A Lady with Cancer

A lady was brought to casualty.  She was in her 40s, and was in desperate pain.  She had been diagnosed with cancer a couple of years prior.  She and her family had been referred to an oncologist.  But someone who called himself a doctor had told them that the hospitals would give her poisons that would make her feel terrible.  The “doctor” instead offered them “supplements” that “will make her feel better and treat the cancer more effectively.”  They chose to use the supplements, and so the cancer grew, otherwise untreated.  She had now developed abdominal pain that rapidly worsened, and was brought to us. 

She was miserable, unable to find a comfortable position.  Her abdomen was greatly distended and tender.  Ultrasound showed her abdominal cavity was almost completely filled with her spleen and liver, packed with cancer.  She was rail-thin, and her nail beds were almost white.  Surely she had a dangerously low red blood cell count.  We started all the “doctor things,” ordering meds and blood and labs and such. 

The family had many questions.  They were kind, educated people.  They said she had been doing so well on the supplements but seemed suddenly to have worsened.  I struggled with what to say.  They had been fooled by a quack, who had been taking their money while the cancer grew.  The cancer was a type which tended to respond well to chemotherapy, and the family had good insurance which would have paid for the chemo, which added to my frustration.  But here she was dying, well beyond most intervention.  We came up with a plan to evaluate her pain and contingencies for the findings. When they asked why she was so sick despite the expensive supplements I tried to gently explain that the cancer had been growing and would soon take her life, and that the supplements had done nothing.  They were quiet. Perhaps they were unsure of my advice.

Her condition worsened and she became unresponsive. I realized that she was near death, and that her illness had progressed well beyond our ability to rescue her.  I felt a push to help the family with realistic expectations.  If her heart stopped, we needed to know what to do.  I told them that her condition was very serious and she could die at any time, that we would continue to treat her well, but the end would come soon. They were not expecting such news, and the truth of the consequences of their earlier decision became an unspoken reality in their faces.  I explained that when her heart stopped, we could try to resuscitate her, but the efforts would probably be unfruitful and dramatic.  The chest compressions would break ribs and the electrical shocks would make her convulse.  None of those actions would change her overall condition.  On the other hand, when her heart stopped, we could treat her with dignity and not do those other dramatic acts.  I recommended this latter course.

We had a time of prayer, and I was very glad to learn that she was a devoted Christian.  There were tears.  The family withdrew to consider.  I checked the clock.  I was about an hour late in going home, and other staff were available to take over her care, but I wanted to stay.  I needed to stay.

The family returned.  They were confident in their decision to go the way of a quiet end with dignity.  To my surprise, they asked me not to continue with CT scans and surgical referral, as we had previously planned.  I took a little time to finish the paperwork, then the family and our excellent resident and I began to push her on her bed to the ward.

As we neared the ward, her breathing slowed.  The ward wasn't ready for us and we paused at the entrance.  Hearing her breathing slow further, I told the family that she was finishing, and we turned  into a side hall.  I was so very relieved that we had discussed the plan for her end when we were in Casualty.   We prayed again, commending her soul to the Lord, thanking Him for an end to her suffering, and rejoicing, with sorrow, for her promotion to Heaven.  Her breathing stopped altogether. 

The family thanked us for our efforts and asked God's blessing on us.  Then they departed.  We did the necessary things for the body, and I walked home.

The walk home normally takes four minutes.   It seemed much longer this time.  My patient had been a young woman with three kids.  Her cancer had been very treatable.  She died “needlessly.”  She and her family had been deceived by a charlatan, with deadly consequences.  A grievous injustice.  I felt sick.  But God remains Sovereign.  “See now that I, I am He, and there are no other gods beside Me. It is I who put to death and I who give life.  I have wounded, and it is I who heal, and there is no one who can deliver from My hand.”  Deut 32:39.  Both were true.  The deceiver had profited from malpractice and she had consequently suffered and died.  And God was sovereign in the whole event.  Surely, He was grieved by the sin of the situation as He is with all sin.  I was grieved, too.

Martha and Meredith and James were already sitting at supper.  I washed and sat.  Martha asked what kept me, so I told the story.  Tears came, which was surprising.  I don't remember being that emotional at the death of a patient since my time in a combat hospital in Afghanistan.  Surprising, but welcome.  James gave me a long hug. 

