Monday, July 09, 2007
Couple of good posts by ema, and Dino, about the obligation of doctors to provide standard care even if it conflicts with personal religious beliefs. For the record, I couldn't agree more: doctors who feel they can't do certain medically necessary procedures or prescribe certain drugs only for religious reasons ought not to be in the field with which they find themselves in conflict. From the other side of that coin, here's a related story:
When you get a call from a doc who, for various medico-political reasons never calls, you have to wonder what's up. Terrible case that he wouldn't want to dump on a buddy? No insurance? Three a.m.? Usually, yeah, one of those. This was a call to the ICU in the middle of the afternoon, which eliminated one explanation off the bat.
The smell of blood in stool is unmistakable. Metallo-putrid, it lets you know what you're in for several doors away from the room to which you're headed. You can even guess whether the bleeding is in the stomach, or the colon, because the former passes through the small intestine, where digestion affects the odor. Even more: the faster the bleeding, the less digestion. A good nose can tell you things before you enter. In this case, I was clued in from well down the hall.
Curled around and resting her chin on a stainless-steel pan splattered red, lying on absorbent blue pads stained with the maroon of partially digested blood at her backside was a woman in her forties, pale, looking frightened and miserable. Her husband was standing by the head of her bed, mutely and resolutely holding a cloth on her brow. The attending doctor, whom I knew vaguely but with whom I'd not worked professionally, looked up as I approached and head-waggled me to a halt in the hallway. "Thanks for coming," he said, hustling toward me and sticking out a sweaty hand. "Tough situation. Jehovah's Witness, bleeding like stink, refusing blood. She's got a duodenal ulcer, I saw it on a scope. Surgeons A, B, and C wouldn't come see her. I appreciate you being here." Maybe I was young and naive, or maybe I was right: I couldn't fathom those other docs refusing to engage. It dawned on me that if I were to operate and do something that caused more bleeding, and if she died for lack of the blood needed because of my error, things could take on an entirely different aura. Still, I didn't see how I could walk away and let her bleed to death. I went into the room.
Some ulcers bleed and stop on their own. If they start up again during the same hospitalization, the odds get serially less and less that it'll heal without surgery. This lady had bled and stopped, and was bleeding again, fast. At least one of the other surgeons had been called during the initial bleed, as he should have, and when she ought to have been operated. Given her refusal of blood, she was hovering very near to deadly danger, and the decision to operate was clear-cut in my mind, and urgent. I told them so. "Just to be clear," I said to the woman, including her husband in the sweep of my eyes, "You refuse blood under all circumstances, even if it means bleeding to death?" It's what we believe, they both indicated. "Blood products, plasma, everything?" "Yes." "OK," I said. "The odds are this will be pretty straight-forward. I ought to be able to get the bleeding to stop. But, you know, nothing is for sure. It could take much more than it seems right now. And surgery always causes some bleeding. No matter what, her recovery period is complicated by her very low blood count. As clearly as I can see it, the odds of getting through this are significantly better if we operate, but I have no crystal ball. She might stop without it, and heal. She could succumb either way. It's just that I think there's more control at this point if we operate. And if you really refuse to receive blood no matter what, I'm prepared to accept having her bleed to death in my hands." I wasn't sure I was, but that's what I said. Plus, I really didn't expect to have to face such a scenario. Surgery, after all, is good for you.
I motioned her husband to come with me into the hall. "I'm OK with this," I told him, "but I don't really like it much. And, just so you can think about it ahead of time, I want you to know that if we get into the soup in there, and if I think the only way to save her is to give her blood, I'm coming out into the waiting room and telling you and asking for a final time." He gave me a leaden and eye-contact-free nod, saying nothing. A nurse came up with a clipboard. "Shall I have them sign the blood-refusal form now, Doctor?" "I don't know, I don't care... uh, sure, have them sign it. Both of them. Not that it'll make any difference..."
