Sylvia and Bruno, A Love Story

I watched an aged couple today as they made love.

She is in her late eighties, he’s a little older. Thirteen years ago, Sylvia (not her name)
became vague and forgetful. Bruno (not her husband’s name) passed the farm on to 
the children so he could care for Sylvia at home. For ten years this worked well, but as 
Sylvia became less active she gained weight and as Bruno aged he lost muscular 
strength, the strength that built the farm that sustained a family. Three years ago, Sylvia was admitted to the nearby nursing home. Bruno visits Sylvia every day.

Until today Sylvia had remained the most placid, easy-going resident in the home. When she was found this morning, burning with a high fever, pale and limp, helpless even to sit, breathing fast, her heart racing, her blood oxygen levels low, she remained that same tranquil, agreeable person.

“She’s severely demented”, said the nurse, “It’ll be cruel if we overtreat her. Let’s just 
keep her comfortable.” This is code for, let her die.’

When I met Sylvia at 0630 she gazed at me, eyes wide. Was this recognition? The opposite? What, who, remained behind that enquiring gaze?
‘Hello, Sylvia, I am the new doctor.’
Sylvia, her face pale, yellowed, smiled. I thought of my mother, another placid smiler.
Sylvia spoke, a voice soft, barely reaching my hard ears.
I leaned over her and listened as she spoke again: “You’re the doctor.”  
Attending at her bedside in the early morning, clad in my running shorts, vivid cap and colourful singlet, I don’t look like anyone’s idea of a doctor  – or a runner. But Sylvia knew. 
These were not the words of one ‘severely demented.’ 

I called Bruno, made the call that relatives know will one day come, the call they dread: ‘Bruno, I’m the doctor caring for Sylvia. She has a fever. I thought you should know… She’s not in danger, but we need to decide what treatment will be best for her and I’d like you to come in and give me your advice.’ A lot of words, too many words. Words to paper over insecurity, uncertainty.
Bruno thanked me for calling. He asked, ‘When would you like me to come, Doctor?’
‘Any time that suits you, Bruno.’
‘No Doctor, you’re a busy man. My time is my own. When will it suit you best?’
We agreed to meet at nine-thirty.

I studied Sylvia’s file. There was a reason for her long stare – she has glaucoma. And diabetes which will make her vulnerable to infection.
I read the family’s biographical notes: ‘Sylvia is a gentle, happy, quiet and kind person; compliant; she has sons, husband, extended family, friends who visit her often; she likes fruit, enjoys stories on television; she understands, even though she answers with only a few words. Please speak to her slowly.’ 
Elsewhere I read a relative’s observation: ‘I believe Sylvia does not have the ability to consent to or decline treatment.’
Once again I thought of Mum, a patient who’d always agree with a doctor, always wish to defer, to oblige.

I found Sylvia’s End of Life Directives: ‘Keep her clean and dry and as free of pain as possible. Please do not provide therapy that is futile. In the event of acute deterioration or critical event, she may have IV fluids, IV antibiotics, CPR, defibrillation not more than twice, a short course of ventilation.’

I tried to decode the directives: the family allows resuscitation, ventilation and defibrillation – more or less Intensive Care – while excluding futile treatments. But you never know whether intensive treatments might be futile. You do know CPR must be vigorous to succeed. In the words of an Emergency Medicine Physician of my aquaintance, ‘If you don’t break any ribs you won’t save them.’  And short ventilation slides easily into prolonged. Dying is prolonged and deformed; and any living that remains is disfigured.
This constitutionally gentle soul, comfortable in her frailty, undistressed even in her febrile state, would she welcome such rough treatment? What roughness, which bodily incursions, can the family tolerate? 
I needed Bruno to help me untangle this nest of contradiction.

At nine-thirty, I found Bruno seated by Sylvia, holding her hand. On her bedside table, a pear, freshly peeled and sliced, waited Sylvia’s pleasure. I introduced myself. Once again I told Sylvia I was the doctor. She looked at me, then over to Bruno. He nodded and her wide face relaxed and fell into a smile. Since my earlier visit her temperature had fallen and her breathing improved.

