Tuesday, December 19, 2006

God of the Operating Room

It's an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. "What the hell was that?" someone asks. "Why does that doctor get cuts?" "Oh, that wasn't a doctor," Pete says. "It was God. He just likes to play doctor once in a while."

But it's no joke. Whereas I don't buy the "playing God" aphorism, I've had to make life-and-death decisions on occasion, and I don't like it. I mean "life and death" literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance -- looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable -- is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?

Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it's fatal. In operating, one may find -- depending on the cause and the anatomy -- a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.

And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it's conceivable that two people might make different decisions; ergo, it's subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you're not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?

These people don't come to see you in the office, don't participate in a leisurely give-and-take about their illness. They show up in the ER in pain, sick as hell, in no position -- much less able -- to philosophize. Nor do they come to you because they like what they've heard about you. Luck of the draw: they show up when you're the guy on call. Their lives are in your hands because of the most random of circumstances. But there's no avoiding it.

It doesn't take long to realize the power of influence you have. In fact, it's my impression that often people -- patients, their families -- WANT to be relieved of the responsibility. Grandma has been in a nursing home for a couple of years. Ninety years old, not always recognizing everybody, she suddenly is complaining of abdominal pain and is now in the ER with signs of some sort of abdominal catastrophe. "We need to get her to surgery right away," you can say. "Or she'll die." Clearly that stacks the deck toward going ahead, and, frankly, it's the easiest way out -- for the surgeon. I know many who always take that approach, and I think it's neither that they love to cut above all, nor that they want the money (what little they'll get from medicaid.) It's just that it avoids all the moral wrestling; with the people, with yourself. But it is, of course, just as subjective.

"It's obvious something serious is going on, something that would require an operation to fix. It may or may not be fixable; she may or may not be able recover from what we'll have to put her through. This could be too much for her no matter what we do; so I want you to know that it's possible to be sure she's entirely comfortable, to be sure she doesn't suffer in any way, and to let her go. You know her better than I; you know her life. I'm willing and comfortable with either approach. What do you think?" That's another way to handle it, one which I've done many times. And sometimes, either when such an approach doesn't lead to consensus, or when even before I've said such a thing I see a family in turmoil, I'll ask, "Would you like to know what I think?" That's where it gets hardest of all.

"We can take a look. I can see what's going on, and make a judgement: if I think it's a solvable problem with a reasonable chance of recovering, I'll do what I can. Or I'll come and talk to you before making that decision." "I think whatever is going on in there, it's too much for her, given her condition, and I think making her comfortable would be a kindness." I've said each of those, more or less, on many occasions. Some people think that if there's a one in a million chance of recovery, it should be taken: as a general rule; as a moral principle. I don't share that idea, but I can't say it's objectively wrong. If a patient in a one-in-a-million situation got me as their surgeon, they'd be more likely to die without an operation. If another surgeon, they'd likely die with one. Should that be a matter of chance? From one point of view, always going for the one-in-a-million chance seems the purest, cleanest, most honorable (life-affirming?) approach. From another, it looks like the ultimate moral cop-out, an abdication of responsibility. Can anyone say for sure?

It doesn't end, of course, with the decision for surgery. In the case of the dead bowel, you'll likely be confronted with operative uncertainty. In the example of the old lady, if virtually all her gut is dead, it's nearly automatic: take a look, and close up. ("Peek and shriek," is an oft-used phrase.) But what about a twenty-year old? It could happen, as a result of blood clots. Most likely you'd remove the bowel and do everything you could to get the person through the crisis, knowing they'd be facing a very abnormal existence. Having the whole gut gone is pretty rare. Having most of it gone, though, is not; enough that you could hook a foot or two of small intestine to a foot or two of colon. Again, it's not something I'd do with an elderly and sickly person; but I did it once with a young person. In both cases, it was entirely up to me, and I made the decisions -- necessarily, far less than fully-assured. And if not ninety, but yes twenty, then where's the line? Sixty-seven? Or what accompanying factors? Heart disease? How many vessels? More than that: what factors am I bringing to bear from within myself? Experience, knowledge of what I can (or can't) do, what decision I'd like made if it were me? Am I allowed those colorations? Given that there are no clear answers, it's not hard to understand how some surgeons would take the approach always to operate, and always to do what's technically possible, no matter the consequences.

A commenter in one of my recent pancreas posts described the misery of his life after a big operation, implying, I think, that he wishes the surgeon hadn't done it, hadn't saved his life. No one that I can recall has ever said that to me, not even the lady I left with severe short bowel syndrome. But I didn't end up seeing her for long after the operation, and I imagine her life was miserable in many ways. I'd not be surprised to learn that she's said it to someone, since. If it were to me, I'd feel really, really bad.


emmy said...

