Wednesday, February 2, 2022

God Of The Operating Room

Allowing time for minds to unblow after Trump’s latest sedition and incitement red-state rallies, here’s something from my “Surgeonsblog” days, shortened:

Doctors play God, is what they say. By some measures, it’s true: in my surgical life, I’ve had to make life-or-death decisions, choosing to render help when the outcome might be regrettable, or concluding it’s best to let things go. It weighs heavily. But I signed up for it. 

Called in past midnight, now opening a belly, you encounter a large amount of dead intestine. (Usually due to a blood clot.) You must decide whether there’s enough left to support life: go ahead or close up, deliver the news to the family. No universal guidelines exist, nor certainty of the result. Wrongful death? Wrongful life? Victims show up in the ER deathly ill, in no position to philosophize. Having little time to establish trust, likely never having met before, and only because you happened to be on call, their lives are in your hands.

She’s been in a nursing home for a couple of years. Ninety years old, no longer recognizing family, she began complaining of abdominal pain and now presents with all the signs of an abdominal catastrophe. "We need to get her to surgery right away," you can say, "or she'll die." Which stacks the deck toward going ahead, and, frankly, it's the easiest way out -- for the surgeon. It avoids the moral wrestling.

"Something very serious is going on, something that likely requires a complex operation to fix. It might not be fixable. She might not recover from what we'd be putting her through. I want you to know it's possible to make her comfortable, to be sure she doesn't suffer, and to let her go. You know her better than I do. I'm comfortable with either approach. What do you think?"

And sometimes, when there’s no 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 how I see it?" That's when it’s hardest of all. "We can take a look. I can see what's going on and make a judgment: if I think it's solvable with a reasonable chance of recovering, I'll do what I can. If you’d like, I can come out and talk to you before making that decision." Or "I think whatever is going on in there is too much for her, given her condition, and I think making her comfortable would be a kindness." 

I've said each of those, or something like them, on several occasions. Some people say if there's a one in a million chance of recovery, it should be taken. I don't share that idea, but I can't say it's objectively wrong. If, purely by chance, a patient with one-in-a-million odds for survival got me as their surgeon, more than likely they’d die without an operation. If another surgeon, probably they’d die with one. Should such a heavy decision be a matter of happenstance? Shouldn’t there be a rule book?

In the example of our elderly, demented lady, if most of her gut is dead, it’s not difficult: take a look, close up. (“Peek and shriek,” we call it, morbidly.) But if there’s plenty of viable bowel, then what? And what about a much younger person with nearly all of it dead? I’ve seen it. 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 rare. Having most of it gone, though, less so; enough that you could hook a foot or two of small intestine to a few feet of colon. It's unlikely I'd do it with an elderly, sickly person; but I’ve done it with a young one. In both cases, it was entirely up to me; lacking a crystal ball, I made the decisions. Hearing nothing from God, playing Him by default.

If not ninety, but yes thirty, where's the line? Sixty-seven? What about co-morbidities? Heart disease? Diabetes? What parameters am I bringing to bear from within myself? Experience, knowledge of what I can (or can't) do; my personal definition of futility; what decision I'd want if it were me? Should those play a role? It’s impossible that they wouldn’t.

Having no universal guidelines, it's understandable that some surgeons choose always to operate, always do what's technically possible, leave it to the patient, family, and medical doctors to deal with the consequences. Not me. Which led to many sleepless nights.

Primum non nocere, we’re told at graduation. “First, do no harm.” Sounds simple, doesn’t it? I wish I could say I never have.


  1. Thank you for insight into the issues that you faced during difficult or potentially unsuccessful procedures, and showing your concern for patients and their families, Sid. I hope that some of the folks who normally page past you will decide to pause and read. This week's also serves as a good example of critical thinking.

  2. Only recently dealt with exactly that decision. I told my loved one, don't get mad at the hospital, as they were looking for something to get mad at. I also said don't get mad at the doctor, some broken hips can't be put back together (the doctor said 10% chance of success, no need to be a statistician).
    He passed away on the way home from hospital in the ambulance. "Home" would have been hospice help to get enough morphine to not be in pain. Been there too, with a friend, here's the conversation:
    "We gave him the morphine and he's still in pain."
    "Give him another dose."
    "We gave him another dose and he's still in pain."
    "Give him another. Double it."
    "He's still in pain."
    "Double it again."
    (I only remember that vaguely, it was years ago. If it wasn't what happened, it's what if felt like to not be able to help someone in pain)
    He passed away in the night.
    Thanks for a good column, more timely than you can imagine, and much more edifying than another article on the ones who cause more pain than we can imagine, and, where morphine is given to the wrong person(s).

  3. When I splattered 2 discs I ran into similar. I was in the emergency room and in so much pain. It was like a spinal tap, only constant. It took a lot of morphine to end that pain and multiple patches to maintain those levels. The Dr. on duty wrote a giant essay on why I was given 100 Vicodin and a stack of patches and multiple injections of morphine.

