Dead Write (Australian Doctor 17 June, 2010)

June 17, 2010 § Leave a comment

DEATH. Certificates. Two words that are unpleasant individually and downright ugly together. But death certificates are eventually written for us all, because we never save lives, we just delay deaths.

I’ve learnt a thing or two about death over the years. For instance, I now know what it means if gentle rotation of an oropharyngeal airway draws dark blood — particularly if the unconscious mouth seems oddly unrelaxed.

This is pathognomonic for ‘do not attempt resuscitation because your home visit patient is already in rigor mortis’.

In addition, I know you shouldn’t decree to relatives that Gran has departed until you’ve witnessed more than a minute of asystolic arrest. And, if she unexpectedly and briefly arises from the dead before irreversibly shuffling off this mortal coil, it is appropriate to diagnose her bitter complaints of chest pain as angina rather than reflecting on that cracking noise heard during your earlier precordial thump.

I’ve also picked up a thing or two about certificates. To be blunt, they are often rubbish. (Okay, that’s only one thing about certificates but let’s pretend it’s two.)

A few weeks back, I received a 3am call from the police. An elderly patient had unexpectedly died at home and the usual quick decision was needed. Could I write a death certificate or was a coroner required?

I had a quick talk to the police (“no suspicious circumstances”), the paramedics (“a run of VF”) and the widow (appropriately shocked and already articulating what I often tell patients, namely that a quick death is often better for the victim but worse for the survivors).

I agreed to write the certificate. Ischaemic heart disease had claimed another victim.

This led me to reflect on a past incident. One week after finishing my intern year, I was promoted to medical superintendent and sent bush.

A local resident suddenly died in a pub and, needless to say, resuscitation proved futile. The ambos asked if I’d write a death certificate or whether the government medical officer should do an autopsy.

I took the easy option. Why write a speculative certificate if an experienced doctor could do an autopsy?

The next morning, I rocked up to work and was surprised to be told a body was in the morgue. The dreadful truth dawned. I wasn’t just the town’s medical superintendent; I was also the region’s government medical officer.

The local police sergeant twigged that I hadn’t expected to do the autopsy. He obligingly suggested that most patients die from “my old car deal in Far Cushion”. I made a mental note of this and proceeded to remove the corpse’s heart. This was partly to pretend I was doing a proper job and partly to placate the salivating wardie doubling as pathology assistant.

After appropriate examination of lifeless innards, I confiscated the circular saw from the disappointed wardie. He still wanted to remove the brain but I was ready to decree the cause of death. It was, as the sergeant had anticipated, myocardial infarction.

This is, of course, the problem with all those murder investigation TV shows. In real life, Constable Plod discovers a body and rings the local GP. Then, before the brilliant forensic team gets the merest whiff of an intriguing case, one of our colleagues signs off on my old car deal.

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