PROSTATES AND EMPATHY

I’ve wanted to tell this story for a long time, but it took me a while to figure out how best to tell it. It’s about a man I met during a nursing placement in my second year of university. I tried writing it as a short story but it felt flat. Then I tried writing it as a verse poem, but quickly discovered it would be the longest verse poem in history, and who has the patience to read a painfully long verse poem?

But I think I’ve figured out the underlying problem: I was telling the story from my patient’s perspective. I thought this would bring some immediacy to the tale, but I’ve decided the power of the story isn’t from showing the elderly patient’s point of view, it’s from showing a young naive nursing student’s. In this case, being an observer is what gives the story its guts.

So now, I’m just going to tell it:

 

The placement was my second effort at actually entering a nursing environment and getting my hands dirty, literally, and my first within a hospital. Before this I had spent two weeks in a nursing home during my first year, and, while shockingly confronting, there was no real acuity to the experience. The patients weren’t patients, they were residents, and the job was to maintain their comfort. This was a real hospital. Looking back, it’s almost laughable; the hospital was the tiny rural hospital of Leongatha, which has a total of twenty-eight beds. A single ward of a metropolitan hospital has more beds than that. But, for me, it was a real hospital, and I felt hopelessly inept within its walls.

I met Ron on my third day. He was in his seventies, a local, and had been admitted because he couldn’t empty his bladder. Or, to be technical, he had benign prostatic hyperplasia. Basically, for whatever strange hormonal reason, when men get over the age of fifty it’s not uncommon for their prostate gland to begin growing. The trouble with this is the prostate wraps around the urethra, the tube through which urine is drained, and a growing prostate literally chokes the urethra. This results in an almost perpetually full bladder. Not a good thing.

I’ve wondered what Ron saw when he first met me. Meeting Ron, I saw a silver-haired old man with smile lines on his face and an ease I immediately admired. He was a person comfortable in any situation because he was comfortable in his own skin. He knew himself and liked what he found. I think, upon meeting me, he must have seen the opposite: an awkward young man unsure of himself and his place within the hospital.

 

The compact nature of the Leongatha hospital meant not only did I get to care for Ron both pre and post his operation, but I also had the opportunity to be there with him during the actual procedure. The operating room was ten meters away from the ward.

I remember stepping back from Ron’s trolley where we had stopped outside the operating room’s double doors to give space for his wife to say goodbye. It felt too formal, that moment, a pause for the wife to say words of sentiment. I both liked the official nature of the final farewell and found it slightly ridiculous, with the staff standing watch like respectful morticians. Ron wasn’t going in for heart surgery, and while there can be complications, death was a very far off possibility. Ron also saw the humour in the moment and joked while his wife attempted to be sincere. She eventually rolled her eyes and laughed him off, telling him to behave with the nursing staff. He threw me a wink as he promised he would.

We went through the double doors, his wife now marooned on the other side, and I waited with Ron while final preparations were made to the operating room. I wanted to keep Ron company, but I also had no idea where I was meant to stand, and beside the patient’s trolley seemed like the most appropriate place. Ron chatted with me while he lay, and I stood, in the cold hallway, and on reflection I realised he did this as much to keep me distracted as himself. Any nerves either one of us felt were diluted with conversation. It didn’t take Ron long to break his promise and give incorrect answers when asked by the surgical staff to repeat his name and date of birth. He found claiming to be twenty-six vastly amusing, and had a way of laughing that made it impossible not to laugh along with him.

 

One of the starkest images I have from that operation was before it had even commenced: seeing Ron have his epidural inserted. The operation Ron had is called a TURP, or a transurethral resection of the prostate, and it is done with the patient fully conscious. The epidural numbed Ron from the waist down. To have the needle inserted the patient sits on the edge of the operating table, curled forward, while the anaesthesiologist counts vertebrae and inserts a sharp splinter of metal into the spine. Given the delicate nature of such a procedure the patient must stay as still as possible, which means they can’t talk.

Seeing Ron topless and hunched forward, his face devoid of the usual animation talking gave it, made him seem so much older than he had before, as if he was now just another patient, a frail and scared man. He looked vulnerable, and it made me admire the strength with which he held himself the rest of the time to hide this fact.

My other vivid memory of the surgery was the smell. A TURP is done by inserting a long tube up the penis to where the prostate sits around the urethra, where the blockage is. The tube does two things: it constantly floods the bladder with fluid that drains away down a separate lumen, taking with it the blood from the soon-to-be bleeding prostate, as well as being tipped with a small metal loop that, when electrified, becomes instantly white-hot. The loop is what does the carving. The surgeon sends pulses of electricity into the metal and then scraps it along the inside of the prostate where it is growing into the urethra, burning away strips of gland. Think coring an apple from the inside.

The smell I smelt was cooking flesh. As the loop fried the prostate the smell of it drifted around the room, the smell of a steak in a frypan. It was made worse by the fact that it wasn’t instantly offensive, only when you realised what it was you were smelling. Ron, of course, was unperturbed by his own cooking prostate and found plenty of humour in the situation, joking about what a fine chef the surgeon was.

