On Death and Dying
Human beings -- Homo sapiens - have been in existence for some 200,000 years. If I would have lived at anytime other than the past 100 of those years I would have died from what happened to me last week. The death would not have been noble. It would not have been peaceful. It would have been excruciatingly painful and were I still alive after a week I would have been begging for someone to kill me.
A couple of weeks ago I woke up at 4:00 in the morning with a moderate pain in my back. I am 61 years old and that is not too uncommon at my age. My thought was that I had slept wrong and it was a muscle pain. I got up took a couple of ibuprofen and sat down in a comfortable chair in the living room to see if the pain would go away. After about 5 minutes it hadn't. It had gotten worse and had now radiated to my abdomen. The main pain seemed to be underneath my rib cage on the right side. It felt worse after 10 minutes so I got up and walked around. At about 30 minutes the ibuprofen seemed to kick in and the pain went away. I went back to bed and didn't think too much more about it.
It happened again last week. Wednesday morning, again at 4:00 AM, I woke from sleep with a moderate pain in my lower back on the right side. I wanted the pain to go away faster this time so I took not only two ibuprofen but two acetaminophen as well. Ibuprofen is a non-steroidal antiinflammatory drug (NSAID). It's mechanism of action is that it blocks two enzymes involved in the cyclo-oxygenase pathway (COX-1 and COX-2). The cyclo-oxygenase pathway produces prostaglandins that mediate pain. Blocking them reduces pain.
Acetaminophen, on the other hand, is not an anti-inflammatory drug at all. It's mechanism of action is not as well understood as is that of the NSAIDS, but it is thought to involve nitric oxide pathway that is stimulated by neurotransmitters like Substance P (the "P" stands for "pain").
The point is that the two drugs work through different pathways, and because of that they can be SYNERGENIC - that is, they complement each other in their pain relief. Except this time it didn't work. The pain got worse. Again it soon shifted to my abdomen, underneath my right rib cage as before. ... And it kept getting worse.
I have had many occupations in my life. The one I have right now is as an optometrist. I work at a community health center and do more medical optometry than I do vision correction. At the community health center one of the standard questions we ask of patients when they come in is "Are you in any type of pain?" If the answer is "Yes", then we ask the patient to grade the pain on a scale of 1 to 10. With 1 being very little pain and 10 being the worst pain you've ever felt in your life. I would have graded the pain at 9.
At about 5:00 AM, with the pain no better, I woke my wife and told her I needed help. We decided to go to the emergency room. My options were an emergency room at a huge medical center complex, or the smaller 24 hour emergency room nearer home. I tried to think of what could be wrong with me. My tentative differential diagnosis at that moment was as follows:
(1) Gall bladder problem.
(2) Kidney stones
(4) Heart problem
... in that order of likelihood.
We decided to go to the emergency room at the big medical center in case I needed surgery then. It took about 30 minutes to get there. The pain was worse. I would have rated it at 9.5.
We pulled into the emergency room. Interestingly, they had valet parking. I thought I could walk to the emergency room but once I got out of the car, I felt very woozy. My visual field began to blacken in the periphery. I sat down in a wheelchair instead. I was rolled into the ER.
My wife filled out the paperwork and I told the nurse my symptoms. He thought it sounded the most like a gall bladder problem as well. A doctor was called and a shot of morphine was ordered for pain relief. I don't normally take a lot of pain killers. For most pain I had rather suffer through it than take too much and have detrimental side effects. But in this case, I was eager for the shot.
He gave me the shot ... and .... NOTHING. There was no pain relief that I could tell what-so-ever. It should have worked, but nothing. Another hour went by. It was 6:00 AM and I would still rate the pain at 9.5. I was given a second shot of morphine ... and NOTHING. No pain relief that I could tell. The doctor was called and they decided to check to see if I was having a heart attack.
An EKG was ordered and I was given a chest x-ray. They were perfectly fine. I was given a stronger pain killer - Dilaudid. ... And ... NOTHING. The pain was still 9.5 and it was now 8:00 AM.
I was taken to have an ultrasound done of my gall bladder. In order to do that a probe was pushed up underneath my rib cage ... right at the site of the pain. It hurt worse. For the 10 to 20 minutes they were doing the ultrasound, I would have rated the pain a 10.
The ultrasound technician refused to tell me anything about the results of the exam but I gathered from all the twists and turns she wanted me to do and the time it took to do them, she was seeing something. So I was becoming convinced the problem was my gall bladder. I was taken back to ER to await the official word from the doctor. The pain was still a 9.5 and this was around 9:00 AM.
The doctor came in and said the ultrasound showed some thickening of the wall of my gall bladder. It could be an infection, she was going to give me an antibiotic and admit me to the hospital, and I was to be seen by a surgeon. She also gave me a second shot of dilaudid. ... And ... SOMETHING. The pain became better. It lowered to a 5. Then down to a 3. And then down to no pain at all.