When time is of the essence, you do everything you can to save minutes, from calling ahead to the OR and telling them it's urgent enough to "bump" a case out of the schedule, going there and helping set up the room, to wheeling the patient down there yourself. Let anesthesia know what's happening, help put in extra IVs, make it a quick prep, shortcut the scrub time. I've described techniques for rapid incision in previous posts; it takes only a minute or so to get in and get the stomach into your hands. These kinds of ulcers are usually within a centimeter or two of the pylorus, so you quickly elevate it by placing a couple of traction-sutures, and cut across it longitudinally. Sometimes the bleeding artery spurts in your face: a finger into the hole gains temporary control, while you place a strong suture on a big needle underneath, then lift it up. Now you have it. The typical arterial culprit runs vertically behind the pylorus, so two stitches, north and south, are what you need. Another stitch like the first, and the bleeding is over. When it is.
It's nearly magical: as soon as you get that bleeding stopped, faster than it takes to refill the tank with fluids, the rapid pulse of hemorrhage slows down, as if the body senses the sealing of the hole and relaxes, even before the lost volume is replaced. You can hear the decelerating beeps on the monitor, and it's like a musical exhalation. When it happens.
Before every operation, I get psyched up: for some, of course, more than others. Sometimes there's great anxiety, concern over what I might find, over whether the existing circumstances are such that I could encounter terrible problems. I bring to bear all the concentration I can muster, focus everything I have -- experience, knowledge, judgment, technique. Knowing that -- probably most patients really don't consider it -- you'd think anyone about to go under the knife would want to avoid like poison putting constraints on the surgeon, interfering with the process; eschew limiting the options, interfering with carrying out the procedure in the best way possible, making specific demands, tying -- of all things -- his/her hands. There have been times when I've responded to certain demands by saying I couldn't, on the basis of my best medical judgment, provide care for the patient given the demanded restrictions. Never, for reasons I can't explain, because of religious objection to blood. In fact, I was on the JW list of "bloodless surgeons."
When I ran my malpractice series (one, two, three) a while back, I got several comments from attorneys. I'd welcome them here. Correct me if I'm wrong: the law covering this stuff is all over the map. In general, doctors haven't been held liable for untoward outcomes deriving directly from blood refusal; but there have been unfavorable judgments when an operation caused bleeding that led to death or complications, even if those outcomes could have been easily avoided by transfusion. Anecdotally, I've heard of doctors being sued for not giving blood (when giving it was contrary to the patient's directive!) when the patient died. And, of course, for life-saving transfusion that led to recovery, but were against patients' wishes. It's grayer still with kids. Court orders have been sought, not sought, granted, refused.
There's a difference, in my mind, between my acceding to patients' religious convictions, and forcing mine on them. It's a question of who's got the power. I could have said no. In the reverse situation, a patient may not have alternatives. A doctor's highest obligation is to do what's medically right for the patient, regardless of that doctor's personal beliefs. Clearly, there's not always a perfectly clear border between medical judgment and personal beliefs. If my choice of a particular operation differs from that of another surgeon, how can I say certain "morality" issues haven't been at play? Quality of life. Predictable time remaining, chance of helping... Still -- recognizing that judgments are made of more than book-learnin' in medicine -- a doctor shouldn't be able to refuse either to provide or to arrange for the obtaining of recognized and standard treatments because of religious belief, any more than a firefighter ought to be allowed only to save those people in a burning building with whom his moral judgments are in conjunction.
I've operated on lots of Jehovah's Witnesses; I know surgeons who never would. Same with people with AIDS. I've been fine with patients using all manner of "alternative" and useless methods, as long as they were adjunctive to rather than supplanting what I thought was best. On at least one occasion, I've agreed to do a lumpectomy for a woman with breast cancer who told me in advance that she refused further conventional treatment and planned to take treatments that I knew to be bogus. Figuring she had at least some chance of cure with the tumor gone, I did what she wanted, while trying like hell to talk her out of her plan. I even encouraged her to keep seeing me so that when the nearly inevitable recurrence happened, we'd find it as soon as possible. (It did; we did; but it was still too late.) I've taken a perfectly normal appendix out of someone planning to climb Mt. Everest, and have removed an asymptomatic (but stone-containing) gallbladder from a person leaving for missionary work in a medically-deprived area.) I guess the common thread is the ability for give-and-take. When lines are drawn, on either side, based only on (most often) religious beliefs, allowing nothing across but a thrust-out chin, the whole relationship is chilled, and bad things can happen. Not that it'll ever change.