I listened to the front of Sylvia’s chest. I wanted to examine further, to hear the breath sounds at the lung bases. Sylvia, aged, weak and ill, would need help to sit up. Ordinarily I’d ask a nurse to support her but Bruno was here. Sylvia would know, her body would remember the touch of Bruno’s hands.
‘Bruno, when I sit your wife up, will you hold her shoulders for me?’ 
I hauled Sylvia’s upper body upright and Bruno leaned forward and placed one hand on each shoulder and steadied her. My stethoscoped ears listened intently to the breath sounds. Faint crackling betrayed the pneumonia I suspected.

Pneumonia, the old person’s friend. Will antibiotics save Sylvia? ‘Bruno, this is pneumonia. It’s a dangerous illness. Do you want us to use antibiotics? We’d give them through a vein…’
But Bruno, raised in a time and a school where the doctor gave orders, replied: ‘You’re the doctor. Whatever you decide will be for the best.’ 

Deep in cogitation, I applied the stethoscope again. Eventually I looked up. Two large brown hands, the joints wrecked by time and work on the farm, supported Sylvia’s creamy shoulders. Bent forward, held by her man, Sylvia gazed into Bruno’s eyes. I noticed her right hand. Sylvia moved it back and forth along the inside of Bruno’s forearm. Up to the elbow, back down to the wrist, up, down, Sylvia’s fingers stroked Bruno’s skin.
The fingers caressing, moving upon the silence.
Two people, oblivious of this interloper, oblivious of all, man and woman made love and confounded me: where I had wondered how much treatment would be too much, now I sensed how much the two still gave and received from each other, how precious to each was time with the other. 
How much treatment will be enough? 

Phone Calls from my Dead Brother

My brother Dennis

My brother Dennis

This evening and tomorrow the family will mark the seventh anniversary of the dying of my firstborn brother Dennis. We’ll light candles and congregations will join us in remembering him.

Two weeks before he died Dennis underwent elective surgery. I wondered if the surgery was wise. Dennis, whose life’s creed was hope, assured me: ”Doff, this operation can eventually cure diabetes. It will transform my life.”
We spoke daily on the phone – he from his hospital bed, I from a hellhole town in the deep Kimberley. Day by day Dennis seemed to be doing well. But on day four he told me: ”I’m OK but my belly hurts”. A belly ache bad enough for stoical Dennis to mention was bad enough to alarm me.

Day five, no phone call. That day the pain was worse. Dennis collapsed, his circulation failing as his abdomen filled with blood and stomach acid leaking from his wounds.
At his bedside in Intensive Care the following day we counted the tubes entering and departing Dennis’ comatose form. One into his windpipe to make him breathe; a second into a great vessel to deliver information; a third to bypass his kidneys which had failed; a fourth to drain his bladder; a fifth and sixth into peripheral vessels to deliver fluids and the hero molecules that just might save him.
The greater the number of tubes in a patient’s body, they told us, the lower the chance he would leave ICU alive.
I sat at his bedside and I watched my brother. Behind the clicks and gusts of his life machines swelled the sounds of classical music. Annette, his loving sister-in-law, thought to play that music, those patterned sounds that ever soothed his troubled breast.
I sat there and watched as nurses, tender or tough, kept my brother alive. The tough ones, resentful of something – were we too many, was this medical brother too medical, that sister too exacting, that aged mother too accepting? – made me feel small, in need again of a big brother.

Dennis turned the corner: blood pressure held firm, sleeping kidneys awoke, fewer molecules were needed. The doctors conferred and announced: “We’ll let him wake up now and breathe on his own.”

Dennis breathed and slept on. We all breathed, went home and slept.
At four in the morning my phone rang. A crepitous, rustling sound, a broken voice in windy gusts: it was Dennis: “Doff, they want to njjhrnnujicxvclbkvn”
“Den, I can’t hear you. Say it again.”
Gales and crackles and Dennis’ voice in fragments: “Doff… inaudible… they…unintelligible…the tube back in.”
“Den, are you saying they advise you to go on the respirator again?”
More gasping, a desparate heaving of voice: “Yes!” More gasping. “Is it a good idea?”
“Den, it’s your best hope. Say yes.”
“Alright Doff.”

