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  • Jan B. Hommel

Of Life and Death

Bijgewerkt: jun 1

Updated: May 28, 2021. Translated by Gert Priem, for which I'm very grateful!


Don't you ever go out?

When was the last time you were out?

Have you ever been out?

Oh dear...

Is something wrong with the air?

Since you can't breathe in here.

How long have you held your breath?

Oh dear...


Sophie Zelmani.



Spring 2004. After a total of eight years of intensive study, I finally get accepted as Neurology Resident in a hospital in Zwolle, the Netherlands. 32 Years old, full of knowledge from books and articles, carefully and orderly stored in my brain for years, full of self-confidence and, if possible, even fuller with doubts about my abilities in daily practice. Eager to prove to myself and others that I really can handle it, and with an amount of swagger slightly larger than supported by knowledge and expertise, I start my first job: People need to be treated and lives saved. Come on, energize, no time for inappropriate dawdling.


Treatments for cerebral infarctions, popularly called "stroke", such as thrombolysis with t-PA and endovascular treatments, are still far behind the horizon. All we have to offer people is the drug Ascal®, anti-coagulants and possibly surgery on the neck vessels. At least if, after the stroke, something is still left of the owner of the damaged brain. The current, usually rapid transfer of patients to geriatric rehab institutions within one or two weeks was still far from common practice in these times.And so, people with severe cerebral strokes, whose initially most noticeable symptom was an almost complete one-sided paralysis of the body, are waiting for weeks in our ward to be transferred to a nursing home or, to the morgue. That one-sided paralysis isn't even the largest problem: More importantly, they are simply no longer aware of the fact that there is also another side in the world around them, right down to, in case the right side of the brain is severely damaged, not recognizing their own left body half. Resulting in them not even recognizing their own left arm and leg as their own. If the left hemisphere is severely damaged, they become severely impaired in language and speech, in such a way, that they in fact experience their environment like a deaf-mute, without any verbal communication at all.


In 2004, a man in his late fifties, having diabetes, is admitted to the neurology ward. He suffered a major cerebral infarction in the left hemisphere. Communicating with him is completely impossible: He cannot speak, cannot even swallow and every time I visit him, he faces me highly puzzled and sighs deeply several times. Using his left hand, he regularly fiddles with the nasal tube and has already pulled it out a few times. Because he cannot swallow, he has already contracted pneumonia twice.

To this day, I still cannot imagine what's going on in these people. I assume to see despair in their eyes, but I really don't know if this is my projected emotion or reality. I don't even know if they realize they no longer have access to language as they used to have it, as with very young children. It is not without reason, that our earliest childhood memories start when we get access to language to express ourselves. What happened prior to that moment, can only be stored in our brain as images, impressions, and emotions, never in language.

But being a young ambitious doctor, I just get to work. I shift into "action mode" like many young doctors do, in the ambition to show what they know and can perform. Complaints and symptoms must be treated, lives must be saved: Do not think, act! This man has disordered diabetes, and no matter what the internist tries, his blood sugars fluctuate like a small boat on a choppy sea. Desperately, I start experimenting with the insulin by myself, and administer him intermediate-acting insulin three times a day; a mortal sin according to all internal medicine laws and regulations. And what no one expects, including myself, happens: His blood sugar levels become stable. The phlegmatic internist can appreciate it and give me a booklet about sugar regulation in diabetes as a present, speaking the wise words: "Whatever works, is good medical treatment". I am gleaming with pride, while the Man with the Scythe watches in amusement at me fiddling with blood sugars and insulin and shrugs with a smile, to, after a couple of weeks during the weekend, drop by after all, to graciously put a ticket for Charon's Ferry on the poor man's bedside table, when an acting neurologist does the only right thing after diagnosing the third pneumonia: He orders to abstain from curative treatment. Even before I start the new working week on Monday, the man dies.