You know, I don't think that I'd ever say to my surgeon that I wished he'd done things differently. He's a good surgeon and overall the reconstruction is phenominal, but he also didn't listen to me in the brief visits I had with him before my surgeries. As a result the outcome was he did the things that were important to him and the things that were important to me were ignored. I know that reconstructive surgery isn't life and death, and it really only improves quality of life not detracts from it. But still, I woke up from a surgery where I specifically said "don't bother to cut me to put the belly button back, it means less than nothing to me." And I woke up with an off centered belly button with a scar around it. It bothers me that he thought that this was his work and to hell with what I thought. Still, what would be the point of telling him that? It certainly won't make the belly button centered without having to endure another operation.

Janet said...

I've seen several patients die from infarcted bowels, some after surgery, some without surgery. Not pretty. What a hell of a position to be in as the surgeon.

Vasha said...

An interesting post, as always. I would like to ask you a related question about surgical ethics/decision-making (apologies if you've already discussed this one somewhere else in the blog).

I know someone who had to have a hysterectomy (I forget why), and during surgery the surgeon found that whatever-it-was had also affected her ovaries, and removed them both. My acquaintance was furious because she hadn't been warned that this could happen, much less asked for permission. She said she felt that she'd been "castrated" against her will (sudden menopause at age 28!)

I'm sure, Dr. Schwab, that it's happened to you a few times that you open someone up and find an unexpected problem either related or unrelated to what the operation is intended for. If it's not immediately life-threatening (unlike the example of infarcted bowel), how do you go about deciding whether to try to fix it immediately, or discuss it with the patient and then probably have to operate a second time?

peter said...

As you said in the blog, it's often easier to do the operation than it is to decide with the family not to even attempt it. There's no training possible in how to deal with the emotions of a moment like this but hard-won experience, but my chairman in residency was one of the best I've ever seen in this situation. That "one in a million" chance is one of the hardest things to deal with, both for the surgeon (or any other physician) and for the family. His view was that telling the family that there was such a remote chance was for most people the equivalent to telling them we should operate, and that you should never use that line.

The problem for most families, in my experience, is that they don't understand what the outcomes are likely to be in a catastrophic situation. Many people seem to expect one of two things: either the patient does great or they die on the operating table ("sure Doc, let's give it a try, he's always been such a fighter, he'd like to go out swinging"). I've often told people in that situation that the operation itself is the easy part. What the families usually don't have the experience to understand is that between those two extremes is a large area consisting of prolonged ventilation, multiple organ failure, parenteral nutrition, possible dialysis, pneumonia due to prolonged ventilation, ARDS, tracheostomy, tube feedings, cardiac events, DVTs, other infections, decubitus ulcers (bedsores), etc. And in many of those cases, the patient will still ultimately die, days or weeks after the heroic operation, with an absolutely horrible quality of life in the meantime.

Deciding not to operate, when that decision will clearly result in the patient's death, is a very difficult one, and never one I'm comfortable with. After all, the point of being a surgeon is stated in the old adage "a chance to cut is a chance to cure." But there are times where it's absolutely the right thing to do, and it's our job to help the family understand the implications of the decision, all the implications, whether we decide to operate or not.

Bongi said...

as always a brilliant post. i once heard someone say a good surgeon knows when to operate, but a brilliant surgeon knows when not to operate.

Medstudentgod said...

As a medical student who has just finished his surgery rotation and was presented with a question related to Vasha's comment I think I can answer what the ethically correct answer is: don't cut. The ethics, as far as I've been instructed, state that, unless immediately life threatening, the operation should only involve those aspects listed on the consent form. Now, if that actually is true in clinical practice is something else entirely.

CholeraJoe said...

Sid, I've only had one patient tell me they wished I hadn't saved their life. He was a 45 yo chronic alcoholic who suffered a very high cervical cord transection. I managed his respirator from admission through discharge from rehab.

He repeatedly told me how much he hated me for saving him.

The Angry Medic said...

Goes to show you just can't please everyone, I suppose.

As long as you can live with yourself and sleep at night, I say you've done your duty. I'm planning on going into surgery (at the moment anyway) and I'm not gonna lose sleep over something like this. Despite the size of some surgeons' egos, they're only human.

Barbados Butterfly said...

The other night we saved a life, although we doubted that we would.

A 94 year old woman presented with suspected dead gut. HR 110, BP 85, only 20mL of urine from the last 10 hours and a lactate of 9. It was the middle of the night.

