The dance

I was a third-year medical student on my psychiatry rotation when a series of events began that would ultimately alter the course of my life.  It started with a middle-aged woman with schizophrenia who complained of severe low back pain.  Well, I thought, even paranoids can have enemies, and even schizophrenics can have legit back pain.  I acquired an MRI performed on the patient during a previous incarceration and placed a consult with the Acute Pain Service.

The resident who came to see my patient was a soft-spoken Filipino man.  He thoughtfully evaluated my patient, then wrote a note providing recommendations for management of her pain.  Afterward, he sat in the residents' workroom with me.

"What do you want to do with your life?" he asked.

I had my answer ready.  "I want to be a surgeon."

He smiled.  "I wanted to be a surgeon once, too.  Do yourself a favor, and do one elective in anesthesiology.  You may love it, in which case thank me later.  If you still become a surgeon, you'll be a better one because you'll know what happens on that side of your patient.  And if you do anything else, you'll still learn how to start IVs, mask ventilate, and intubate, and those are useful skills for any physician to have."

His advice made sense, and four months later I found myself on an elective anesthesiology rotation at the public hospital across town.  For the first two weeks, I enjoyed the specialty's combination of applied pharmacology and procedures.  But it was during my third week on service that the course of my life changed.

The event that changed my life began when my attending received a page from the OR control desk.  "Dr. Evans," said the head nurse, "General Surgery has posted an emergency ex lap on a patient in the ICU.  They think he's hemorrhaging.  They say we should treat it like a trauma.  Our trauma room is OR 12."

My attending started walking down the hall as he called an available senior resident.  "Steve?  A patient from the unit is bleeding out.  Set up room twelve for trauma."

Within minutes, Dr. Evans and I were running alongside an ICU bed getting information from the surgery team.  The patient was a 50-something male with a history of alcohol abuse who'd been admitted to the hospital with Mallory-Weiss tears.  He'd been stably ill in the ICU for a day but had acutely decompensated that morning.

We arrived in the OR where Steve was ready to receive the patient.  He'd enlisted the help of Megan, another senior resident, and activated the hospital's massive transfusion protocol.  The OR became a blur of action as we moved the patient to the OR table, attached monitors, and started high-flow oxygen.  The patient looked terrible: heart rate in the 160s, blood pressure of 50s/30s, and altered mentation, all consistent with hypovolemic shock.  Dr. Evans administered scopolamine and rocuronium through the patient's IV, I applied cricoid pressure, and Steve intubated the patient.  I noticed that nobody turned on any volatile anesthetic for maintenance anesthesia.  Megan leaned over and explained, "He's too shocky.  Gotta make him earn his gas."

The next hour was a blur.  The surgeons opened the patient's abdomen and found that he had nearly exsanguinated from his left gastric artery.  They stopped the bleeding, then searched through his abdomen for any additional sources of hemorrhage.  But I hardly noticed them, so enthralled was I with the anesthetic dance that unfolded before me.  For a dance it was, with the three anesthesiologists coordinating their efforts to thwart death as it sought to claim our patient.  There was no wasted movement.  There were no wasted words.  There was no duplicated effort.  Steve, Megan, and Dr. Evans danced around and with each other to administer drugs, transfuse blood, draw labs, evaluate and adjust, evaluate and adjust.  They put me to work as their go-fer, running between the OR and the lab, the pharmacy and the blood bank, retrieving the precious information and materials with which they would save a man's life.

As quickly as it had begun, the dance ended.  The surgeons had controlled the bleeding, closed the patient's abdomen, and applied clean white dressings to his wound.  We moved him back to his ICU bed, made up during the case with fresh linens by the attentive housekeeping staff, and began the long journey back to the ICU.  The patient was critically ill, but alive.  We gave report to his nurse, then gathered our equipment and returned to the OR suite.

The rest of my workday was unremarkable -- just bread-and-butter patients receiving bread-and-butter anesthetics for bread-and-butter surgeries.

As I left the hospital that evening, I pondered the events of the day.  That's when I had a sudden thought, so simple and profound that its arrival could herald nothing less than a life-altering shift.  They saved his life, I thought.  That whispered thought seemed to echo across my mind.  They did.  They saved his life.  A pause.  Then another thought.  I helped.  I did.  We did.  We saved his life.  My shiver had nothing to do with the cold.