I am confused, feeling a mixture of anger, disappointment, and frustration. Have I tried my best just for that? And it went so well! That is, with the blood sugars, as there was no sign of improvement neurologically. Every day he looked at me again, occasionally shrugging his shoulders, and sighed deeply a few times. I often found him sitting crooked in the special chair on which he was placed carefully and lovingly by the nurses, in front of the window with a view over the surroundings. I could neither assess whether he liked sitting there, nor whether he was enjoying the view. Visiting him became increasingly difficult for me; I kept sitting with him for less and less, preferring to focus on the numbers that appeared in red and blue on the computer screen. To finally just be proud of the blood sugars I had managed to regulate.

In the end, I had not done anything right for the man himself and probably had prolonged his suffering. Was it suffering? I do not know. Still don't. Anyway, the Man with the Scythe had let me calmly do my things and after my temper cooled down, he stoically finished his work. I now consider the Scythed Man may have had more empathy than I did at the time. I wanted to save a life, but not his life.


What the hell was I thinking?


What the hell was I thinking?

Time passes. I succeed in entering the neurology residency at the Canisius hospital in Nijmegen, where, three years later, I get discharged. I file a lawsuit against the "educator" and the training group, which I win gloriously, but whoever has soiled the medical nest will be an outcast in medicine for the rest of his life. No one dares to venture further training a trainee specialist who has fallen out of favor. All because it would be the ultimate sign that the concerned doctor does not wish to conform to the rules of the Guild of Medical Specialists, which is nothing less than betrayal of the Guild itself. Therefore, I am forced to move to Germany to continue to practice neurology, after a correspondence course to learn German. On to a small hospital in Kevelaer, where a new Head of Department, 'Chefarzt', has just been installed, taking two of his friends with him, appointing them to Consultant, 'Oberarzt'. My experiences there during six months, defy any description: Just being forced to leave a department of neurology, managed by an expanded Monty Python Clan, I enter another department, managed by a similar Clan.


Apparently, God was favorably disposed to me: I got to know Helmar. Helmar, Austrian by birth and 'Facharzt Allgemein Medizin' (specialist in general medicine). Being a true Austrian incredibly punctual and polite. He already works as a free representative, called 'Honorarvertreter' for years and travels all over Germany to offer his services as a general physician, or 'Allgemeinmediziner'. He is a welcome guest, simply because of his personality, and of his vast knowledge of general medicine. Helmar and I become friends, very good friends. He teaches me the facts and details of the German language and I teach him the tricks of clinical neurology. We talk about everything important and unimportant in life, and I learn German (and Austrian) humor from him. Whoever says that Germans have no humor, does not know the language, or does not listen well. It's just a much more subtle humor than our Dutch one, always with a hint of civilized irony, only audible to the good listener.

Despite spending a lot of time with Helmar during my stay in Kevelaer, and because we have a Head of Department, 'Chefarzt' who thinks it is completely normal to perform ward rounds and bedside reviews again at eight o'clock in the evening, I can't always judge him properly. At such a moment I think that it is because of my, still limited, knowledge of the German language, but sometimes I also get the feeling that Helmar is consciously shielding part of him from me. After six months, when we jointly decide that we have had enough and that our role in the tragicomic theater of the neurology department in Kevelaer is now over, we part, but agree that we will keep in touch. And so, my girlfriend, now spouse, and I travel to Moers a few months later to have dinner at Helmar's home.

He welcomes us in his simple and small apartment, furnished the way I know Helmar: "Pünktlich und ordentlich", on time and neatly, no frills. We catch up and decide to stand in together for a vacancy in Schleswig, even though I think my German is not sufficient for that. Then my eyes wander to a picture frame: A friendly, pretty girl with dark long hair, about fifteen years old, smiles at me at eye level from a shelf in the bookcase, pure and joyful. I pick up the photo and unsuspectingly ask who she is. A long silence results, and I am amazed to see that the always imperturbable Helmar is fully confused for a moment. He rubs his eyes briefly and then tells me who she is: She is his daughter.