 

The climax of Ron’s tale, and moment that awed me and made Ron unforgettable even after five years of patients, came on the day after his surgery. He was back on the ward, only his bladder still wasn’t emptying.

After a TURP, an irrigation system is set up so that fluid constantly runs through a catheter into the patient’s bladder and out again into a giant catheter bag that sits beside the bed. The prostate is a highly vascularised gland, and, even with the cauterising effect of the searing hot loop, still bleeds profusely after the surgery. The fluid goes into the catheter clear but drains away a deep red. The liquid lightens as the bleeding slows and eventually stops and this is when the hospital staff know it’s safe to cease the irrigation.

The risk? Clots. Blood pooling in the bladder and urethra is a bad idea on the best of days, but the real risk comes when the blood congeals and becomes a plug, effectively creating the same outcome as a urethral-choking prostate. Unfortunately for Ron, despite the irrigation, clots had still formed and blocked his catheter.

This was the scene: Ron sat reclined on his bed, legs spread and his gown flicked back over his stomach. Two doctors crouched between his open limbs, working with the catheter inserted up his penis. Blood and saline soaked the beds sheets as the doctors took a large syringe and squirted further fluid up Ron’s catheter.

The idea is to create turbidity within the catheter and bladder by quickly shooting liquid up the tube, thereby dislodging any clots. The doctors then draw back on the syringe and hope to suck the catheter-plugging clots out of the bladder.

The problem was the clot stopping Ron from being able to drain had wedged itself in the lumen that took fluid away from the bladder. This meant the doctors could squirt saline up but not drag it down. Ron’s bladder was already full from the irrigation and the pressure was only getting worse. Imagine that moment when you have held off from going to the toilet for too long, the worst incidence in your life, maybe a car trip, or a meeting, when your whole lower abdomen is cramping and you’re bitting your lip to stop from whimpering in pain. When it feels like something might literally rupture inside you. Now multiple it tenfold. Every time the plunger of the syringe went down Ron fought to stop his body from buckling in agony.

So there’s the scene – Ron in torment as his already overfull bladder gets another shot of fluid that has no way of coming out, blood staining the sheets from previous attempted recatheterisations, and all dignity discarded in the heat of the acute situation. Even with his gown covering his top half, Ron was as exposed as a human can get.

This is when his granddaughter chose the unfortunate timing to visit, and to make matters worse, with a new boyfriend in tow.

Naturally the nursing staff intercepted Ron’s granddaughter on the other side of the curtains and explained the situation, suggesting she wait or come back another time. Ron, however, found the idea of his family coming to visit and his failure to welcome them rude, and so insisted they come in. His granddaughter took a chair beside Ron’s head and held his hand, and Ron joked that he never did anything the easy way. The boyfriend, as unsure of his place as I was, and visible overwhelmed by the intensity and intimacy of the situation, stood to the side of the room, his face a beacon of the fear I was hopefully hiding with my professional demeanour.

I can still remember the exact moment when Ron’s gaze lifted and he saw the young man well and truly past his comfort zone. A shudder racked Ron’s frame and I watched as he bit down his pain, forced his face to relax into a smile, and asked the young man how he was going.

He was fighting down agony, blood spilling from his penis, and he cared enough to reach out and attempt to comfort the stranger who had intruded on this mortifying moment. He had seen a person in distress and acted. I’m sure it was that simple to Ron, regardless of his own torture at the time. He was just that kind of man.

 

The last memory I have of Ron is as I was leaving, having finished my final shift at that strange and small hospital of Leongatha. We had shaken hands, he had wished me luck, and thanked me for my help. I can’t remember if I thanked him, but I hope I did. If I was back there again I would remark on what an incredible human being he is. I would tell him I admire his strength, and his consideration, and thank him for teaching me an important lesson about empathy, and humour. The final image I have as I left that ward was seeing Ron, the ringleader amongst four other men his age, all having had a TURP, holding up his catheter bag and remarking on the lovely pink colour of his handbag. The men all chortled and displayed their respective bags, commenting on the various shades of red they each had.

He had turned something as embarrassing and awkward as a blood and urine filled catheter bag into a joke they could all join in on, and I think that one example is enough to show why Ron’s is a story worth telling.

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4 thoughts on “PROSTATES AND EMPATHY

  1. Christopher robb says:

    An excellent “tell” Jonathan. Thank-you for sharing. Most often, empathy is all one can give. It is a beautiful gift. While not expected, in addition to their skilled care, we experienced it from some of your colleagues in Maureen’s recent lengthy hospitalization. C.

  2. sue robb says:

    Another great story Jon, thanks. I remember you first telling us about Ron and the impact the made on you. It is trully special to be able to participate in someones life at times like this.

  3. nallac says:

    Thank you for sharing this story. I happened across it after reading another of your blogs shared by your aunt, my friend, in FB. You have a wonderful gift for observational writing and a beautiful empathy for your patients.

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