I had spent 5+ hours of the worst pain of my entire life, and now it was better. I was happy again. I was taken upstairs to my room. The surgeon was waiting. Since I was no longer in acute pain, he said that I COULD wait on surgery if I wanted. He said that the acute pain probably wouldn't come back after the dilaudid wore off, but that I would probably eventually have another episode. Also waiting increased the risk of pancreatitis, a potentially very severe condition. He said most people would rather have it taken out.
I didn't spend a long time thinking about it. I NEVER want to go through another episode of pain like I went through. I wanted it out. I wanted the problem removed. He said fine and he would see if he could work me in.
I was fortunate in that I had not eaten anything since about 7:00 PM the night before, so it was a good time to do surgery. As it turns out I didn't have to wait long. It was 12:00 noon. I had been in my room about 30 minutes, and they came to wheel me away for surgery. My wife and son were to go out and get something to eat ... I was to have my gall bladder cut out.
The gall bladder was removed laproscopically. That is instead of making a long incision through the abdominal wall, they punched 4 small holes in abdomen. The biggest one went through my belly button. Three others were underneath my rib cage. The surgeon removed the gall bladder and used disolving sutures to close of the internal wounds and used super glue to close off the external holes. I was back upstairs by 2:30.
The surgeon came in to tell me that my gall bladder was much worse that the ultrasound indicated. It had actually died and become necrotic. It was well on its way to rupturing and it was a fortunate thing to have it out when I did.
All was great ... right. Well ... no. I suffered an unexpected complication. Following surgery I couldn't piss on my own. After all the pain medications evidently my bladder wouldn't contract to expel the urine. I was making plenty but I couldn't get rid of it. My bladder expanded. Another ultrasound was ordered to see just how much urine was in it. The answer was 800 ml's. I was given a "straight catheter" and the urine was expelled into a wash basin. The catheter was removed.
The idea here was that my bladder would come back soon after the drugs wore off so let's see how well I did the next time I felt like I needed to go. I awoke in the middle of the night with the urge. It was not easy to get out of bed so soon following surgery but I went to the bathroom and tried to pee into a urinal (they wanted to measure my urine production). And ... NOTHING. The ultrasound showed 900 ml in my bladder. I got another straight catheter was used to get it out.
The next time I was able to pee a little bit. About 10 ml's at a time. That was all. And it even though I peed frequently my bladder was filling faster than I could empty it ... another 900 ml. I can tell you now with a great deal of certainty that my bladder holding 800 - 900 ml's of urine does not feel good. In fact, it hurts. I was given an indwelling foley catheter this time and sent home with instructions to see the urologist on Monday. That meant 4 days of having that catheter inside me.
I can tell you now that there are few things I like less than having that catheter in there. But one of those few things happens to be the feel of my bladder with 900 ml's of urine that I can't piss out. So I tried to make the best of it. I found that staying in the house wearing loose fitting underwear was the best way to go. Pants rubbing against the catheter line every time I took a step quickly became uncomfortable.
Once while watching TV I crossed my legs. That is a habit I do quite often. It had never been a problem before but when you are wearing a leg bag on the leg you use to cross over and it becomes higher than your bladder, the urine goes from the bag back into the bladder. And again I soon had my bladder painfully extended.
Another time while trying to sleep at night the bag fell off the stand I had put it on. The floor was a little farther away than the drain line of the catheter would allow. The catheter pulled painfully on my urethra. Chronic irritation of the urethra caused some minor bleeding and occasionally chunks of blood would go through the catheter line. Nothing major ... but nothing that I was glad to see either.
Yesterday came and I went to the urologist. The question was, "Could the catheter be permanently removed or not?" The hope that it could rested on two different things. (1) It had been 5 days since the surgery and perhaps my body was moving back to normal, and (2) I had been sent home with a prescription for Flowmax, a drug to treat benign prostatic hypertrophy (BPH).
Again, I'm 61 years old. the urethra runs right through the middle of the prostate gland. As a man ages his prostate enlarges and it compresses the urethra making it harder to urinate. Before the surgery I had noticed that I seemed to need to go more often. Perhaps by shrinking my prostate with the Flowmax I would be able to pee easier.
The first thing that was done when I went to the urologist was to take out the foley catheter. It burned when it came out but I was happy to have it removed. The second thing that was done was to stick a smaller line back into my penis and up into the bladder. This smaller line had a pressure sensor and pathway in which to inject saline into my bladder. The idea here was to inflate my bladder with saline and see what type of pressure my bladder could produce as it tried to expel it. It did OK. I was able to expel it. That was first real piss since the surgery. It burned but It also felt satisfying.
But that wasn't all. One possible reason that following surgery I couldn't piss was that I may have had prostate cancer. Before he sent me home he wanted to rule that out. And just how was he going to do that? By shoving a camera up my penis into my bladder and taking a look. OH FUN.