His daughter, who is no longer alive. She lived with her mother in Vienna and went out with a boyfriend one night. With her sitting on the back of a scooter, the boyfriend overtakes a BMW X5 on the right-hand side to come to a stop at the traffic lights in front of this BMW. This action hurts the ego of the BMW-driver and as soon as the traffic light turns green, he steers in the direction of the two young people on the scooter. The boyfriend startles, they fall and Helmar's daughter ends up with her head under the front wheel of an oncoming car. She dies instantly. Her friend, also only fifteen years old, is fine. The driver of the BMW X5 drove off, and has never been found again, and thus destroys the life of Helmar, for whom the main reason for his existence after divorcing his wife, was his daughter. He regularly traveled hundreds of kilometers from his temporary workplace to Vienna to spend the weekend with his daughter. And suddenly his daughter was gone.

The Man with the Scythe likes to reside in the big cities: There is a lot of business for him, and he is not very picky when choosing his customers. He is also rarely concerned whether his clientele is old enough to use his services. Helmar's daughter also unexpectedly receives a ticket for the Boat of Charon, which unintentionally transfers her across the Styx, way too early. Once one gets a ticket from the Man with the Scythe, one can no longer refuse the crossing. Without even a moment of attention to the parents, who never want their children to make the crossing before they have done it themselves.

Ironically, at that time, my wife is pregnant with our oldest child, already 11 years old when I write this.


We are indeed moving to Schleswig together, to stand in for the vacancies in the Martin Luther Krankenhaus, where, during the week, we share the same hotel for almost five months, spending every day with Helmar. I don't even have to apply or get a welcoming interview: The 'Chefarzt' gladly follows Helmar's judgment and accepts me for the period up to the birth of my daughter. When nature calls, I finally head back to the Netherlands to await the birth of our child. Afterwards, we welcome Helmar several times at our home. One day, I ask him if he doesn't mind seeing us with our daughter and the happiness it brings us: "No". It reminds him of the early years with his wife and daughter, and it makes him happy. "No", he doesn't find it painful. "Not at all".


Time leaps again. It is the end of 2010, the beginning of 2011, I don't recall exactly: I have been able to continue my involuntarily interrupted training as a neurologist at the UMCG, where I wallow for three wonderful years in the Groningen sobriety, which permeates the university hospital, as if it were a mirror image of the hospital in Nijmegen. The three of us are again heading towards Schleswig-Holstein to visit Helmar. During the previous summer, our threesome also visited Helmar over there, as he is still working at the same hospital where the two of us previously worked together. He rents an apartment, to allow his parents to come over from the Ruhr area with some regularity to enjoy the beautiful summer. Our daughter is a few months old and sits on Helmar's lap in the doctor's room. He visibly enjoys himself, while the ever 'freundliche und immer höfliche Oberarzt' Herrn Peter Wittenhorst, holding his 'Käffchen Kaffee', watches us with a smile. It's only a short visit, not more than a few days, but our reunion is intense, and I return home a happy man. My comrade is doing well, and he even seems to be enjoying life, something that I have not seen this way before. He and Peter Wittenhorst, whose wife died of breast cancer not long before, spend a lot of time together and have become good friends. They regularly take time for a cup of coffee, and they also regularly attend a therapy session of the 'Inhalationsgruppe' at the helicopter landing site just outside the hospital, where they enjoy a cigarette. In the evening they often have dinner together in the city or at Herr Wittenhorst's home. Helmar seems to be doing well and although I know very well that the big wound in his soul will never heal, time, and the friendship with Wittenhorst, seems to do him well.