In that moment, all the other clinical work I'd done shrank to insignificance in my mind.  I'd helped care for inpatients and outpatients, children and adults, women and men.  But all of that work had been chronic or subacute care.  This was different.  This altered the framework of my very thoughts.  Never before had I seen a life rescued as death was in the very act of claiming it.  Never had I seen a man tumble from the precipice, only to catch hold of a lifeline thrown by an angel of mercy.

Suddenly, I knew what I wanted to do with my life.

End-stage

“Dr. Sutton, have you taken a look at our next patient yet?”

I looked up from my computer to see my CA-2 resident standing in the workroom doorway.  “I was just pulling her chart, Joel.  How’s she look?”

“You’re not gonna like it, sir.”

It was 11 pm and our general surgery colleagues had posted an ex lap on a 55-year-old woman with free intraperitoneal air.  I opened her chart and started scanning her notes as Joel watched from the doorway.  One entry in her problem list stood out: alcoholic cirrhosis.  “How bad is it?” I asked.

“Horrible,” he said.  “Pull up her labs.”  He entered the room, followed by Kaitlin, the CA-3 resident on call.  Joel waited while the screen loaded, then pointed to a series of sequential BMPs.  “See that?  Right there, from one draw to the next.  Her chemistries looked stably marginal, then in the last two hours they just fell off.  Her kidneys just gave up.  And she’s on a non-rebreather upstairs with a gradually increasing oxygen requirement all day.  She’s in florid hepatorenal and hepatopulmonary syndromes.”

“You know I hate it when you’re right, Joel,” I teased.  Joel was an exceptional resident – one of the brightest and hardest-working people I’ve ever met.  I’d rarely found a reason to doubt his instincts or thought processes, and on this night I agreed with him completely.  Still, it’s my job to teach, so I swiveled my chair to face him and started to elicit his thoughts.

“What do you think we should do, Dr. Pierce?” I asked.

Without missing a beat, Joel told me his plan.  “I think we should ask the surgeons if they really think this is going to help.  Her perioperative mortality risk is off the chart.  She’s an optimal candidate for comfort care.”

“And if they say, ‘Damn the torpedoes’?” I asked.

“She’s already lined up,” he said, referring to the patient’s pre-existing arterial line and venous access sites.  “Induce with etomidate and a prayer.  Albumin for volume, get a gas and switch to product if indicated.”

“Extubate?” I asked.

He thought for a moment before answering.  “Maybe see how she does.”

I shook my head and pointed to her serial ABG results.  “She’s got progressive respiratory decompensation and they’re gonna do a big abdominal whack.  I think we’d get called to tube her at some point tonight regardless of whether she had surgery.  Let’s just plan to leave her intubated.”

“Makes sense to me,” Joel agreed.

I turned back to the computer and paged the attending surgeon, who returned my page almost immediately.

“Hi, Matt, you guys ready to bring our ex lap patient down?”

“Hey, Raji, I wanted to talk to you about that.  Her labs look like the beginning of the end.  Have you guys had a ‘goals of care’ discussion with her and her family yet?” I inquired.

“Yes, we did,” he answered.  “She’s got hepatic encephalopathy, but we discussed everything at length with her mother.  Her mom wants to go forward.”

I sighed.  “OK, they’re setting up room 6.  We’ll go see her and bring her down.”

Joel, Kaitlin, and I gathered the equipment we’d need to transport the patient to the OR, then went to the ICU to meet her.  We arrived to find a cachectic-appearing woman with clear increased work of breathing.  Despite the non-rebreather facemask, her oxygen saturation was 93%.  Her mother was at the bedside, an anxious woman who appeared to be in her mid-70s.  Two other women, who appeared to be the patient’s sisters, were also present.  A surgical resident was in the room writing orders, and two nurses were preparing the patient for transport.

As I took in the whole scene, I made introductions.  “Hi, ma’am, I’m Dr. Sutton and these are Drs. Berthold and Pierce.  We’re the anesthesiologists working tonight.  We understand the general surgeons think you could benefit from an operation.”

The patient nodded, but her mother answered for her.  “Yes, they think she has a hole in her intestines.”

I stepped to the bedside.  “We want to talk to you about your health and our plans for your anesthesia before we get going, OK?”

For the next couple minutes, my residents and I gathered information and learned little that we didn’t already know.  Her cirrhosis had decompensated to the point of impairing her pulmonary and renal function.  Otherwise, the patient and her family denied any significant medical issues.  Kaitlin and I stood back while Joel explained the anesthesia plan.  He told the patient she’d be intubated and remain unconscious throughout the operation.  Then he said that we intended to leave her intubated postoperatively.  The patient and her family went quiet as they digested this new piece of information.  After a moment, her mother spoke.

