The Mortality Audit (or, My First Death)
Based on the early career of Dr Willy Liangco, author of Even Ducks Get Liver Cancer.
Willy Liangco attended one of my first writing workshops in 2015, and continues to join us whenever his schedule allows. Several of his comic essays about the doctor’s life “premiered” at the workshop and are included in his first book, Even Ducks Get Liver Cancer, which has just won the National Book Award for Non-fiction in English. (So far Writing Boot Camp has produced a Palanca winner and a National Book Award winner, so we must be doing something right.) Recently we were talking about the differences between the essay and the short story. He sent me a draft he wrote about losing a patient for the first time, and I changed some of the details and turned it into a short story. So this story is based on the early career of Dr. Wilfredo Liangco.
The Mortality Audit (or, My First Death)
by Jessica Zafra
Sleep was the first casualty of my residency. I had been an internal medicine resident for exactly a month, but I felt like I hadn’t slept in a year. I was constantly ducking into supply rooms and toilet stalls to steal fifteen minutes’ unconsciousness, ten minutes, five, two. Forget about having a social life, or any semblance of a life; all I craved was a tiny hit of that sweet, sweet sleep.
This was by no means an unusual situation, but the common state of doctors in training. After a few months of this, we would seem to be racing our patients towards the brink of death. To survive my training long enough to practice medicine, I learned the time-tested ways of stealing…well, time. The monitoring rounds were good for thirty minutes, maybe more. We were required to take the vital signs of Intensive Care patients—pulse, respiratory rate, blood pressure—every hour and record these on their charts. A particularly tedious and time-consuming task: if you had the usual twenty patients to monitor, by the time you finished one round it would be time to start all over again.
Sometimes—not all the time, we’re not monsters—my colleagues would skip the actual measuring of the patients’ vital signs. Instead, they would make a visual estimate of these vital signs. Obviously if the patient was playing video games on their laptop, then their blood pressure must be in the normal range. And surely the patient who was laughing and chatting with their visitors was breathing properly.
I liked to think that I was employing a more sophisticated method than this guesswork, for it required a bit of time travel. I would take the patients’ vital signs at 2:30am, and then record them as the measurements for 2:00am and 3:00am. It was only a half-hour’s difference, there were way too many patients to monitor, and it was not my fault that the system was so overburdened and inefficient. In a way I was striking a blow against an unnecessarily unjust system. Besides, my half-hour time saving method was not as bad as the other interns’, who would measure the patients’ vital signs at 1pm and record them as the measurements for 2pm, 3pm, and 4pm. The nerve of some people.
And then this happened.
I was doing my rounds when I found that one of my patients in the ICU was suffocating. That Mrs Bayani was critically ill was apparent from the moment she was brought to the Emergency Room two days ago: she was severely dehydrated, her pulse was thready, she had diarrhea, and the left side of her face was a purple mass encrusted with pus. She would’ve gone into cardiac arrest had she not been revived by the ER residents. She should’ve been confined in the ICU, but there was no more room so she was given a bed in the ward, beside the nurse’s station. Her teenage son was told to watch over her at all times, and an intern had to check her vital signs every hour. That intern being me.
In a panic I flipped through her medical records and read that before her current confinement, Mrs Bayani had been in the charity ward for several weeks for a soft tissue infection on the left side of her face. She was the patient of another resident, who pronounced her recovered and discharged her a week ago. That resident had since been promoted to second-year resident, leaving me, the new first-year resident, as Mrs Bayani’s primary doctor. I, a blank slate with no significant clinical experience, was face to face with a patient who was about to stop breathing.
I had had exactly one previous experience at intubation, and it was on a mannequin. Gingerly I inserted a tube into her windpipe and prayed to any cosmic powers that might be inclined to grant my request. To my relief air and phlegm shot out of the pipe! I wanted to roar in triumph and do cartwheels down the hallway: I inserted the tube into the correct hole! The correct hole! But there was more work to be done.