I discussed palliation. I discussed the complications of surgery, mentioning stomas, pneumonia, respiratory failure, heart attack, stroke, anastomotic leak, DVT/PE, wound infection, a long ICU stay and death.

The patient and the family wanted surgery. When I told the anaesthetist he came to see them having already decided that he would try his hardest to encourage palliation, not surgery. I suspect he figured (incorrectly) that I'd used the "if we don't do it she'll die" approach.

We went ahead and did the surgery, resecting 90cm of dead small bowel. She did amazingly well; she was extubated the following day and discharged home 5 days after surgery, ambulant and self-caring.

I suspect that the family thought in retrospect the medical staff were extremely callous in suggesting palliation rather than operation. I actually feel a little guilty about the suggestion, in retrospect. But 94 year old women with dead gut usually do very badly. And yes, if she'd been in hospital for weeks before succumbing to multi-organ failure in the ICU I would have felt similarly guilty.

But I shouldn't feel guilty. Like every other doctor I have to make my decision based on the information available to me. Sometimes the decision will be vindicated, sometimes not.

We all make difficult choices in our lives. Surgeons make more than most.

Anonymous said...

"A commenter in one of my recent pancreas posts described the misery of his life after a big operation, implying, I think, that he wishes the surgeon hadn't done it, hadn't saved his life. No one that I can recall has ever said that to me, not even the lady I left with severe short bowel syndrome. But I didn't end up seeing her for long after the operation, and I imagine her life was miserable in many ways. I'd not be surprised to learn that she's said it to someone, since. If it were to me, I'd feel really, really bad."

The significant portion of this passage, to me, is the off-hand remark : "But hI didn't end up seeing her for long after the operation". My naive question to you is, why not? You wrote previously about the evolution of surgical training from your generation to the newest class of trainees in the program. But it seems a significant shift occurred during your training as a surgeon as well. Whatever happened to the idea that “once a patient of a surgeon, you are his for life?” A well respected medical doctor recalled this quite wistfully to me some time back when discussing how the medical / surgical fields are evolving. In her view, a surgeon was the person who, once he took you under his wing, would never kick you out of the nest. I interpreted this as meaning that the surgeon-patient ties were never severed; stretched maybe, but never completely broken. Why is it that the surgeon doesn’t get a long-term view of the outcomes of his patients? Do you not think that this could add value to both the personal satisfaction of his career choice as well as give him that knowledge so desperately needed to make those critical life-and-death decisions that you mentioned? Do you not think that only seeing a patient in terms of weeks or even months after the surgical procedure gives you a very narrow view of those long-term consequences that have been mentioned? Or is this the “callousness” that you hesitantly wrote about that is needed in order to stay the course?

Another commenter stated that she noticed the difference between two surgical encounters that illustrated this point – that one specialist took the “wham, bam, thank-you ma’am” approach; the other stuck with it when the going got tough. She speculated that anonymous wasn’t so much upset at the perceived surgical error as much as being abandoned when the complications became apparent. At what point is “moving on” a rationalization for shirking responsibility? A response was to point out the difference of philosophy between the medical and surgical approaches: that the one specialist was a “pure” surgeon, whereas the other was a hybrid of medical – surgery training. Those that know the field, can gain understanding from that explanation: it is accepted at face value. But I question why we do that. Why do we accept that the surgeon is only interested in the patient for the short pre-op through post-op follow-up, period, an average of 6 to 8 weeks total? Is this the only way a surgeon can preserve his sanity in the age of modern medicine? to distance himself from his patients so that he can move on?, to let things go? to develop a short memory? So that he can go on to do the greater good for the many after leaving behind the aberrant, and regrettable, less-than-optimal outcome?

I understand that getting to know a person prior to a surgery is unlikely, especially in the emergency cases that were mentioned, but “… I didn't end up seeing her for long after the operation, and I imagine her life was miserable in many ways” seems to me to be a willful choice of the surgeon. And I wonder why………..

Sid Schwab said...

Before I came to my current location, where I've been for 25 years, I practiced for 5 years elsewhere. I moved away. That's the reason. In my practice I followed all my patients for as long as they wanted to. I never ended a relationship. I was always available. Simple as that.

Anonymous said...

To Dr. Schwab & Peter (the poster):

The family of the patient with the dead bowel is even less prepared than the surgeon to make a life or death call like that.

Unlike you, we cannot foresee all the complications that Peter mentioned in his post when we agree to surgery for a family member with this urgent condition.

I was with my mother when she agreed to the surgery for my dad. I cheered with surgeons when he came through. Then we sat with him as he died a slow, painful death, enduring complication after complication in the months that followed.

I believe we would have chosen a painless death for him (over the one that he ultimately suffered through) if his surgeons had half the sense of you gentlemen.

