I was a first-year resident in downtown Toronto when I got a page. The emergency physician started the conversation in a way that makes every resident's heart sink. "I've got an interesting one for you."
"Eighty-seven-year-old gentleman with an incarcerated hernia. I reduced it, but he continued to have pain, so I scanned him. Imaging shows a sigmoid volvulus. I told him he needs surgery, but he doesn't want it. Will you talk to him?"
A sigmoid volvulus is an emergency; the colon twists on the axis that carries its blood supply, creating a closed loop obstruction. Without intervention, it can lead to perforation and death. "Time is bowel," we say. I hurried to the patient's bedside.
Through the doorway, I saw a frail, well-kept older Black gentleman accompanied by a man who looked to be about my age. Before I entered the room, a colleague in the emergency department called out to me, "Hey you're gen surg right? Heads up in there, he's a difficult patient." He said the man didn't want an intravenous line and had come to get his hernia reduced, get pain medication and go home.
I nodded and walked in. The patient's eyes were as dark as mine, and in them I could see his immense pain. I introduced myself as the junior surgical doctor and saw a look of relief on his face. He spoke with a thick Guyanese Creole accent as he introduced me to his companion, his grandson, and told me his story. His vital signs were stable, but my physical examination revealed a tender and distended abdomen. I explained the critical nature of his condition and that he needed an urgent colonoscopic procedure to untwist his bowel.
"A suh yuh want mih fuh dead? A kill yuh want kill mih? Ail a mih family dem, dead out in dis place!"
I pause. Though not grasping every word that came from his mouth, his body language, expression and passion are something familiar to me. "No Granddad, I don't want you to die," I responded. "I understand your concerns and I want what is best for you. I know you are in pain. With this procedure, we can treat your pain and get you home as soon as possible. Without it, I worry it won't get better on its own, and if it gets worse you may require an emergency surgery."
We...