Attitude, gratitude, resilience and recovery
Posted on 16 Jan 2022
As everyone involved in clinical medicine would have encountered, the attitude and will to recover play a major part in a critically sick patient’s ultimate clinical outcome. As an outstanding example of this principle I would like to share the unusual case of Ronald*.
In the stormy first weeks of Ronald’s hospital treatment two senior nurse managers had approached me at different times with the same question: “Why do you as clinical team keep him alive? Surely he would have no life after this?”
With much the same sense of foreboding I approached his bed in the ICU. Communicating bad news never becomes easy; in 40 years of clinical practice this has not improved. Nonetheless the anaesthetists, surgeons and orthopaedic surgeons who had kept him alive thought the physician would be the best equipped for this task.
Ronald had clinically stabilised adequately for weaning from ventilation. This was almost accomplished and all sedation had been discontinued. Extubation was set for the next day. He was alert but largely ignorant of the end-result of the cataclysm that had befallen him.
In his mid-60s and a vibrant, strong man, Ron developed staphylococcal sepsis. After 2 days of “flu-like” symptoms, he was referred to the hospital with a “rash and low blood pressure”. He presented in circulatory shock with wide-spread red skin discolouration and purple fingers and toes as the body attempted to save his vital organs by shunting blood inwards. Despite our efforts to support, he still ended up on a ventilator and on short-term dialysis.
When I neared his bed, this is what I saw: the legs’ impression under the sheets seemed unnaturally short. His hands and arms were swathed in bandages. He still had a tracheotomy connected to the ventilator, so he could not speak, but his eyes met mine alert and enquiring. His (usual) white nose was black and crusted with dead tissue, and so also the central half of his upper lip, a spot on his chin and ends of his earlobes.
I introduced myself and proceeded roughly like this.
“Ron, I am the physician who originally received you in the hospital and admitted you to the intensive care unit. You were very sick and I would not be surprised if you have no recall of meeting me. You developed a blood-stream infection by a germ which usually lives on the skin called staphylococcus. While there is no clear understanding we speculate that a minor skin infection could have seeded germs into your blood-stream, resulting in infection around the vulnerable metal inserts of your previous back surgery: this can often remain latent for long but eventually the germs overcome your defences and spread prodigiously through the blood stream: this then cause the sudden shock state which brought you here. You had developed lung damage from this severe inflammation and we needed to support you with the ventilator and had to sedate you deeply for that. You had been here for three weeks but I expect you would have little or no memory of that. Now I have to give you some distressing news. I am sorry to tell you that the collapse of your blood circulation has done wide-spread damage. Your lungs and kidneys needed support but they, your liver and heart should recover without any long-term dysfunction. However the circulation to your limbs and skin were impaired very badly and some of the tissues were damaged beyond repair resulting in gangrene. If we did not remove dead tissue it would have threatened your life. So I am sad to inform you that both your lower legs had to be amputated just below the knees. In addition, you also lost all your fingers on your left hand and also most fingers on the right side. The surgeons fought hard and eventually saved a third of both your right thumb and index fingers. There is still a lot of damage to the skin of your lower arms which may need skin grafts. There is also damage to the skin of your face which may well need plastic surgery repair.”
Giving bad news to a patient who is unable to respond increases the grade of difficulty (a reason why I always hate to give bad news over the telephone). I completed my devastating message, promised to come back the next morning and had to hold myself from running to the door.
The next morning I walked into the ICU to find that the patient had been extubated and had a speaking tracheotomy tube in place. I greeted Ron and asked if he remembered me: he did. I then ask if he remembered what I told him and he acknowledged. I offered to briefly run through the details to make sure of complete understanding. He agreed and I ran through the awful catalogue of his bodily damage once more.
Ron gave it all a thought for a few moments, looked down to take in his shortened leg silhouette under the sheets and his bandaged hands. Then he said the most unexpected thing and blew my mind: “All considering, Doc, I still think I am the luckiest person alive!”
As you can expect, this took my breath away. When able to speak I countered: “I am happy to hear you say that, Ronald. However this response is a bit unexpected! Can you explain to me what you mean please?”
He replied: “You may not know this, but my right eye is blind from an accident as a boy: what you see here is a glass eye. When my blood pressure fell when I became so sick my vision became vague and cloudy and I panicked that I might end up blind. And now I find I can see you in full focus! I had retained full vision in my only eye. I can hear everything you are saying. Just before you came they served breakfast. I could smell the fried egg, bacon and toast across the ward! I had some yoghurt and orange juice. It was delicious. You see: I had retained all of my senses and that is the greatest gift I could hope for.”
It was then clear to me: Ronald was not only going to survive, he was going to make it.
This was not the end of Ron’s in-hospital struggles. Not by far. He had many challenges to face – amongst other recurrent infections of stumps and wounds and one of his skin grafts failed and had to be re-done. Fortunately the dead skin on his face, nose and ears neatly peeled and recovered with minimal scarring without the need for surgery.
