Patrick Russell
Med J Aust 2015; 202 (7): 389-390. || doi: 10.5694/mja14.00539
Published online: 20 April 2015

Highly commended — Practising and retired doctors category

When I first met him, Jack was in a hospital bed, tired with cool feet. A small hand-held AM radio was at his bedside softly playing golden oldies, though the radio itself did not appear old. Even in bed, his heavy frame, built to last, showed how mighty a force he had been in his prime. His chief complaint was progressively worsening fatigue, which he blamed on his age. But his physical examination suggested otherwise: the soft, whining systolic murmur; the left ventricular heave; the tell-tale carotid upstroke that felt as though it was grunting against the dead weight of an old refrigerator. All these signs bore evidence of his diagnosis: calcific aortic stenosis. His was a stolid, stubborn valve with hinges rusted quiet, though he was, as he said, old.

Still, he was mentally clear. He spoke about symptoms present or absent, about his medical history, his life and his priorities. His wife of 63 years had dementia and he was her primary carer. He described his daily routine in detail, attending her needs and the needs of the house he had built with his bare hands, making every single brick himself when he was still young and strong. He said the brick-making helped him get on with his life after the war; helped him pick up the pieces, to emotionally repair and nurse wounds without much fuss.

“Was it worth the trouble?” I asked. “Trouble?” he asked dryly, “what trouble?”

My job for him was brief: I confirmed the diagnosis and spoke to the interventional cardiologist, who was happy to help. The risks of the procedure were made clear, as well as the benefits — this was purely to make him feel better and would not add a single day to his life. Jack listened carefully, thanking everyone for their bother and accepted the stated risks in order to continue helping his wife. He had no other reasons. With no further need for me, I signed off on his case.

The endovascular repair of his valve, an expensive exchange for quality of days, went off without any technical glitch; but, of course, things are never that simple. There are always risks not included in the brochure. Neutropenia developed, a complication of a pre-existing problem, followed by nosocomial pneumonia. A month later, I slipped past him in the hallway working with a physiotherapist. He looked frail, feeble and destined to fail. I thought he was finished.

The next and last time I heard Jack speak was at the ANZAC Day service 6 months later, a service to pay respects to war veterans alive and dead. Australian and New Zealand Army Corps. Courage, loyalty, trust and mateship defined his era of soldier, qualities that linger long after a war is over.

The service was attended by more people than should be available in a town of only two hundred: old people who know the unromantic sounds of war — sounds base and arbitrary — as well as young and middle-aged people who do not. The eulogy was read as wind blew through the maroon and burnt orange leaves falling from the pear trees along the main street. The crowd of a hundred people circled the dark grey polished granite memorial and listened to the reading as sparrows flitted playfully and a crow called rudely in the distance in tapering tones. In the breeze, I thought I could hear the mortars drill through the air and explode without malice in no-man's land; the machine guns firing warning shots at Gallipoli; bomber engines droning over the North Sea. Just faintly, the mundane sounds of war mingled with those of the day. On the obelisk were the names of the fallen, engraved and painted with gold, as well as those who had returned; written across the bottom “For Our Clarendon Boys who died in the Great War 1914–1918”, with addenda as other wars and other names were added. And they were, indeed, boys' names, mostly.

I recognised Jack in the crowd only moments before he spoke. He was much thinner than when I had last seen him in the hospital corridor. He sat on the seat function of his four-wheeled walker with brakes set, elbows resting on the handlebars and eyes staring downward without care. He blinked slowly, listened carefully, and waited. When his turn came, he stood with assistance from his son under one arm. Without reading, he spoke the words with the slow, crackling voice of a 93-year-old man, but deliberately as a man who knew his time was short:

They shall not grow old as we that are left grow old;
Age shall not weary them, nor the years condemn.
At the going down of the sun and in the morning
We will remember them.

He spoke the words on that clear autumn day as birds played in the trees, the same sparrows that gave men hope when things fell quiet on the Western Front.

He spoke the words without haste, as an old man can speak without tears about things that break hearts and make mothers weep.

He spoke the words by heart, from the same stubborn loyalty to remember so often felt during the quiet times of a day when a person is alone, such as when laying the bricks of a house, or driving to work on a rainy day, or sweeping the kitchen floor after kids are safely in bed at night. A loyalty to remember mates and the sound of their laughter, though the sounds of war always intruded without invitation, a drizzling rain of quiet grief from wounds that never fully heal. And wounds Jack would not discuss.

Those words, the last I heard Jack speak, served as the benediction of the memorial service and the backdrop for the raising of the Australian flag. An honoured boy hoisted it to the top, the flag blowing and popping in the wind, while the squeaky pulleys turned. The rope hit the flagpole irregularly with a mechanical baritone pitch, “thunk, thu-thunk”, the same irregular cadence of a malfunctioning machine of war, hobbled by enemy fire. A lone bugler played the “Last Post”. There was no other sound but the birds. A few other official words were spoken, awkwardly juxtaposed with the sacred, then everyone adjourned across the street to the town hall for morning tea.

Jack was tired and was taken back to the brick home he had built and to the care of his wife. A few weeks later, he had a fall and died.

Was his endovascular valve repair worth the trouble? The medical economist would say no, label it a “low-value intervention” or even a waste, and state that the expense of this procedure could have been spent elsewhere — vaccines; education to prevent teenage pregnancy; or public transportation safety ads. This calculation would not, however, factor in the inspiring words that filled the gathering with reverence that ANZAC Day when Jack spoke, just as the pneumonia, deconditioning and the prolonged hospital stay could only be factored in with hindsight.

Was it worth the trouble? Would I have paid cash out of my own pocket to fix that crusty, stubborn valve of his just to see Jack stand unconquered and hear him say those last words against the backdrop of a fluttering flag and a lone bugler? Words about men fallen many years prior, words charging me not to forget them, or what they had done, ever. And words that linger still.

Was it worth the trouble?” I asked him.

“Trouble?” he asked dryly, “what trouble?”

The MJA Dr Eric Dark Creative Writing Competition was judged by Leah Kaminsky, MJA Deputy Editor, Poetry and Fiction.

  • Patrick Russell

  • Royal Adelaide Hospital, Adelaide, SA.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.