It is my wish that all surgical interns reap the wisdom of words like yours. They need to learn that it takes bigger balls to be pragmatic than to be heroic.

Keep up the good work, Dr. Schwab! Love your blog!

Anonymous said...

Your scenario hits too close to home. A week ago today my Grandma who was 80 went in for knee replacement surgery and came out incredibly. While she was doing her physical therapy two days later she complained about feeling nauciuos with a pain in her stomach. It seems like over night her stomach became hard and surgery was scheduled immediately. What was to be a scheduled 3-4 hour surgery became a 20 minute "peek and shreek". The family was told the whole bowel was dead. Grandma was back in her room in about an hour and surprisingly awake though unsure of her state of mind. We got to tell her we loved her, say our good byes, and be with her when she passed. Wow, talk about a kick in the head. Knee surgery to Death. This I know is not the first time this happened and definetly not the last but it hits close to home. To the "God of the operating room" at Western Arizona Regional Medical Center in Bullhead City , Az. "Thank you, for the hard decision you had to make". -Dossey

Anonymous said...

Since no posts have been made in 2 years, I don't even know if this is worth saying here, but after reading over the site, I felt compelled to at least mention this point;
As you admit, you don't know much of the HX of the pt. That's understandable. What I have an issue with, is age discrimination. If a surgery would work for someone in their 20's, and a 90 yro. presents, with the same required surgery to treat a similar problem, why not at least give it a try? I also undertand the delemma of trying to make that decision on your own. It seems to me that being in the Medical Field, gives us an oppertunity to guide those who have no training, into doing what is, dare I say, "right," based on ethics and our knowledge base. Remeber the 'go forth and do no harm' thing? Sometimes by doing nothing, can cause harm.
Please understand, I am NOT challenging your decision making, whatsoever! In my personal perspective, it would be far better to try and resolve a problem, than do nothing, and simply accept the results.
I do respect, from what I have read here, that in most cases, you will do what you can as expertly and with the upmost attention to detail.
In closing, age isn't always the best definitive choice, though popular. The elderly are getting stronger, with advances in medicine, and life expectancy goes up each year. Truely something to consider.

Sid Schwab said...

anonymous: actually, my most recent post was just a few weeks ago. As to your point, there's nothing I said in this post that disagrees with it. I think you might even have missed the point: there are lots of gray zones, there are no absolutes, and making a decision requires bringing to bear all the knowledge, skills, and sensitivities we have.

Anonymous said...

My beloved 84-year old cousin is in the hospital as we speak, with ventilator and a star wars atmosphere of tubes and monitors around her. She has been in very good health and has hardly ever been sick in her whole life. My cousin has never wanted any extreme measures taken and has made her wishes know to all. She is critically ill now, with virtually her whole system broken down. The hospitalist suspects "dead gut syndrome and has arranged tests to confirm/reject the diagnosis. I woke up from a sound sleep a couple of hours ago convinced that my cousin wanted the tubes gone and the testing cancelled and to be left in peace, come what may. I talked with the SCU nurse, who was very calming, and I wrote a long email about the situation to my minister in response to her earlier communications. Then I looked up "dead gut" and found this blog -- perhaps an mircle? God at the computer? Anyway, I have read the blog and the comments; knowing that there is a community that is wrestling with these questions provides a lot of comfort and helps solidify my own thoughts. Mind you, we have not yet reached this particular diagnosis; if the diagnosis is positive for "dead gut" I am certain that the answer will be no invasive intervention. My question is, though, should we even go through the mechanics of the diagnostic testing? Should I ask them to remove the ventilator and let things proceed naturally, which is what she has always wanted (she has expressed this opinion vehemently and repeatedly)? Or is it premature? Should we at least get a diagnosis before we give up? This is what I know is wrong now: no kidney function, no blood pressure, on a ventilator, very anemic (is having a couple of transfusions), urinary tract infection/sepsis, atrial fibrillation, dehydradeted, no response to any of the medications administered for the past approximately 40 hours...what do you think? Thanks for listening and for commenting.

Sid Schwab said...

anonymous: you have my sympathy. These are the most difficult of situations. I really can't answer the "should I" questions from this far away: they're hard enough when one knows the whole picture.

I can say a couple of general things: being very anemic isn't consistent with dead gut, because usually when that's what's going on, fluid shifts are such that the blood gets "thicker," and red blood cell counts tend to rise. So either it's not dead gut, or there are other things going on as well. Also, if it is dead gut and it's been going on for 40+ hours, it may well be that surgery won't be able to turn things around. If there hasn't been a surgical consult, it would be a consideration, just to cover the bases. On the other hand, you describe a situation in which many surgeons might choose not to intervene.