I believe that God arranges for us people to intersect with each other for a reason.  So why did He put me in contact with that family, with that lady?  I hope that I was able to guide them medically and spiritually in an important time.  I hope that it was right to choose less medical intervention and more spiritual support.  But those God-arranged intersections usually have purpose for both parties.  What was I to learn?  I think I was supposed to be reminded that ideas matter, and that we must be teaching to prevent the suffering that comes from deception and greed.  I think I was supposed to feel a little of God's grief at the brokenness of this world, and cry about it.  And ultimately I think I was supposed to really live in a situation in which medicine was largely futile, but God's sovereignty was the source of all comfort.  Ps 116:15: “Blessed in the sight of the Lord is the death of His holy ones.”

God's Kindnesses in Tragedy

I believe we just saw a situation in which God let us know that an event which we would call tragic was actually according to His will.

Casualty (our Emergency Room) was quiet in the cool of the morning.  The three beds were empty and the staff were chatting socially.  Our Family Medicine Resident, Yulu, and our PA, Derek, and I decided to hold a resuscitation drill.  We invited the Casualty staff, and two nursing students were interested in participating.  I went to the storage area on the far side of the hospital compound and brought out our old CPR manikin and the ventilation bag and mask which we had stored with it.  We moved our “crash cart” and its defibrillator next to the bed and started to attach leads to the manikin “patient.”  I was disappointed to see that all of the defibrillator pads had been used but not replaced from storage, so made the journey back across the compound to retrieve a new supply while Yulu taught the students some of the operations of the defibrillator.  After I returned, we showed the nursing students how to attach the cables and leads properly and we proceeded with our teaching case drill. 

Abruptly, one of the clinical officers stuck her head in the door and said, “We need you.”  A lady had been brought by her family, unresponsive.  The lady was young, about 40 years old, and did not appear to be chronically ill.  But she was entirely unresponsive.  We all joined in her care.  She was breathing rapidly and her heart rate was a little fast, but she had a normal blood pressure.  Her blood sugar was normal.  Why couldn’t the monitor read her oxygenation level?  We tried another device with no success and gave her 100% oxygen.  Her heart sounds and lung sounds were normal.   Her eyes were open but pupils weren’t reacting very well.  The family said nothing unusual had happened and there had been no trauma.  She had taken her usual medications.  Her daughter, a young adult, was distraught.  What was going on?

Yulu said, “She has stopped breathing and has no pulse.  Start CPR.”  We brought the “crash cart.”  We needed to attach defibrillator leads.  Glad for our opportunity earlier, I handed the pads to the student nurse and said, “Attach these.  You know how.”  And she did.  I was also glad we had discovered earlier that we needed to resupply the pads.  We didn’t need to shock our patient, but we kept the defibrillator in case the situation changed.  We used our suction device (glad we had that out for the drill).  We asked for a bag and mask, and I was again disappointed that all had been used and not replaced.  But we had the one that we had been using for training with the manikin, and brought it out.  There had been no delay. 

Our patient had normal electrical heart rhythm on the monitor, but no pulse.  We gave adrenaline and started chest compressions which produced an excellent pulse.  Then she regained her own pulse so we stopped compressions.  Still no oxygenation level on the monitor.  We tried to intubate but the situation made it technically difficult.  So we used one of the only LMA devices in the hospital to be able to breathe for her.  It worked well. 

Someone had called for the chaplains, and our Evangelist, Nancy, came.  I explained the situation to her and that we had tried everything but we were not being successful.  We prayed and she went to the family to update them.

Then our patient's pulse stopped again, and we started chest compressions again and called for the ultrasound machine and looked at everything but we couldn’t find a reason for the dysfunction.  Normal hydration, normal lungs, anatomically normal heart but now with slow beats, no unusual fluid anywhere.  The blood count returned with near-normal values.  No clues.  We tried fluids, drugs, maneuvers, and more, to no avail.   Her own heart rate had slowed to about 20.   She was dying.

The pulse would sometimes return and we would stop compressions, then the pulse would go and we would resume compressions.  We rechecked the history with the family and reexamined her and asked for ideas.  The Medicine team came and helped with ideas, compressions, and tries. 

Yulu said, “Shall we continue?”  I was surprised that I had lost track of the time.  I asked how long we had been doing CPR.  “About 40 minutes, Daktari.”  We looked again with the ultrasound machine.  The heart movement was minimal.   Any further action was futile.

