The Scent of Death

Death has a peculiar scent. In the business of saving lives, one ends up hanging around that scent quite a bit. It assaults your nostrils, clings to your clothing and messes with your mind, tauntingly reminding you of your failure.

In my early days of medical school, I learnt all of the basic medical sciences but nothing about looking death in the face. The first I heard of it was from a friend whose story about how he felt when he first saw a patient die has stuck with me. At a ward round, he and his fellow students had brought up the rear in the almost demeaning hierarchy of the medical team. They went from bed to bed, patient to patient; listening to consultants and senior residents bloviating endlessly about obscure medical conditions. At some point during the round, a patient they were seeing suddenly clutched his chest and started gasping. All the medical students were herded away and the patient screened off from view as the doctors set about trying to revive him. It wasn’t long before they reemerged and matter of factly recommenced the ward round with nary a word said to anyone. As they passed by the patient’s bed, my friend glimpsed through the screen and saw the man wrapped in a white sheet. He was shocked. Someone who had chatted cheerfully with his doctors only moments before now laid there, expired. “What struck me most was the manner in which the doctors just went about their business as if nothing had happened” he told me. “I hope I never lose my humanity to the point where a patient committed to my care passes away like that and I feel nothing” he said shaking his head despondently.

My own baptism of fire came soon enough. It happened during a clinical rotation in “O&G” in my fourth year of medical school. It was an “outside posting” at a maternity hospital quite notorious for its poor facilities, essentially a relic of colonial healthcare. I had heard bad things about the place, still I was terribly excited. I’d never been in a delivery room before and I looked forward to assisting in delivering babies. The first day of my week started normally enough, I checked in with the medical officer who waved me over to the intern on call. “Keep an eye on him”, he warned, “things have a way of going wrong when these medical students are around.” The intern looked quite glum at the prospect of acting as a chaperone in addition to his already punishing schedule of duties. The cold reception I received from both doctors did nothing to dampen my enthusiasm. I tailed the intern on his rounds, intermittently asking him inane questions. He perked up a bit when I told him I recognized him as a recent graduate from my school and didn’t seem to mind so much after that.

It wasn’t a particularly busy shift, it was early evening and luckily the power was on. I hoped they had a generator and that it was well stocked with fuel as power supply was sometimes very unstable. Two patients awaited us in different delivery rooms, one who had just given birth and another who was still in labor. We checked in on the woman in labor and everything appeared to be in order, she had no specific complaints and her contractions were strong and regular. A quick pelvic exam showed that she was making steady progress. The midwife on duty took her vital signs and reported normal parameters all round. The intern smiled, I could tell that he was looking forward to a good night’s rest. He appeared to be in a good mood and I was curious about the woman so I asked about her history. I learnt that she was an “unbooked” patient, meaning she had received no antenatal care in what was her first pregnancy. She came in a short while earlier in established labor. She looked basically healthy but the baby’s heart beat was inaudible and she could not recall the last time she felt her baby move. The conclusion was that the baby was dead. “Have you tried to confirm with an ultra-sound scan?” I asked. He looked at me like I was crazy, “the ultra-sound machine broke down years ago” he retorted.

We went up to the doctor’s call room. The medical officer was squinting up at an old 21 inch color TV. “Is everything ok?” he asked, the younger doctor gave him a brief situation report. He merely grunted in response and shifted his attention back to the fuzzy television screen and its dreary soap opera. The intern and I renewed our acquaintance, we chatted about anything that came to mind, medical school, politics, sports. Every two hours or so, he had to go and check on the woman in labor but he had nothing significant to report. I had lost a bit of interest in the case by now because I obviously would not be allowed to assist with her delivery; medical students can only help with uncomplicated cases. A few hours later, I was drifting off to sleep when there was a knock on the door. It was the ward attendant informing us that the woman was about to deliver, we went down to the labor room, the intern and I.

Deliveries are usually taken by the midwife but because complications often arise, a doctor’s presence is a required formality. The delivery itself went well enough, the baby was a macerated stillborn male, obviously dead for days. She had to be given a cut to facilitate the delivery of the head and I could tell the intern wasn’t happy about that; he would have to repair it. He was getting ready to do just that, gloves and instruments set, when all hell broke loose. The placenta slipped out followed by a gush of blood which quickly turned into a geyser. I had to jump out of the way to avoid being splattered with blood. In a flash the scene around me changed. I felt like a clueless extra in a really bad horror movie. The patient screamed whether from pain or fear I couldn’t tell, she became extremely agitated and tried to sit up. As the midwife rushed to hold her down, the intern slapped on his gloves and tried to stem the flow of blood with a vaginal pack. “Get me the medical officer!” he shouted, the ward attendant ran out the door. I was transfixed, I couldn’t move. “Help the nurse hold her down” he barked at me. I put on a pair of gloves and slowly moved towards the delivery couch, I reached for one of her arms which were by now bathed in blood and very slippery. She kept calling for her mother and then asking after her baby, it was a very tragic scene.