One day I entered his room in the general ward while the physiotherapist (Hein Atwood) was busy with him. Ronald chose this moment to make an announcement: “As you know I ran a small factory for metal work. I cannot see myself getting back to that for many months, if at all, and in the interim there are expenses and no income while I am here. So I asked my wife to put the business up for sale. I can tell you today that the sale is going through and I got a very good selling price!”
We congratulated him and then he became thoughtful: “I am still in doubt about my private workshop though. I got some fantastic wood and metal work machines and tools at home. I suppose I would never get back to that either, although designing and making things had always given me such joy.”
Here I must come clean. I doubted. Despite what Roy said in the ICU and his evident fighting spirit, I just could not see it. I was possibly dragged down by the struggle to finally get him up and going and the recurrent infections and complications. So I hesitated. I almost said: “Yeah, Ron, I cannot see it happen.”
But Hein jumped into the breach. “You do not want to do that Ron!” he exclaimed. “Your stumps are almost ready to fit prosthetics. We are going to get you up and walking. You can still design and plan the stuff you want to make: you just need a youngster to pick and carry and fit the stuff together.”
Eventually everything came together and Ronald left for further rehabilitation and fitting of his bilateral prostheses. We lost contact. There was no medical need for me to see him for follow-up.
A few months later I happened to see a referred patient in the emergency department (which in our facility also sometimes doubles as short-stay for minor procedures. I was happy (but concerned) to see Ronald sitting in one of the beds. “Hi Ron”, I said, “I’m happy to see you here. Hope nothing serious is wrong. Must say you are looking particularly good!”
“Hello Doc,” said Ronald “Nothing much, I am happy to say. Just popped in for them to smooth out a spot of scarring on my stump which hurts in the prosthesis.”
We chatted a bit and then I asked him a burning question: “Back in the day while you were still here in the ward you were considering selling your home workshop equipment and Hein was particularly adamant that you should not. How did that work out?”
“Very well,” explained Raymond. “I pay a ‘handlanger’ who is a retired carpenter’s assistant to help a few times per week and have two keen youngsters from the neighbourhood who want to learn wood- and metalwork and come over after school. I do the designs and have one more vital job.”
“And what is that?”
“I push the planks into the saws.” He smiles with a twinkle in his eye. “I have no more fingers to lose!”
What did I learn from this experience?
We should be careful to pre-judge or underestimate a patient’s ability to recover even against enormous odds. Human resilience can be a powerful force.
Our positive attitude can also be a powerful force for motivation as Hein’s strong affirmation served to keep Ron’s belief that he can still aspire to continue his creative work alive and likely further bolstered his desire for recovery.
A good question is whether our attitudes impact on facilitating recovery. Could an attitude of empathy and support bear fruit? One last vignette to illustrate this point.
A few years ago my wife and I were sitting at an open-air table of a local restaurant. We suddenly became aware of a commotion. Chairs of neighbouring tables were being bumped as a large lady came barging through toward us pushing her walking frame. As she came close she was saying (with a voice somewhat slurred): “Hey Doc, Doc. I am it! I am it!” Damn my prosopagnosia (failure to recognise people’s faces). I had no clue.
“Sorry madam! You are?”
“Yes Dr Tredoux look at me. I am the flower!!!”
Then realisation dawned and suddenly (as if a spotlight hit her face) I recognised her.
She had, some months before, suffered a sudden total occlusion by a blood clot of the main artery to the right side of her brain resulting in a very large area of brain tissue damage, which caused coma and made survival doubtful and even if so, significant rehabilitation hugely unlikely. Against the odds (and may we claim: some good support) she regained consciousness. Very dense hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body) and initial severe speech impairment persisted. After days; just as we were giving up hope of recovery, like the sprout breaking the earth from the seed, a flicker of movement was detected in the arm, then in the leg. Her speech improved. Her power gradually improved up to the point of lifting limbs against gravity (with lots of encouragement). By this time she was depressed, tired and demotivated. All cajoling and encouragement from me, nurses and therapists seemed to fall on deaf ears. She just wanted to go home. This would mean long term bedridden care. In desperation I took out my cell phone and showed her a photo. In 2008 we had a devastating bushfire in the fynbos above our home. A few weeks later my wife and I walked halfway up the mountain and found the fire-lilies. They always appear 2 to 3 weeks after fynbos fires. I took a photo of the devastation of the fire with the beautiful red lily in the foreground. I told her that her life maybe seems just as scorched and dismal as the ground after the fire. However, with some effort, just like this beautiful flower, she could rise up and have a meaningful life again.
This seemed to penetrate and make sense. She began to participate in physiotherapy sessions and we were able to refer her to rehabilitation.
And here she was. Mobile and walking (albeit with support) outside. And she remembered: she was the fire-lily rising out of devastation!
* Name changed for privacy and confidentiality