Angel of Death by Emmon Raza (guest writer)

Illustration / Photo-credit: Saniya Kamal

We are told it is an ‘angel’ who takes lives. Maybe that is a good thing. But there’s nothing angelic about it when it happens to 28 year olds. Recently married 28 year olds.

Syed Iftikhar Hasan (not his real name) used to bring his ‘wet, wobbly and weird’ father to the Neurology clinic. The said man was old, rigid and irritable. His bulging ventricles on cerebral CAT scan settled down when he got a VP shunt placed and his visits stopped. In all this time no one paid any attention to the son. Of course he was a good son bringing daddy dear religiously for his checkups, but no more than that.

Then a year later, Syed Iftikhar Hasan presented as a patient to the same Neurologist with the complaint of new-onset headaches. This was the first time he revealed his own medical history, being an ‘initial patient’. It was late evening and I was immensely enjoying the Neurology clinic.

I learnt how to ‘pull myself together’ that day. I stood there, listening; without so much as a twitch of my facial muscles; as gruesome, heart-rending details unfolded before our ears and eyes.

This 28 year old well-built, reasonable-looking, recently married young man was on the verge of death.  It was as if Vonnegut was practically unfolding. A display of gallows humor. Ill-timed or rightly-timed, I cannot say, for, perhaps that is what it is supposed to be near your death. If it was a display of the mature defense mechanism of humor on his part to counter the unthinkable hurting truth, I am no authority to suggest. I was merely justifying his behavior or perhaps coming to terms with my own feelings towards it because I was at a loss for words.

Four months prior to his presentation, he first developed facial pain and nasal congestion. He must’ve been treated for this ‘rhinosinusitis’ multiple times by local doctors with the ever favorite Xynosine. But his symptoms would just not go away. Finally some able person decided to get his paranasal sinus X-Ray done. In his left maxillary sinus there was indeed a bleb, a ‘thing’. This needed to be checked. A CAT scan done suggested that it was a soft tissue density arising from the lining of the sinus and not just something floating.

Otorhinolaryngology found another scapegoat for their residents to hone their surgical skills upon. And so he was operated upon. An endoscopic sinus surgery with a subsequent procedure to remove the maxilla after the mass was found to be invading the bone.

It is perhaps only patients and their families who know what it really means to make the decision to go forth with something like ‘surgery’ because it doesn’t end there. No it truly does not end when you see your patient waking up in the recovery room. You cannot breathe a sigh of relief just then. It will prove premature to do so just then.

The surgeon sends a sample of the tissue from the operating field to the Histopathology people whether they suspect anything sinister or not. Just to be on the safe side. Just to detect it early if anything sinister is going on. Just to nip it in the bud. The results usually take 7 days to come back. Only the family knows what goes on with them in those seven never-ending days. And they are not promised a happy ending. Not always.

Iftikhar Hasan’s sinus mass found its way to the Lab. It was frozen and sliced and mounted and painted with the pinks and blues of H & E’s and Periodic Acid-Schiffs and all the other stains pathologists play with.

All things colorful, the truth when it unfolds, is very black. The un-named mass was christened. It now had a name: maxillary sinus carcinoma.

After a tissue diagnosis is obtained, the logical sequence is to find the extent of the disease because that determines the future course of action. And so begins the staging workup. Imaging the head and neck, chest and abdomen to look for lymph nodes and the progeny of the cancerous parent while it mocks us.

His CT-chest revealed lung nodules bilaterally. For a man who never had a CXR ever in his life, this is what he ended up with. And he is not to blame, how many seemingly fit 28 year olds get routine CXRs? None, unless, they immigrate or get recruited into institutions with a health policy.

Ironical as it is, the final nail in his coffin was the report of his MRI-Brain which revealed brain metastases. He was labeled a stage IV patient. The intent went from ‘curative’ to ‘palliative’.

Over the course of time, his brain lesions grew. A war raged on in his skull. The new lesions were occupying space as his mental faculties fought. But it was meant to be futile. As the dura stretched, the headaches came. Although he would take acetaminophen or aspirin but that wasn’t even taking care of the symptom let alone the cause of the symptom. Soon his brain functions would disrupt. Soon he'd cease to be him for a few days or weeks before the final heartbeat.

When he presented to Neurology he was considering palliative radiotherapy to relieve some pressure on his brain. Whether he presented for an actual opinion or just to have a final talk with the Neurologist who had somehow become his friend, only Iftikhar Hasan would know. He spoke about everything with a smile. He joked in between about random silly things, like cricket, which in that situation should not have mattered at all. His demeanor was not matter-of-fact. He had certainly not dissociated himself from the truth. Had he jumped through all of Kubler Ross' stages and reached acceptance? So soon? If his wife of a few months was in denial or she too was a master at hiding what she was actually going through, remains a mystery.

We are taught how to deal with patients in denial, patients who are angry and unaccepting and we with our empathetic training somehow excel at dealing with depression. So theoretically, a patient who has accepted his fate and is humoring about it should be easy, right? But, it was not. His response lay at that end of the spectrum which I was ill-equipped to handle.

I have seldom felt this uneasy as I felt as I stood there. 

[from Narrative Medicine]

CREDITS:

About the Author: Dr. Emmon Raza, AKU MBBS Class of 2012, is currently working as an Academic Assistant at the University of Sydney. She is fascinated by how the brain and mind work. She feels life's too short for her to pursue both Neurology and Psychiatry in all their awe-inspiring dimensions but it is something she intends to do. She enjoys writing about the impact patient interactions have had on her.

About the Reviewer: Saad Hafeez is from the AKU MBBS Class of 2020.  

Illustration / Photo-credit: Saniya Kamal, AKU MBBS Class of 2018, hopes to become a neurologist, pursue art, popularize meta-fiction, conquer the world and stay happy.

Editorial Note: This is from a series collected as part of the Narrative Medicine Workshop at AKU on January 20^th, 2016. The editorial work was performed by The Writers’ Guild, an interest group at AKU, with the purpose to promote love of reflective reading and writing, within and outside of  AKU.

DISCLAIMER: Copyright belongs to the author. This blog cannot be held responsible for events bearing overt resemblance to any actual occurrences.