By now the noise had attracted other staff on call in the hospital, we were joined by a couple of nurses and attendants from other wards. The patient grew more restless as we struggled to hold her down; somehow she managed to pull out the intravenous line that was in place from the time of her admission. At this point the senior doctor sauntered in, obviously not happy at his beauty sleep being disturbed. A quick appraisal of the situation told him this was a dire emergency if there ever was one. He became more animated than I had thought possible and started giving orders. He began to reset the IV line and instructed the intern to pass another one “we need two just to be safe.” Scooping blood from the couch into a specimen bottle, he handed it to an attendant, “go down to the blood bank and get three pints of blood” he instructed. Putting another IV line in place proved extremely difficult, not only because she was so restless but each time the needle went in she bled profusely. After some time both doctors looked wearily at each other and at the blood that ran in rivulets out of the patient and pooling on the couch, there was no clotting. “D.I.C” the senior doctor mumbled, “how could this happen?” I vaguely recalled what D.I.C meant and I knew it wasn’t anything good. He looked menacingly at his junior colleague, “If this woman dies …” his voice trailed off, it was obvious where any blame would be laid.

All of a sudden as if on cue, the power went out and everyone groaned. A very difficult situation had just been made ten times worse. Someone noted that the blood bank could not process blood without electricity. “Get someone to put on the generator!” the doctor shouted in frustration. Another attendant sped out obviously relieved to be leaving the room. I wanted so badly to leave too. A few minutes later the rumbling sound of the generator drifted up, only for the ancient contraption to cough and splutter and finally give out after a few minutes. Several attempts to restart it were fruitless. The nurses produced lamps as they all battled valiantly in the dark to save this young woman’s life. Someone asked if she had any relations available. “Her mother is in the waiting room”, someone else replied. “Tell her to go to a private blood bank to get us blood”, the senior doctor requested. Everyone knew it was pointless though, people who have money for private blood banks do not patronize state hospitals. At this point the patient’s breathing started to get more labored and intense. It was obvious her brain wasn’t getting enough oxygen, she pulled and strained as we held her down. The much needed blood was not available and even if it was, there was no IV access to get it into her system. I have never felt that helpless in all my life as I watched this young woman die. She was about my age and very pretty but obviously indigent. I wondered what kind of life she had led. I wanted to cry out in shame and frustration as we all looked on, medical student, nurses and doctors all equally helpless.

All of a sudden, she stopped struggling and went limp, just like that. She didn’t grow weaker and fade gradually like I thought might happen. One minute she’s struggling with us and the next; nothing. Both doctors were quick to commence CPR, I slowly moved away from the couch and backed out towards the door. I stopped at the door and took off my gloves as I observed their futile attempts to revive the patient. The whole place looked like a slaughter-house; there was blood all over the floor. The room reeked of death, an overpowering metallic odor that reminded me of the stone slab behind our house where my mother killed her chickens every Christmas. After a few chest compressions they gave up and pronounced her dead noting the time. The medical officer looked back, saw me cowering near the door and said; “useless medical student” or something to that effect. I didn’t care, I wanted to get as far away from that place as possible, especially before the mother of the deceased returned. No doubt, there was bound to be chaos when she found out her daughter was dead.

I went upstairs to get my bag, it was well past midnight by now but I couldn’t bear to spend the night in that God forsaken place. I met the intern downstairs as I headed for the exit. “You’re leaving uh?” he asked, except that it wasn’t a question. I thought I detected a tinge of envy in his voice. “Where can I get a taxi?” I asked. He gave me directions to the taxi park, “you’ll be lucky to find one still operating at this time” he warned. “Good luck.” He turned and walked back, towards his responsibility and the rest of his life. As I walked in the pitch darkness down the unlit street, I felt sorry for this young man who was just starting out in life under such deplorable conditions. And I felt sorry for myself because I knew I lacked the courage to do what I really wanted to do that night. I wanted to drop out of medical school and find another career path, preferably one that did not involve supervising the needless deaths of young people. At the taxi park I found a cab driver who took one look at my ashen face and named a price so outrageous it was obvious he wanted to cash in on whatever had got me so petrified. I didn’t even blink. I opened the car door and told him where I wanted to go. I never went back to that posting again.

I would like to be able to say that in the years since then, I have held on to my humanity. I would like to, but I can’t. It is impossible to grieve for every loss as there is only so much emotional capital one can invest in each case. Even worse is when you are stuck in a resource limited environment where you’re given more excuses than explanations. You are left with so many what ifs? What if the power had not gone out that day? What if the generator was duly functional? What if there had been enough blood? And what if it was my fault? In my profession, life gives you a new opportunity to learn from your mistakes. By the same token however, death may deny the same of your patient. Who can bear such a burden? The grim reaper wears a cloak of depression with a pungent aroma that dulls the senses as with his cold gnarled hands he collects eternity’s dues. When you see death often enough you eventually get used to it, everyone does. I know I did.