A few months later, we are again heading to the North of Germany. It starts to snow during the drive to Schleswig-Holstein, it really starts to fall. The world is covered under a thick layer of snow, making all details of the landscape around us disappear. Only the dark line of the highway ahead of us remains somewhat visible, kept clear with the greatest difficulty by spreaders and snow ploughs. We leave the highway, the roads narrow, the dual carriageway becomes a single road, we drive over crunching snow, and there is no snow plough or spreader in the distance. Only very occasionally a car is oncoming, the beams of its headlights broken by the still massively falling thick snowflakes. Our journey is progressing more slowly, and although it is still early afternoon, it is so dark that it seems as if night has already fallen. Car navigation is guiding us further and further away from civilization. Every now and then we see a light in the distance, but otherwise forest and meadows alternate, everything covered by a thick layer of snow. Eventually we arrive at our destination, a low building in the middle of the infinite no man's land where most of these clinics are located: We arrive at the Wachkomaklinik, a clinic for patients in a persistent vegetative state, where Helmar has been admitted.


In 2010, The Man with the Scythe appears to be also on vacation in Schleswig and has observed us silently and imperturbable, while we celebrate our warm reunion with Helmar. The Scythed Man also has endless patience, knowing what it means to wait, to then make a sudden move at the end of 2011: On his drive home, Helmar is seized by a subarachnoid hemorrhage, skids off the road and crashes to a tree. He's been taken to Kiel University Clinic where the aneurysm in his head is being treated. Unfortunately, with a bad prognosis. He undergoes surgery twice, gets a drain in his head to remove the excess cerebrospinal fluid, but he does not wake up anymore.

The Grim Reaper plays one of his most cruel cards: He does not offer Helmar a ticket for the Boat of Charon that would take him across the Styx to reunite him with his daughter but a one-way ticket to the Wachkomaklinik instead. This just pushes Helmar into oblivion, in the end only visited by his grief-consumed mother, who first had to take her granddaughter to her grave, and now is only allowed to see and touch the shell of her remaining son. And his father, equally barely surviving this fatal outcome, finally learns to live with it. How could he otherwise?


The last meters to the clinic are sinister. Under the white, silent dome of snow, which thickness has grown to half a meter, we make our way to the front door. Snowing has stopped for a while, but the sky is still gray and dark. At the entrance, the receptionist does not even look at us and imperturbable continues with her knitting. The tapping of the needles is audible all the way down the hall, in the intense silence of the clinic, brightly lit by fluorescent lamps in an otherwise dark world.

A little further down the corridor is a family room, occupied by two elderly people and a younger man in a wheelchair. I greet them, waiting for the arrival of Helmar's parents, who have checked in at a hotel 20 kilometers away. The older couple greets us, but the younger man stays quiet. We take a seat at a table a little further and I only now notice what is wrong with the younger man: It is a patient of the clinic, with a tracheostomy in his throat, allowing him to breathe in a soft, rattling way. It seems the only thing his brain is still capable of. He stares into space seeing nothing, not even the two old people in front of him. He does not respond to the touch of the old woman rubbing his forearm and speaking to him softly. He doesn't move, his face is completely blank, like that of a corpse. A urine sampling bag hangs from the wheelchair and the wound plaster of a PEG feeding tube is visible under his partially open hospital gown. It's a living corpse sitting in a wheelchair. His personality has long since moved elsewhere, but his body has been left here in the Wachkoma Clinic.


After ten minutes, Helmar's parents arrive. The despair, the weariness and the intense sorrow can be read on her face and Helmar's mother immediately starts to cry when she sees us. It makes me uncomfortable; I don't know her that well, but the grief is so tangible that I can't avoid it. Helmar's father gives me a look of understanding and, almost invisibly, shrugs discouraged. Together we walk down the hall to Helmar's room.

What I observe here is unreal: The clinic contains 20 rooms, spread over two levels and in almost every room someone is on artificial respiration. Not a single patient is moving, not a single patient is conscious, and the only sound I hear is the sound of the breathing machines and pumps pumping tube feeding into the stomach through a PEG tube. I count no more than two nurses who seem to float across the corridors on their yellowed crocs, apparently managing the entire clinic. Three times a week a physician from a hospital nearby comes to make his bedside rounds, there is no doctor during the weekend.