Nancy was there.  I told her that we had done everything possible in our hospital and that she had died.  We needed to speak with the family.  She said we should wait and that she would prepare them.

We stopped the resuscitation attempt at 11:55.  We reviewed the events of the attempt, asked for questions and asked if anyone had concerns or reservations or burdens.  We should have prayed collectively, but several did individually. No one knew where Nancy had gone with the family, so I called her.  “Dr. Jim, come to the Chapel.”  There were sounds of singing in the background of her call.

Yulu and I went to the Chapel, which is in the heart of our hospital compound.  There were over twenty people – family, neighbors, friends; they had come as soon as they heard something was wrong.  The daughter was sitting and crying just inside the door, being hugged by two ladies on either side.  Our Chaplain was speaking to them, mainly in the Kimeru language.  It became obvious that some in the group only spoke Kimeru, though some also responded in English and Swahili.  Yulu and I sat among them.

After the Chaplain finished his words, he asked us if we had something to say.  Yulu stood and gave a very compassionate account of what had been done, speaking mainly in Swahili with some English.  Well said.

Then a mature lady stood and gave one of the finest speeches I ever hope to hear.  She spoke directly to the daughter, who was still in school and had lost her mom and still had younger siblings.  And she spoke indirectly to the rest of us.  The lady introduced herself as a neighbor.  She gave testimony to the life of the fine and generous lady who had died.  The mature lady explained that when she was a girl, she had three younger sisters.  Her mother died giving birth to the only son.  The death occurred at our hospital long ago.  And despite heroic efforts, the boy died, two days later.  And the lady gave testimony as to how God had raised her, and had seen to it that she had what she needed.  She was not allowed to leave her education, and the community had joined with her in raising the family.  All of her siblings had finished their education and were well.

She said to the daughter, “You will finish your education.  God will be your parent.  And you will find Him faithful, as I did.  We will see to you and your younger ones.”  She challenged all of us to do this.  It was a beautiful act of the Body of Christ in the midst of a very difficult time.

I needed to say something, too, and the Chaplain gave me the time.  So I spoke to the family and told them some of the remarkable things that had happened that morning.  I can’t remember the words, but the sentiment went something like this:

Lord, God of the Universe, who made our souls and gave us life, you say in your Word in Psalm 116, “Precious in the eyes of the Lord is the death of His saints.”  You also have said , “'See now that I, I am He, And there is no god besides Me; It is I who put to death and give life.  I have wounded and it is I who heal, And there is no one who can deliver from My hand.”  We surely did not ask for this event today and we do not know its purpose.  But it is clear from these people gathered that this was a loved woman who was very important in the lives of many.  And believing the testimony presented here that she was one of your children, we know she is rejoicing with You right now. 

Lord, it is remarkable to me that as we were trying to keep this lady alive, we had everything available to us right away.  Even the things we found missing in the morning, we had replaced.  Even the training we did this morning helped us be prepared to help her.  We had all of our tools, even the uncommon ones, immediately available.  We had lots of help.  Even now gathered here, this excellent lady was here to give us a very fine word and encourage us all with her testimony of your goodness.  I believe you have arranged all these events to show that you brought this about in Your perfect will and for Your perfect purpose.  We are not so foolish as to think we know better than You.  We bow to Your wisdom and Your timing.  We are grieved at this loss, and we ask for Your blessing.  You have said, “Blessed are those who mourn, for they shall be comforted.”   Let it be so. 

It was difficult to leave this gathered group.  God was doing something.

Three days later, I met with our Chaplains for our weekly combined training session.  They spoke of the death and what happened after.  They said the family were so appreciative.  The family were grieved, to be sure.  They were mourning, but not as those who have no hope.  They were mourning as those who have confidence in a sovereign, good God who had seen to it that all human effort had been tried.  There was no reason to despair that the medical care had been poor or uncaring.  It was the best available, with many good doctors and nurses and clinicians trying their best for a very long time.  This was something that God had done.  What a kindness!

I am convinced that God’s highest plan was for this lady to be “permanently healed,” as Nancy calls it, and go to Heaven.  And in His kindness, He arranged for there to be no “what ifs” regarding the medical care.  What must that mean to the daughter?  What does that mean to those of us who tried and “failed?”

There are times in the service of the Good King when I have to kneel down, put my sword down, and just worship because of something He has done.