    I was 8 when I had spinal meningitis. I was that one in a million kid. I was left dying in bed at home for 4 days until my mother took me to Kaiser in Santa Clara county. My temperature was 106 at that point and for 72 hours they tried to break the fever. They came in to do a spinal tap. They couldn't hold this 8 year old down with 5 there to help. Later that night/early morning they made another attempt...2 people on each arm and legs and two people holding my body. I remember my Mom saying "Stay still, stay still please they need to do this." But I was at 108 degrees and they had to do SOMETHING. They got my sample somehow. It was the most painful thing I've experienced. That pain is equal to my discs ruptured and w/o medical care for weeks and months.

    They were certain I'd have brain damage. They were pretty certain I'd succumb to my illness.

    But that didn't happen. After 2 weeks in the hospital I recovered and went home. But I was dead pretty much. The fact I recovered is a mystery. I came out unscathed somehow.

    I've always been a survivor. My whole life is a story of survival in all the possible forms. I've survived 4 attempts on my life. I've survived mental health issues...On and on. I've always found a way to make it to the next day.

    My grandma was my whole world. Seeing her with arthritis and hands and feet balled up. Jaw seized open. But still very much alive in her mind. She knew what was happening. I was not educated enough to know what was happening. They were putting her down that night. She said to me "get me outta here". I broke down and told her I'd be OK and I can't do that.

    I couldn't give her, her dying wish. I didn't realize it's the last time I'd see her alive. I wish I'd have known. I'd have broken her out of there. I'd have taken on anyone in my way to do it too. It would have happened. It's not the first time I broke someone out of the hospital. I am

    I don't know if I could have made the decision to kill her. I look back and there's nothing I could have done legally. But could I make the decision to end her life if she didn't want it? I could never. She's at peace now and I am cool with that.

  4. Wow, this struck a chord with me. Over the long years of Mom's declining health, she lived with me, and I learned so many things I never thought I'd need to know. How to fill syringes with two kinds of insulin and give injections. How to plan meals for someone in kidney failure and make them delectable enough for an 80-year-old woman to not realize their healthfulness. Equipping my home for diminished mobility and learning the proper way to assist Mom out of and into bed, the bath facilities, and her wheelchair. Creating an environment that compensated for her declining capabilities physically but still providing stimulation for her mental and psychological health. No awards will be given to me because I did have help from my siblings and when I started to crumble, they were there to step in and cover for me. I am no hero, but the toll on me was also a fairly severe financial one too, and I will just suffice it to say that because of her expenses and my own in providing a seamless existence for her--I never wanted her to go wanting--her life continued as it should have until it didn't.

    She underwent vascular surgeries to install a temporary, then a permanent port, for her dialysis treatments. She also eventually underwent surgery for an amputation of part of her foot. That didn't heal as well as it should have--she was near 90 at that time--and eventually the doctor said they needed to take her leg up to her knee. This is where our friend Sid's piece hits me.

    My siblings and I were divided in what we thought should be done. We listened to the surgeon lay out the options for us, much as Dr. Schwab elucidates in his diary. The outlook was grim no matter what we thought and even though Mom could still reason her way through the process before her, she wanted our opinions. We seven kids knew we needed speak with one voice. Five of us did not want her to have more surgery but the two that did want her to have surgery made it plain to all of us that this was the hill THEY would die on. The rest of us swallowed our feelings and we told Mom that if she wanted to take this chance, we were with her. We were with her no matter what.

    I will never forget going into her room after surgery. She was still sedated but fretful. Neither sleeping nor awake, she thrashed and moaned, and I reached to comfort her, and my hand fell on her stump. At that moment, all my strength and reserves fell away, and I was undone. Why had we allowed this? Why prolong her suffering? I am crying now as I write this just remembering that moment eleven years ago when I had to escape her room and collapse to the floor in the hallway and sob my heart out. I still regret our decision, but in reality, it was Mom's decision and we had to honor her. It was horrible. She never regained consciousness and died a week later.

    I am grateful for that beautiful woman who birthed me, raised me, taught me about life, listened as I practiced piano, suffered with my disappointments, rejoiced in my triumphs, cared for me through my own devastating injury, surgery, and recuperation, and gave me a model of strength. She was extraordinary in the most ordinary way. I feel tremendous compassion for those who have to experience what I did, and many of my friends have now done so. As Smooth so succinctly put it at the end of his comment, "she's at peace now and I'm cool with that" but man, that was a hard time for me. I think sometimes now about what it will do to me when any one of my siblings passes on. I know I will be crushed. Again.

    1. Thanks for laying bare that heartfelt and heart-rending story, Mary Ellen. It's not unlike what my wife and her siblings are going through now. And, I know from my professional experience, it's all too common. It seems the end of life is cruel, more often than not.

    2. I prescribe extra hugs for your wife and extra patience for all of the siblings. It is so, so difficult.

  5. I can hear those raisins clanking from here.


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