The tube had to be connected to a mechanical ventilator which would pump air into her lungs and assist her in breathing. This ventilator had to be rented, and the patient had no money. In the absence of a ventilator, someone had to sit beside the patient and manually deliver air into her lungs using a bag valve mask—a rubber balloon the size of a football. I instructed her teenage son to press hard on the bag with both hands to ensure that she would receive enough oxygen; meanwhile I would do all I could to get her a bed in the ICU, where there were ventilators that could be used free of charge. “Meanwhile, you will have to be the ventilator,” I told him, and then I strode forth, the triumphant intubator, to see twelve other patients.
I returned a few hours later to find the patient’s son pumping the bag with just one hand. The bag was lying on the bed, and he was lazily pressing it with his left hand or his elbow. “You have to do this properly,” I scolded him. “Watch me. I am pressing the bag with both hands, causing your mother’s chest to rise. That means I am supplying her lungs with enough air.” I would have continued with a lecture about his filial responsibility as his mother fought for her life, when he raised his right arm. To be precise, his right forearm, which ended in a stump. He had, in fact, no right hand.
As I issued what I hoped was a sufficiently profuse and sincere apology, I wondered whether for the sake of politeness I should ask him how he’d lost his hand. I was born without it, he told me, in a manner which suggested that he’d been answering this question all his life.
I managed to find a bed for Mrs Bayani in the ICU. 24 hours later she was dead. I had lost a patient barely a month into my residency, but even before I could begin to deal with this loss the exact cause of her death had to be determined.
“Definitely an infection,” I told my fellow interns, flipping emphatically through her chart. “I suspected colitis at the start and gave her antibiotics for it.”
“But she was sufficiently hydrated, and her stools were notably bloody.”
“The mass on her face could be cellulitis, or an infection on top of a hidden cancer.”
“But it’s been drying up,” said my senior resident. “She was given a month’s worth of meropenem in her last admission.” The infectious diseases specialist concurred—it was she who had obtained funding for a full course of this powerful antibiotic for Mrs. Bayani. The patient had been stable when they sent her home, and the infection on her face almost completely healed.
“Colon cancer? Diverticulitis? Amoebiasis?” Even as I mourned the death of my patient I wondered if my medical career would follow her to the grave. I would probably get the dreaded mortality audit.
“I know what killed her,” declared the intern, pausing for effect. I waited for an all-encompassing diagnosis that would explain every aspect of the case, some erudite-sounding reason like “Churg-Strauss Disease, also known as eosinophilic granulomotosis with polyangiitis.”
“Poverty,” she said. “Poverty killed her.” She was not wrong, for we all know that disease has socio-economic implications, healthcare is a political issue, and the state of the people’s health is a reflection on society. But what I needed was not a discourse on public health, only the name of a disease to write on the death certificate.
“I think we’re going to need an autopsy,” my senior resident sighed. This would require the patient’s family’s consent, and most families did not like the idea of having their recently deceased cut open for study. To our surprise Mrs. Bayani’s sister said yes, they agreed to the autopsy, and then she and the patient’s son burst into tears.
The post-mortem examination would answer all our questions and reveal the final cause of death. It also meant that I would have to submit to a medical audit, that is, present this case to an audience composed of consultants, fellows, and medical students who would judge my decisions in the patient’s treatment.
I had wondered when it would happen, my first death. We were admonished that death was a natural and possible outcome, that we could not expect to work miracles, that we should not wallow in grief for this was self-indulgent and we had other patients to attend to. For some reason I had imagined myself locked in heroic combat with Death itself, desperately pressing my palms against the patient’s chest and willing them to Breathe, damnit, breathe! I steeled myself for a wave of emotions. What was the sequence: anger, denial, bargaining…But I felt only a bone-deep weariness, and when I lay on my bed I immediately fell into a deep and merciful sleep.
Three weeks later my senior resident and I appeared at the pathologist’s office to get the autopsy report. I had expected to be handed a sheaf of papers; instead the pathologist told us to sit down and make ourselves comfortable in a room furnished with unidentified body parts and creatures swimming in jars of formaline.
“We start with the brain,” she said, sliding a large glossy photograph towards us. I stared at the matter inside my dead patient’s skull. “No significant findings.”
“The eyes.”
“The neck.”