“How long will Patty have the breathing tube?” she asked.

Joel took a breath.  “We’re not sure,” he replied.

I stepped forward to take the lead.  “Ma’am, we sincerely hope she can wean off the ventilator over a period of hours and have the breathing tube removed.  But you’ve seen how her breathing has worsened throughout the day.  As sick as she is, there’s a chance that she might not be able to come off the ventilator at all.”

Again, the room went quiet for several moments.  “So she might have a breathing tube for the rest of her life?” the mother asked.  “For years and years?”

I looked around the room.  The nurses had stopped what they were doing and the anesthesia and surgery residents were still.  One of the patient’s sisters had tears in her eyes.  And in the mother’s eyes was a look of expectation and confusion.  She doesn’t understand, I realized.  She doesn’t know her baby is dying.  A pause.  Then, another thought: We’re having the wrong conversation.

I looked around the room.  When I spoke, my voice was steady but gentle.  “May I please have a few moments alone with Ms. Foster and her mother?”

The others in the room looked at one another before moving toward the door.  As the last of them left the room, I quietly sat facing the patient.  My words were addressed to the patient but directed toward her mother.

“Ms. Foster,” I began, “I need to be very frank with you.”  Both women eyed me anxiously.  I took a deep breath before continuing.  “I don’t think you’ll be able to wean from the ventilator, and I don’t think you’ll need long-term mechanical ventilation.  You’re dying, ma’am.”

Silence.  The faces of the patient and her mother registered unrestrained shock.  I had dropped a bomb, its impact just beginning to be felt.

The mother mouthed something before finding her voice.  Her next words were shaky as she grasped for hope.  “She can still get better, can’t she?”

My heart ached for this mother.  She'd clung to the hope that her daughter would recover, would live for years yet, and I had just torn that hope from her hands.  “I’d love it if I’m wrong,” I said, “but I don’t think so.  Everything that’s going on right now – this is the end of end-stage liver disease.”

Shock and silence before a feeble protest.  “But she saw her doctor six months ago, and he said she had plenty of time to turn things around.”

I shook my head gently.  “I can't say what she looked like then,” I answered.  “I can only base my opinion on how she looks now.”

“How long do you think, Doctor?  Months?”

Again I shook my head, and pulled out the last remaining foundation on which this mother had built her hope.  “Days.”

The mother's face was a picture of devastation.  Silently, I allowed her a moment to process my words.  Eventually, though, I had to go on.  “Ma’am, I’m sorry to have to give you that news.  The truth is, I don’t think your daughter will live much longer with or without surgery.  And we don’t have to do the surgery if you don’t want to.  We can initiate comfort care.”

“The surgeons said she would die without the surgery,” the mother said softly.

Just as softly, I answered, “She’s dying either way.”  I watched as the mother continued to survey the devastation of her world.  “Ma’am, your daughter’s liver has failed.  Her blood ammonia levels are very high.  That has the effect of impairing her judgment.  She’s not mentally capable of making an informed decision or consenting to an operation.  She has no other power of attorney.  You’re the one who has to make the decision.”  More silence.  Then, the final bomb: “Ma’am, I believe if we take her to the OR tonight, you will be called upon to decide – some time in the next week – to pull the plug and let her go.”

The mother stared at the floor in disbelief.  After several moments, I stood.  My face and voice conveyed my sympathy.  As a parent, my greatest fear is that I might have to bury one of my own children.  “I’m sorry.  I’ll leave you alone to think about things without outside pressure.  Take all the time you need.”  I stepped out of the room and closed the door.

My residents approached me and I told them what had transpired.  Then we stood in silence for the next five minutes as the heartbroken mother decided what to do.  Finally, the door opened.

“Please do the surgery, and do the best you can for her.”

I nodded.  “We’ll give her our very best, ma’am.”

Patty Foster survived surgery that night.  Six days later, with her mother and sisters at her side, she was compassionately extubated and allowed to leave this world.

Years ago, I was an eager young premed student.  I volunteered and was chosen to shoulder the mantle of a physician.  For years I trained, learning the art and science of my profession.  I've blessed thousands of lives, ushering people through the perioperative period.  Not a day goes by that I don't thank God for His goodness in making me a tool in His hand.  But with that gratitude often goes a plea: God grant that I not outlive my children.