Living and Dying with Dignity

In the summer of 2009, an Afghan local national (civilian) was shot in the abdomen. He was transported to Bagram for life saving treatment. He likely would have died had he not been brought here. His abdomen was opened, the bowel injuries were sutured together, and he was given an ostomy (bag for collecting stool). His intestines were left in discontinuity. The plan was for him to return months later for his bowels to be sewn back together. Similar patients present to our hospital nearly every day. However, this particular patient was destined to become one that most of us will never forget. He would get many nicknames during his stay. I will simply refer to him as Mr. G. He was a middle aged man with a large family, nine children and a wife to be exact. He maintained a long black beard. He was quite thin and short like many Afghans. Mr. G was pleasant, easy going, and likeable.

This past January, Mr. G was admitted to the hospital to have his ostomy bag removed, a hernia repaired, and his bowels to definitively repaired. My good friend Dr. Mike Greene was his attending physician. The operation went as planned. Mr. G spent the next few days recovering. All seemed well. Dr. Greene prepared his discharge papers. Mr G was set to leave, but then we noticed a foul smelling discharge coming from his incision. It was feces. Mr G had developed a dreaded enterocutaneous fistula. What the heck is that you ask? Well, essentially it was a tract from his bowel to his skin. Fistulas are a rare complication of any surgery. It is the body's response to the trauma of surgery. I do not claim to be a fistula expert. In fact, Mr G's fistula was the first I had ever seen. I hope I do not ever see another one.

It is difficult to summarize what happened in the next 140 days of Mr G's hospitalization. I'll do my best. The irony of a fistula is that it was caused by surgery and by doing more surgery you can actually cause more fistulas. One fistula is bad enough. You do not want more! So, we had to calmly wait to see if Mr G's fistula would heal. The output of feces needed to be controlled to avoid infections. Mr G was not allowed to eat. We started him on Total Parenteral Nutrition (TPN). This is basically an entire day of nutrition in one bag that is given intravenously. His bowels needed to rest in order to have any chance of the fistula closing. TPN is labor intenstive for the pharmacy and it is very expensive. The cost would make the hair on the back of your neck stand on end. At any rate, the fistula was given time to heal. Weeks turned into months. The darn fistula just would not heal. The surgeons were chomping at the bit to do something about it. After all, a chance to cut is a chance to cure... except in the case of fistulas!


Mr. G eventually did go back to surgery. In fact, he had over 50 trips to the operating room. Our team of excellent surgeons did everything they could to find a solution. His abdominal musculature was removed and thrown into the bucket. This left him with the grand canyon of all abdominal wounds. It was not pretty. In addition to his fistula, Mr G had numerous complications. One of the main risks of giving TPN is infection because it has to be given through a large IV inserted in the chest or neck. Mr G developed overwhelming blood infections that made him critically ill not once but actually 6 TIMES! I am not exaggerating. He was put on a ventilator (breathing machine) for prolonged periods of time. We treated him with the best medications known to man. He always pulled through. Simply stated, Mr. G is a survivor. One night I was on call and we had a power outage in the hospital at 3 in the morning. The patients in the intensive care unit were prioritized because their ventilators had no power. Mr G was considered a low priority. I walked into the ICU and Mr. G was breathing on his own despite the fact that his endotracheal tube (breathing tube) was still in place. It was like breathing through a straw and he was doing it no problem. We took out the breathing tube because he obviously did not need any help breathing. He left the ICU later than day and was back to his normal self. The legend of Mr. G grew larger.

As the weeks passed, the surgeons kept trying all sorts of different ideas. Unfortunately, nothing worked. He had 5 skin grafts done to close his abdomen all of which failed. After over 4 months taking care of Mr G, my colleague Dr. Greene needed a break. I became the attending physician for Mr. G. It was clear to me that we were reaching a crossroads. An incredible amount of resources has been used in his care. Mr. G had been on an emotional roller coaster. So, Mr. G and I had a frank discussion through the interpreter. I told him that he was in charge of his health care, not the doctors. I told him that he needed to do what was best for him and his family. It was important to say this to him because in Afghanistan people will do whatever doctors say. They do not question us. I let Mr G think about this for several days. Then, one morning with his father by his side Mr. G informed me that he wanted to leave the hospital. Enough was enough. We began to make arrangements for this to happen. However, there was not agreement among the doctors about what was best for Mr. G. In the meantime, Mr G became critically ill once again. I was called to his bedside during the night because he had a fever of 105. He once again has bacteria in his blood. He went back to the ICU. Those of us that had taken care of Mr G for over 4 months were disgusted. It was difficult to see him so sick once again. But, Mr. G survived this trip to the ICU yet again. He was back to his normal self in 3 days. After all, Mr G is the ultimate survivor.

Several days later, Mr G was lead out of the hospital in a wheelchair. It was early in the morning on a clear day. I pulled a wagon full of medical supplies for him. We loaded him onto the ambulance for the short ride to the base entry control point for his release. The ambulance doors were closed. Mr. G waved good bye. Some tears were shed as they drove away. His fate was now out of our hands. He was scheduled for a follow up appointment at our hospital. I doubt he will be back. In fact, he may not even be alive today as I write this. One thing I know for sure is that Mr. G is either living or dying with dignity.