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Updated 03 September 2013

Mandela medical mysteries

When it comes to Nelson Mandela's state of health, it's impossible to know who to believe, says CyberShrink.

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Saturday morning, major international news media report Mandela had been discharged from hospital and is now at home. South African media seem not to have heard of this.

Shortly afterwards, the Presidency insisted he was still in hospital, still critical, but stable. The world media say they were informed by a family member, some say a daughter, who, they later say, has told them that she was misinformed by someone else in the family. But that he will definitely be discharged later on Saturday.

Sunday morning, the Presidency confirmed that he had indeed been discharged, but a day later than previously reported, and is still critical, but stable, occasionally unstable. It’s no wonder people now don’t know who or what to believe.

It’ been reported that his home’s been converted so as to provide for essentially an ICU ward in which he can be cared for, and a report mentions doctors from the military, state and private sector being involved in providing that care, which is a unique medical event. If this is satisfactory, one wonders why this was not done before, and why it’s been decided to return him home at this particular time.

Not long ago, the world's media camped outside a hospital near my home, eager to report real news about the international icon, Nelson Mandela.

So where was he?

As before, media were left trying to guess which hospital held Madiba. Rumours were rife, vans sped about to wherever he might be. I spotted a street blocked off by military ambulances outside the local Urology Hospital, which seemed unlikely. How undignified and pointless to play sordid games about the whereabouts of the man considered a national treasure.

Maybe they were concerned that some of the media might behave badly, though there are laws easy to apply if any of them misbehaved, and over months I can't recall one single instance when any member of the media damaged the dignity of the great man in any way. The clumsy attempts to avoid this were actually more damaging than anything the press scrum did.

The information provided was really poor in credibility, quality and quantity, so the press were left with very little to report. For a time there were silly news items in which they showed us the other guys hanging around, also waiting. This was a potent way to encourage reporters to dig for gossip and tempt them to use underhand ways to get news from inside the hospital. To a remarkable extent, they resisted the provocation.

There was a statement handed to a court saying he was in a "persistent vegetative state" which would mean enduringly unrousable and barely alive; then a visitor said he was sitting up in bed watching television.

Usually, elsewhere, it’d be done differently. Doctors would, with the consent of the individual himself (and of the immediate family only if he were not able to form or express an opinion), issue through a medical spokesman, a dignified statement about the famous person's progress. The information should be suitably detailed and informative, without being intrusive or undignified. Having the statements made by a political spokesman inevitably politicises them.

The puzzle of odd statements

Official statements have been puzzling, but largely unquestioned. For long periods we've been told he was "critical but stable". This is curious. Critical implies a crisis, something urgent, liable to change at any moment, dangerous, risky, perilous, hazardous, fragile, and not long-lasting. It means the essential signs of life are precarious, the outcome unpredictable, with a significant risk of death.

How long can an emergency last before it is no longer emerging but fully present? "Critical, but stable" is really not good news, as the stability means things aren’t at all getting any better, while the ‘critical’ means they can hardly get much worse. It’s like wobbling on the edge of a high precipice --- one really hopes to hear the person has moved away from the danger, not that they’re remaining close to it.

They're saying he's stably unstable; certainly uncertain, definitely indefinite, and firmly fragile.

Then more recently we’re told he's been improving steadily, but is still critical. Improvement would necessarily move one away from a critical state. It’s like saying he was teetering on the edge of that high cliff, and has now been walking steadily away from it for some weeks, but is still at the edge. How’s that possible?

Now he's "critical but stable ---at times unstable". And "his condition tends to stabilise as a result of medical interventions" (you’d hope so?). Doctors are said to be "working to effect a turnaround, improve his health, and keep him comfortable." There’s been no explanation of what required the long period in hospital. Usually with a chest infection, once the infective organism and the appropriate antibiotic(s) are identified , management is straight-forward. If it’s an unusual organism, perhaps one that’s become resistant to multiple antibiotics, it can be difficult to find a useful treatment, but it usually doesn’t take months in hospital.

The puzzle of why he was moved

It was never clear why a seriously sick old man in Johannesburg - where there are a number of excellent hospitals and a famous medical school - would be transported at significant risk and delay, to Pretoria, which is no better supplied with suitable facilities.

In some countries there's a tradition that a current head of state, who’s formally Commander-in-Chief of the military, would be treated in a military medical facility, but though we were told that some military doctors and nurses were indeed attending to him (which they could just as well have done in Johannesburg) and a military ambulance used, his destination was a private hospital.

Later reports of serious deficiencies in the conditions and facilities at the 1 Mil Hospital in Pretoria may explain why he was not admitted there, and rather confirmed when we learned that the ambulance broke down completely and after a lengthy delay at the side of the road, our idol had to continue his journey in a different vehicle. But why Pretoria? Surely no scintilla of risk to Mandela could have been considered simply to convenience the military medical staff? As their experience would presumably be mainly with young soldiers and their injuries, were these really the most experienced doctors in the entire country, to help a very sick geriatric patient?  

The apparent lack of speech


In some bizarre and incredible comments after the video of President Zuma's visit to Mandela at home, was released, when we saw the poor man immobile and unresponsive, but were told he was up and about and chatting.

Since then nobody has mentioned Mandela as speaking at all, for a really long time. If there’s no other obstacle to his speech, this suggests serious compromise of his consciousness or brain function, so as to render him unable to achieve speech. But if he’s been on a respirator, as reported, with the machine is breathing for him, that suggests serious compromise of brain and lung function.

Being placed on a respirator, one would usually have tubes in one's mouth and throat, and would be heavily sedated, as this is very highly uncomfortable and difficult for anyone to tolerate without sedation. Speech would then be impractical for mechanical and chemical reasons.

One doesn’t lightly place anyone on a respirator. It's very unpleasant for the individual, and even in a fit young person needing such help briefly after, say, a car crash, it can be really difficult to wean them off the machine and enable them to resume breathing independently and comfortably. In an old and frail person it may be exceedingly difficult or even impossible to achieve.

Some reports stated that his kidney function is being artificially maintained on a kidney machine, suggesting a broader level of organ failure. This does not seem to have been contradicted or denied, so it’s apparently true.  In such situations, not denying something, strongly suggests it's true.

Controlling life


Situations arise, where the body can be kept going, in a fashion, with respirator, dialysis, and other mechanical and chemical support, for a prolonged period, even if the brain, the centre of self-hood, is no longer functioning. Even someone effectively brain dead, can be kept body-alive for a time. They then cannot die naturally. Someone then needs to decide to switch off the sustaining machines.

Whoever controls this decision-making while the individual is unable to indicate their own wishes, can decide to keep them going for personal or political advantage, and then to switch them off when this is more convenient. Without very adequate back-up generators, a power-cut could be lethal. Nobody can say what’s happening in this particular situation, of course, or that it’s not happening: the relevant information isn’t available. But we continue to hope that all decisions are made solely in the interest of Madiba’s own comfort and best interests, and his previously expressed wishes.


Professor MA Simpson is Health24's CyberShrink. A South African psychiatrist, he qualified in medicine and in psychiatry in Britain. He has been a senior academic, researcher, and Professor in several countries. Read more of his columns.

 

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