Having made the decision for my own father, I know how terrible it is. Part of it, I think, is that family are as sure as they can be that all appropriate measures have been taken and that the decision to withdraw feels right.

Anonymous said...

Thank you for your quick response, your comments, and your suggestions. I did, in the end, think that it was right to do the CT scan; it isn't invasive and it answered a lot of questions. Amazingly, her GI system look quite good. The have confirmed that she had a mild heart attack and that a huge infection probably precipatated most of this crisis. She is responding a tiny bit to treatment; for example, her kidney function has returned and her heart has calmed down a little. A couple of blood transfusions have brought up her counts, etc. We have decided to wait until Monday before making any more decisions about her care, just maintaining the regiman she is on unless there is a major change one way or the other. Now the question is about her prognosis; the doctor thinks the infection is treatable and that he can get it under control, but he can't in any way predict her outcome in terms of her ability to live at least as active a life as she has been doing -- he said she would be very weak and would need a long convalescence, and she might or might not improve enough to be independent again. I don't want to "cure" her only to condemn her to ten or fifteen years in a nursing home -- that is definitely not what she wants. The struggle continues. It seems as though the "dead gut" diagnosis might have made it a lot easier -- we would have vetoed surgery and she would have died in peace...

Anonymous said...

My Mother died of dead bowel in July of 2007...her surgeon advised us to not put her through the surgery & to allow her to die in peace...he said he wouldn't do it to his Mother...my Mother really liked her surgeon & I hope to God we did the right thing to let her die in peace...she was such an independant person I believe it was what she would have wanted...but it's still so very hard to know whether you did the right thing...you always wonder...I so appreaciate him being honest with me...it's a very difficult decision & it will bother me the rest of my life...but I have to trust that our surgeon knew best. I have such great respect for surgeons!

Jen said...

Dr. Sid, I truely enjoy your blog. I have been a med/surg nurse for 9 years. I have taken care of countless bowel surgeries and countless patients where family has pushed for surgery that prolongs the inevitable and where surgeons have leaned towards surgery when it may have prolonged and complicated the inevitable. It really can become six of one half dozen of another.
Reading your posts really does help to keep me centered!
Thankyou for all that you do!

Sid Schwab said...

Thanks, Jen. I really appreciate hearing that. As you may have noticed, I'm losing my blog mojo of late; but I'm glad the earlier stuff is still getting some notice and doing some good.

Nurse and Hospital Stories said...

Losing some parts of our body through surgery will always have a side effect of an abnormal life. Indeed, there are some regrets for the patient, yet what matters most is that he/she is alive. But, how far is being alive to being normal, eh. Sometimes, this is also an ethical question, not just to doctors but even to nurses,when it comes to patient care. Is it important that the patient will be alive yet living in an abnormal way or painful way or let him/her die so that he/she will never feel pain anymore.

Thanks for sharing,
Peny@Baby phat scrubs

AutumnHelva said...

Thanks for an interesting post. My mother died a couple of years ago in dead bowel, she was 84 years old. She went through the "peek and shriek" operation as I don't think the doctors were aware how bad the situation was before it was done. It took about 30 hours from the operation until she died and I'm thankful that she was given as much morphine as she needed to keep the pain awey, and in the end she was free from pain (due to the amount of morphine she had been given). Even if it took a long time for her to die, and felt even longer sitting by her side, I know that she preferred a quick death rather than waste away slowly, as we had discussed it after having seen my father slowly die from lung cancer for a year and a half.

Sid Schwab said...

AutumnHelva: It sounds like the right thing was done for your mom. Your being there through the end had to have been very difficult but, hopefully, something on which you can look back with comfort that you were able to do it.

Amanda said...

My grandmother had emergency surgery for dead bowel earlier this year. Not doing the surgery wasn't even given as an option. She suffered with pneumonia for three months before she died. I wish we had known the side effects of this surgery before she got it. She only had one lung and she had asthma and a blocked heart, so her chances were already low. We weren't told this by any doctors. No one even told us that she was dying until two months after her surgery... She was 74. Most of the doctors and nurses pretended she would get better and didn't tell us the truth. Only one doctor told us the truth. We are thankful for his honesty. Knowledge and honestly is always a better choice.

Cortney Shewbart said...

I am a writer for a medical device company and I have recently been asked to write blogs appealing to surgeons. Not being a surgeon and all, I am not sure how to approach this. How do I entertain them? How do I get them to read this blog? How do I reach them? I would love your input

Sid Schwab said...

Seems like a sort of bass-ackwards way for your bosses to approach it. But good luck.