At the end of the hall, in the penultimate room on the right, lies Helmar, on artificial respiration via a tracheostomy. I recognize him by his hair and moustache, but nothing else remains of the man to whom I owe so much and with whom I hung out so intensely. He almost continuously grinds his teeth, which is perceived by his mother as a sign of life, expressing her desperate hope for recovery of her son's consciousness. I do leave it at that, but I know better, as his father does, Helmar will never wake up again.

I am devastated, deeply sad and could cry with misery. The last thing I need. For Helmar, suffering may be over now, thank goodness, but not for his parents. We stay in the Wachkoma Clinic for several hours, while Helmar’s mother continuously tries to provoke statements and my verdict as a near-neurologist, who could tell her that her son is going to be fine, just to desperately cling to. Gently, I try to tell her that Helmar will never come right again, but that message is deflected by her despair. She can't understand, she doesn't want to understand. We drive back home that same evening, into a dark world, only lit by the glow of headlights, causing the ghosts in my head to dance on the road ahead.


I haven't visited Helmar after that. No excuse given; I just couldn't bring myself to it. Moreover, there was nothing left to return to; Helmar was gone. A few months later he was transferred to a Wachkoma clinic close to his parents' hometown. It also appeared more accessible for the Man with the Scythe, who, as an act of forgiveness, still provides Helmar with a ticket for the crossing; Charon would sail extra that day. Helmar died of pneumonia, the fifth in several months, leaving his parents in loneliness and intense grief. I sometimes wonder whether it is the Man with the Scythe who is the cruelest, or rather his subordinate, God, who seems to be responsible for life.


The clock is ticking. Less than a year later, I am in the Intensive Care for Children of the UMCG. Although I have already done my pediatric neurology internship in Nijmegen, there is a shortage of physician assistants in pediatric neurology, so I am assigned to step in for two weeks.

In a bed, an almost translucent pale, and emaciated eleven-years old boy is on a respirator. He is worn out, and one after the other, his organs are failing functioning. Several years before, he has been diagnosed with acute myeloid leukemia. He courageously endured chemotherapy and even reached a moment of complete remission, with no more leukemia cells present in his blood and bone marrow. However, research on genetic changes in his malignant white blood cells predicted that the Man with the Scythe was unlikely to leave him alone and would still claim him in a few years.

That's what now has happened. He is getting chemotherapy again, which now no longer works, and that's not all; Because of the chemotherapy, his immune system has collapsed, and every bacterium and fungus can walk in unopposed, giving him a last nudge in the direction of the gangway, to then push him onto Charon's boat. That morning we examined the MRI of his brain in which a fungus has nested. A certain death sentence at this stage of the disease. That afternoon, the treatment team will talk to his parents, informing them they will be stopping treatment as there is no longer any valid reason to continue.

While I look at the boy, his parents are coming in and stay at a few meters distance. Simple folk, hard workers, and like me, coming from a farm. With a still sacred respect for doctors, as "educated people". There is nothing left to examine, and I carefully put the sheet back. I can't help rubbing his bald head, even though I know he won't notice any more. His parents see it. Not able to avoid them, I stand with them for a moment, not sure what to say. Then his mother says, with a mixture of hope and despair in her eyes: "He's doing a little better today, isn't he, Doctor? I think he looks a bit better than yesterday."


As tears come to my eyes, I briefly rub her shoulder. I can't keep a tear running down my cheeks. I do want to say something to them, but I'm out of words. We stand in silence for a while looking at their son, who, as I already know will not make it the next day, but they don't know yet. After a while, I leave them alone. I then lock myself in a remote toilet to let my helpless anger burn out. After half an hour I have finally regained enough control over myself and am able to get back to the pediatric neurology ward. The image of these two people, looking at their abandoned son, that little broken heap of misery in the bed in front of them, is carved in my memory like in granite, for the rest of my life.