“The liver.”
And so on, the better part of an hour ticking away until we got to the intestines. We looked at the photograph of her dissected viscera and screamed.
My older colleagues had advised me on how to conduct myself at the audit. I was to maintain a smile—not too wide, just enough to put people at ease, nod faintly but not too often, evince interest and gratitude in whatever the interlocutors had to say, and conceal even the slightest sign that I wanted to run screaming from the hall. The conference room was crammed with senior consultants, junior consultants, fellows, senior residents, junior residents, interns, medical clerks, and medical students, each of them raring to confront me with the evidence of my failure. To think that twenty years ago, when my mother was convincing me to go to medical school, one of her arguments was that I would not have to answer to a boss, I would be the boss.
My classmate C waved at me from his seat—I had asked him to raise his hand in the middle of the audit to ask a question I already knew the answer to. This was to ensure that I did not come across as a total idiot during this two-hour interrogation. C never got the chance to ask the question, because the consultants in the audience began to speak, not to me but to each other. Or in Dr A’s case, to himself, for he began with a question, furnished a long and complicated answer, and then forgot that he had asked me something. A well-loved senior consultant newly returned from a fellowship in Australia arrived in the middle of my presentation, causing an unscheduled intermission as everyone wanted to know how she had spent every day of the last six months. A group of my fellow residents arrived late, among them my friend P, who looked especially morose. I thought he had been chewed out for filling up the monitoring sheets in advance, but it turned out that he was despondent because Miss Philippines had not made it to the finals of the Miss Universe beauty pageant. I had become a spectator at my mortality audit.
At length the moderator bade me continue, and I resumed reciting my report to the indifferent audience. I had spent weeks studying the case, making this presentation, preparing the slides, rewriting my lines. I had been consumed with anxiety, questioned my choice of career, considered a new profession answering phones at a customer service center or writing the wrong names on Starbucks paper cups. Starbucks! Not too long ago I was a starving intern who could only dream of going to Starbucks.
Then it was time for the autopsy report. When the pathologist stood behind the lectern a hush fell over the audience. As the final arbiter of mortality she commanded a special respect, like Charon ferrying miserable souls across the river Styx.
“I’ll begin with the external examination,” the pathologist boomed at the microphone. “Subject is a 52-year-old female with a violaceous patch on the left side of her face…” She proceeded to describe the appearance, weight, texture, and other characteristics of each organ of the deceased. Heart slightly enlarged, liver normal, lungs pink with some congestion. There were the tiny hemorrhages and other physical changes consistent with the approach of death. There was bruising on the chest wall from the attempt to resuscitate her. As the intern had pointed out, there was ample evidence of hardship: malnutrition, wasting of the facial muscles, general skin darkening from years of toil in the fields.
“Now the intestines,” and the slide of the dissected viscera appeared on the screen. “Pseudomembranous colitis,” she announced. A gasp went through the audience, for while everyone knew of it they seldom saw what it looked like. The powerful antibiotic which treated the infection on the patient’s face had resulted in the growth of an opportunistic bacterium in her intestines. C. difficile had caused the infection which eventually killed her. We had prescribed a different set of antibiotics, but by then she was too severely dehydrated to respond to them. In short, Mrs Bayani’s death was caused by an infection from the drugs used to treat her earlier infection.
After I gave a summary of the case there was a smattering of applause, and then the audience drifted away. The photograph of Mrs Bayani’s intestines remained on the screen, red and swollen, covered in places by a yellow-green film. I had been absolved of incompetence, I had survived my first mortality audit. In the now-empty conference room I sat and waited for the wave of emotions to crash over me and grant me some profound insight into the mysteries of life and death. The minutes ticked by. I waited.
If you are interested in Writing Boot Camp, email saffron.safin@gmail.com. There are workshops for beginners and advanced practitioners. You have to be over 21 to join.
Aiiiiiiiiiieeeee! I had a horrendous case of food poisoning in December which required 2 antibiotics. They worked, but they also triggered my anxiety.
Wow. This was gut-wrenching, literally. I’m on 2 antibiotics now for an infected keloid on my navel and am scared shitless.