It turned out everything was fine. I could go back home catheter-free. I was happy again. I'm at home right now. I have peed several times on my own. I no longer take it for granted. I enjoy doing that. My belly is still sore from the surgery and I don't get up and down as easily as I did before the surgery, but that will return. I have decided that I am going to use a bit of that unused sick leave I have accumulated and take the rest of the week off. When I go back to work next Monday, I expect to be fully OK.
But ... this episode has given me some time to do a little thinking. I'm 61. My father would have been 61 in 1974. He would have survived my gall bladder problem OK. Except where I have 4 small holes that will heal and be almost unnoticeable, he would have had a 6 to 8 inch scar. His heal time would have been a month or more.
My grandfather would have been 61 in 1939. He would have PROBABLY survived it OK much like father. He would have faced a larger risk of developing a post-surgical infection since antibiotics at that time were not so good. My great-grandfather was already dead before he turned 61. I do not know what he died of. My great-great-grandfather would have almost certainly died from the problem. He would have been 61 in the 1870's. He lived in the rural mountains of North Carolina. The nearest place to go where he could have been treated would have been Atlanta, Georgia, 130 miles away. He would never have made it there.
There would have been morphine to try to kill the pain but that is about it. And for me the morphine did nothing. Eventually the gall bladder would have ruptured exposing the abdominal cavity to digestive juices and bacteria. Peritonitis would have occurred with severe fever. He would soon become delirious with the pain and fever and then die. That is not a death I would like to have.
We have come a long way in a relatively short period of time. What has gotten us here. The answer is science. As far as I know, no one prayed for me (me and my family are atheists). If my father would have had the problem a lot of people would have prayed for him; and they would praised God for his recovery. A lot of people would have prayed for my great-great-grandfather too. And they would have thanked God for relieving him of his pain when he finally died. The prayers for my father and grandfather would have been indistinguishable. But my father would have made it and my great-great-grandfather wouldn't have. The difference again is not God. The difference is science.
Human progress has NOT been a function of religion. It has been a function of science. I'm alive today because of science. It never once occurred to me even during the worst part of my pain to ask God for help, even when science didn't seem to be working. I always thought that my best hope for relief of problems came from science. If the pain medications never worked the answer to the problem would have been to do the surgery and remove the gall bladder. Asking God to magically make it go away would have done nothing. I think almost everyone would agree with that, even the religiously inclined. Yet I also think that most people (especially the religiously inclined) would have asked God to magically make the pain go away. I also think most people would have thanked God when the second dilaudid shot removed it. But dilaudid is a product of science ... not a product of religion.
I can certainly understand the feeling of helplessness one gets in such a situation. I can understand the desire to have some loving superbeing with the power to stop your pain stop it. I can understand the feeling like if something didn't work the first three times it was tried perhaps it was God who finally relieved the pain. I can understand it. But my understanding doesn't make me any less convinced that you are wrong to feel that way.
My great-great-grandfather would have died from this. People DID die from this back then. God was just as much there then as he is now. Why do we now get a relatively free pass and the people back then got a one way ticket to a very painful death? What is different now that then? The scientific knowledge.
One of my other occupations had been scientist. Besides having an OD degree I have a PhD in neuroscience. I remember when I was in graduate school and reading everything I possibly could about neuroscience in particular and science in general, I came upon the statement (I don't remember the exact source) that said, "80% of all scientists that have ever lived are still living".
This is the age of science. We have learned how to do it. It took us a hell of a long time to do that, but we did it. And it has paid dividends like no other human activity (including religion) ever has. A religious person may argue that it was God that made the scientists. If so then why did he wait so long? If he had done it earlier people who DID die painful deaths during my great-great-grandfather's time would have been spared the suffering. God was just as much there then as he is today.
Science wasn't. There were very few people doing it. They didn't have a great idea on how to do it. It has been a very difficult process of making sure that what you know is true. It is a process that is not perfect. Sometimes you are convinced that what you know is true even though it isn't. But eventually science (the process, not necessarily the individual scientists themselves) figure it out. It is a human process; no supernatural involvement what-so-ever. In fact, science can ONLY deal with the natural world. It doesn't have access to any supernatural world. If science is going to look at the supernatural it must look at putative instances in which the supernatural world affects the natural world. And every time it has tried those instance have disappeared.
Earthquakes are due to movements of tectonic plates, not due to the anger of the gods. Disease is due biochemical abnormalities of the body, not to actions of evil demons. I'm alive and spared a painful death not because of supernatural magic. I'm alive because of logic and science. The supernatural had no apparent role in it. As far as we can tell the supernatural has no apparent role in anything. It has been uniquely useless. Why? God may have been just as much there in the past as he is now; but that still amounts to nothing.
I feel very fortunate and thankful that I survived with only a few hours of pain and a few days of annoying discomfort. I give my thanks to the many unnamed people who worked their asses off to discover facts that led to the science we have today.