Sometimes the Scythed Man is a huge bastard. A psychopath. The boy dies the same evening.


Time jumps back an odd forty years. September 1, 1980, it's my mother's birthday. Sitting on the sofa in our small living room, I watch in dismay, no, in astonishment, how my mother is hysterically crying and screaming, drops to her knees, and is helped up by two of her big strong brothers. They then put her awkwardly in a chair and keep a close eye on her. She just came out of the hallway leading to the "Sommerhuus", a part of the duplex residence, used by my grandmother. My eleven-year-old brother Wim has been laid out there, in a natural oak coffin, for an hour and a half. My incredibly smart brother, heir to my parents' farm, skipping a class in elementary school. An incredible hothead, sometimes expressed as a literally life-threatening furious rage. My ten-year-old brother, who relentlessly smashed another farmer's son, two years older and two heads taller, into the rose bushes, because this bully pulled his sister from her bicycle by her backpack, causing her head to smash on the concrete tiles. And then needs to be relieved by two schoolmasters, themselves receiving several hard blows from my enraged brother, because otherwise he would not have survived. Unyielding and crystal-hardheaded, like my mother in her best days. In the previous two weeks, at the age of eleven, he cycled 18 kilometers up and down to secondary agricultural school for the first time.

In the morning of that Saturday, September 1, 1980, my brother cycles out of the driveway of the farm on his way to the Queen's Birthday festivities in our small village. He wants to quickly go and watch the local parade, as he watched over our newborn brother that morning, while our mother assisted in milking and feeding the cows. Upon finishing her tasks, she urges him to quickly leave to go watch.

He gets hit by a car that drives way too fast and does not brake. A hundred meters away, the car comes to a halt on a milk churn which disappears half into the ground. My brother has been thrown headfirst against a tree and dies instantly. The bare spot on the tree is visible to this day, 40 years later, overgrown with tree bark, but nevertheless still recognizable. As if it were the enormous bomb crater, slowly filled with water and plants, that this event creates in our lives.


The sight of my broken mother scares me so much, I don't dare to look at my dead brother for two days. In the evening, needing to go through the same hallway on my way to the stairs and my bedroom, with pounding heart I sincerely hope that the door to the 'Sommerhuus' is closed.

Only two days after his death I dare to sneak over to the 'Sommerhuus' to look at my brother. It is my first acquaintance with the result of the work of the Man with the Scythe, which, until then, I only considered a meaningless theme, not realizing its real meaning and result. I am amazed and relieved at the same time; Has this been causing my mother to cry so hysterically? My brother lay still behind the glass, a bruise on the left forehead, eyes closed. So peaceful, so serene.

Until the funeral, I repeatedly check on him and quietly sit next to the coffin without anyone seeing me. This image will never leave me again.

It is only much later that I realize what the Scythed Man has done: My mother has been hospitalized at a psychiatric ward, although I don't remember much about it. A professional family aid stands in to care for us, but that memory has also been erased. Eventually, my mother returns home but never speaks about my brother in the years since, and the subject is painstakingly avoided. I remember seeing my father turning around and cry again when I ask about Wim once. It ends with that. When asked in front of my mother how many brothers and sisters I have, I always doubt whether to say five or six. I usually stick to five because that's more comfortable. Only after my mother passed away in 2005, the existence and decease of Wim is discussed again. My father can easier express himself and does talk about it, with us, the other kids, and with his own brother. There will not be a successor to continue farming. Whether my brother and my father, also not the least stubborn, would have made it together on a farm, I will never know.