That was the final phone call. Dennis and I never spoke again. By the time I reached the hospital Dennis’ coma was renewed, the respirator breathing for him. Soon his circulation collapsed again, the doctors tried heart-lung bypass (“It’s only ever been shown to work in children. It’s your brother’s last hope..”) and on the eve of Shabbat Dennis died.

***

I can speak or write of Dennis dying with a composure that surprises me. Even my fatal advice does not trouble me. Perhaps it was not the dying of my big brother, but his living, that calls to me and troubles my dreams.

How to Widen the Gap

In my novel “Carrots and Jaffas” a whitefella doctor working in an outback Aboriginal community has a recurring daydream. The doctor’s dreaming is of a pathway into a healthier unobese, normotensive, undiabetic, heartwell community. That pathway is the path of a sugarless past, a path followed by gatherers and hunters, who are not fast and fizzy food consumers.

That dreaming, a sort of longing for escape from the simple carbs that destroy his flock, that widen the Gap, is born from the reality the Doc sees at the checkout in the community’s foodshop. The local people stock their trolleys, proceed to the checkout, proffer their paycards and wait. The cost of the foods frequently exceeds the funds in the card. The customer removes this food, that food, the next – until the tally equals the funds. First to go are milk, vegies, fruit. Then meat. Finally the customer is left with white bread and brown fizzy cola.

The Doc reels at the choices, at the grip on appetite and taste of these poisons: “more harmful – because more widespread  – than alcohol”. The Doc, an old utopian, dreams of a switch to the Zero option, the sugarless drinks that will please the taste for sweet and the pull of caffeine…The Doc does not fear the scaremongering over artificial sweeteners; thirty years ago these were going to cause cancer. Thirty years on he is still waiting for those cancers. Meanwhile sugar’s harm is here, everywhere…

The experience of that old doc is my experience precisely. In fifty communities, over twenty five years, I have seen these carbs at work on babes in arms, on youths and matrons, on aunties and uncles. In go those carbs and the gap widens that we are successfully closing elsewhere.

A crunchier cereal than usual

While eating my breakfast cereal this morning I noticed a small brownish-black, curved item, the size and shape of a carraway seed. It didn’t taste like carraway, lacking that distinctive aroma.

As I ate I noticed more of these and removed some. The cereal I favour is GrapeNuts, manufactured in the USA by Post. It is crunchy and malty (and doubtless full of salt and sugar to enhance my hypertension and to speed the onset of diabetes.)
I really like Grape Nuts.
If you examine the packet you’ll notice the letter “K” that signifies its kosher status.
I tried to avoid eating the little brown-black crescents because, although they too were crunchy, and not without aroma, I could not be certain whether they too are kosher*,
Quite quickly I surmised that a mouse had breakfasted before I had and then used the cereal packet as his toilet. While chewing on my compound breakfast I thought of my friend’s brother who had invested all his savings in superannuation over a period of twenty years. One day the manager of his Super ran away with his life savings. My friend’s brother said: “It was only money. It was never really mine: money never is anyone’s – not permanently. It came to me from others and it went to my Super man. Now he’s spending it and it’s going to other people.” I realized that my GrapeNuts were just like that money. Made from wheat and barley, they came from the earth. They passed through my mouse and now they have entered me and will eventually make their exit and return to the earth. Like my friend’s brother’s money, the GrapeNuts were never really mine. Presently they will fertilize new wheat and fresh barley an someone else can have a turn.
Perhaps you will be next.
* Guidance from rabbis or others is sought on the kosher status of mouse droppings. As we know
a Jew may drink the milk of a non-kosher animal, so long as that animal is a human. Can we consume the ordure of another mammal?

GrapeNuts

GrapeNuts