, which is a handful. I do feel it is less offensive than the term ‘vegetable’ however. So I’m going to use the term ‘brain dead’ throughout. I’ve seen the term used in my medical lectures too, so I’m assuming it’s not necessarily as offensive as it sounds.

The state of being brain dead; it’s a mysterious state – the state of existing, but having no existence mentally.

The person essentially, just exists, sort of like how a desk just exists. The person still has relevant physiological processes occurring, like the body can maintain itself plus a little bit of support from external sources like ventilators, but there is no deeper cerebral function to actually define a brain dead person. The person loses all personality, loses all abilities to make judgements, loses all their emotions, for none of that they can possibly do.

And that is just the tragedy of facing such a situation. A person who once had a uniqueness about them, who had a character and personality that defined them, are no longer there anymore. And it happens so suddenly.

Speaking back from one of the first such patients I had encountered, it was very sad. The patient was in her mid 30’s. Three weeks prior to presentation to hospital, the patient had some cosmetic procedure of varicose vein removal. Two weeks after her surgery, she started getting some leg swelling, and some shortness of breath, but ignored such signs. It wasn’t only until another week afterwards, that when she saw the GP, she collapsed in front of the GP, having cardiorespiratory arrest, with the GP having to provide full CPR. The estimated downtime of lack of perfusion to brain was around an hour. The patient had had a massive PE secondary to DVT developing in her legs.

Investigations I believe, showed her to have a massive saddle embolus, which caused her sudden collapse.

The prognosis from the outset of hearing her presentation wasn’t good. A full hour of no brain perfusion, would certainly lead to irreversible brain damage. Seeing the family was heart breaking, as the husband held his wife’s hand, and ran his fingers lovingly through her hair.

There were hopes of the patient surviving, as there were talks that the patient was spontaneously breathing. But I’m not sure if it was a reliable finding or not.

CT brain scans however, confirmed the worst possible news; there were irreversible brain changes, with loss of white matter differentiation, and changes consistent with someone who was ‘brain dead’.

The thing that makes it so sad is the young age of the patient, and the fact that something so devastating happened from a procedure that had cosmetic value only.

A few days afterwards, I heard that the surgeons were busy retrieving her organs for organ donation. To me, it is very noble of the family to allow organ donation to proceed ahead, and I’m sure no doubt that the doctors bringing up such a topic would have had a hard time in doing so. The fact that someone beloved does not mentally exist anymore, and then to have them get asked whether they would like for doctors to extract all healthy organs would be even more traumatizing.

Seeing the patient during my ward rounds was something that still kept me thinking. She exists in terms of being alive, but she doesn’t exist, because she is no longer who she used to be.

I remember my registrar saying that she hoped this patient dies. Taken out of context, it sounds like something really horrible to say. She added on later “because if she didn’t she’d be continually suffering, and putting her family through suffering.” In that regards, I too had the same wishes as my registrar. The suffering would be too great for her and her family.