It takes at least 25 years before I gradually lose the automatic reflex that every accident, without exception, is fatal. The Man with the Scythe has gotten a steady place to live and stay in my head and will never leave. The image of my older sister walking towards me crying and saying: “Wim is dead, Jan. Wim is dead”! The image of a nervous man, skittishly turning and squirming on the edge of the kitchen chair, as if he, more than anything, would like to run away. My mother blocking the escape route, hands on her broad hips, slightly bent over looking at him. Hellfire shooting from her eyes, filled with an intense hatred for this man, such as I have never seen in anyone and will never likely never see again, while commanding me to go to bed, with such intention that I wouldn't dare to argue with her. Compared to my dead brother, I am a softie, a reader, but above all a dreamer, and only much later I realize, that the driver of the car that killed my brother, must have been alike.


I do not know why I am writing all this. As if by themselves, the stories flow from my fingers to the screen.

I do not know why I am writing all this. As if by themselves, the stories flow from my fingers to the screen.

For a long time, I have conceded to the supremacy of the Man with the Scythe. He's in charge. He is also my boss. One day he will also take me to the bank of the Styx for the crossing and I am at peace with that. At best two thirds of my life is over and as we say in our region, Salland: "I've already eaten the majority of all potatoes". Several times in recent years I have felt His most keen gaze, as a weight on my shoulders, like a heavy burden. The Man with the Scythe will explicitly announce when being nearby. But apparently, he can't use me yet and I haven't earned my ticket for Charon's Boat yet. Every day when waking up, I check whether my arms and legs move, whether I know who I am and who the woman next to me is, whether I can still recognize both sides of the world and whether I can speak, to then deeply grateful conclude that I was probably allowed another day with my wife and dearly beloved children. With every death certificate filled out by me - there are not that many anymore, they are usually filled out by physician assistants - I realize being one death certificate closer to my own death certificate. I don't count remaining years, but death certificates, taking comfort in the fact that I shall certainly not have to fill out mine myself.


The clock is set forward again, some 25 years: I am fulfilling my gynecology and obstetrics internship in Apeldoorn. I do not resent female beauty, but rather look at faces than vaginas. In this medical specialty I feel totally out of place, and I hate the sight of women sitting on an examination table with their legs in leg supports. I would prefer to walk away, but I must endure this, to be able to call myself a medical doctor in a year's time. It takes me many years to realize that this part of the human body can also fail and become ill and therefore specialized doctors must be educated, regardless of whether they are male or female. Thank goodness I'm not one of them.

My educator is a handsome and gracious woman in her fifties, slightly elitist, with a radiant and catchy smile and an understated sense of humor. The beauty of her youth is far from gone, but I don't know whether this is because of her appearance or her character. I remember her coming in for the morning briefing roaring with laughter. It's shortly before Easter and she shows a cartoon that she cut from a newspaper, one that I have never been able to find again. The cartoon shows a woman lying on an examination table, her legs in stirrups, while the gynecologist rolls up his examination gloves up to his elbows with the text below the cartoon: "So, my lady, where did you hide your eggs for Easter'? Even I laugh about it.

This lady is specialized in obstetrics and perinatal care. I often watch in amazement as she supervises a complicated delivery, hands behind her back, completing it successfully, where other gynecologists quickly turn to determining blood gases, evaluating a cardiotocography and rely on forceps and suction cups. When I ask her the question of 'why?', she teaches me one of the most important lessons one should learn in medicine:


Jan, what you see is mainly normal physiology. No pathology. And you should stay away from physiology, as a physician you can never beat nature itself. As a doctor, only when pathology takes over, you must intervene. You should only act when necessary.”


"You should only act when necessary."


Jan, what you see is mainly normal physiology. No pathology. And you should stay away from physiology, as a physician you can never beat nature itself. As a doctor, only when pathology takes over, you must intervene. You should only act when necessary.”



"You should only act when necessary."


It is a lesson that people like Mark Rutte, Hugo de Jonge, Diederik Gommers and Ernst Kuipers have never learned. It can't be expected from politicians either; they don't know any better. They are selected by appearance, not content. It is not at all surprising that they shift into action mode, comparable to young and inexperienced doctors when they first enter clinical practice. Tests need to be executed, followed by more testing, test lanes need to be built. It must unavoidably be bigger, better, faster. More testing. Better source and contact research. Quarantine should become mandatory. More and harsher measures. During every debate, politicians roar in unison without even briefly evaluating whether the right path has been chosen. The virus must be fought, crushed, and destroyed. Regardless of any social damage caused by this strategy.


Operation successful, society died.


But Diederik Gommers, acting Head of all Intensive Care Units, should know better, because exactly his department, despite all the diagnostic and therapeutic possibilities, is the major supplier to the Man with the Scythe. He is a frequent and welcome visitor at the intensive care units often collecting several boats full of clientele for a last crossing over the Styx.


Ernst Kuipers on the other hand, fulfills what I expect him to do: This man firmly believes that life can be shaped and thinks he is smarter than the Man with the Scythe. He thinks he can even rise above the Man with the Scythe. Ernst Kuiper is the protagonist in the tragicomedy, set in the Theater of Death, the regular night out of the Man with the Scythe. Ernst Kuipers is the one who handed us the raw deal of national screening for colon carcinoma, to the effect that principally healthy people in their seventies, with an inherently shorter life expectancy, are given priority to get a colonoscopy over younger people with a diseased colon. As a result, the latter category is forced to wait much longer for diagnostic tests which they need far more urgently. (1). All this without any hard evidence that screening for colon cancer leads to a significant decrease in mortality. No more then this has been proven for breast cancer or cervical cancer screening (2).


This can't be any other way because with increase of age, the 'law of the competing death causes' applies: The Scythed Man's Toolbox is becoming over filled with the ever-aging population and is bulging as soon as old people reach the age of 75 to 80 years. The Man with the Scythe no longer needs to meticulously search in his toolbox, each grab in it provides a tool that meets the needs of bringing people across the Styx. Alas, Ernst Kuipers has skipped this chapter while studying, or simply ignored it during his impressive career.


Last week at the polyclinic, I re-examined a woman, who had earlier been referred with pain and numbness on her chest side, shoulder, and arm. She had also unintentionally lost 15 kilograms of weight. Twelve years ago, she had been treated for early-stage breast cancer. She has long since been discharged from checkups by the oncologist. As I feared, she appears to have severe breast cancer metastases. She asks how long she has left and whether she will be having a lot of pain.

I tell her I don't have the answers, also because I don't know exactly what the oncologist still can offer as possible treatments. Knowing that she will not recover, I honestly, calmly, and clearly inform her about that. I advise her not to postpone any things she still wants to do in this life. Exactly how I would really like to recommend to everyone. Finally, the ultimate question is posed:

"What's it like to die, doctor?"


I reply that I don't know because I've never done it. That usually puts a smile on people's faces. I also indicate that we can generally treat distress, pain, and shortness of breath well, and that every doctor generally does the best he can. As a final remark I mostly come up with the following:


"I don't know what dying is like. Like I said, I've never done it. What I do know is that you only have to do it once. There is no dress rehearsal and if it comforts you, even the largest dorks succeed. Always."


Usually, that clears the air.


With or without screening for colon cancer, breast cancer or cervical cancer, the Man with the Scythe always provides the last trip. No matter how many test facilities are built, no matter how well source and contact research is performed, no matter how many vaccines are injected into old human wrecks, and no matter how many harsh measures that destroy our society are taken, the Man with the Scythe has the final say.


Always.


What the hell are they thinking?



1. See "Rapport Verdringingseffecten binnen het Nederlandse Zorgstelsel uit 2018", commissioned by Nederlands Zorginstituut.

2. "Minister, I want a population screening". Joost Zaat, 'Tijdschrift voor Geneeskunde', 2018. https://www.ntvg.nl/artikelen/minister-ik-wil-een-bevolkingsonderzoek



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