I could not let this patient die

March 5, 2001

Looking at the man's fear-stricken sons, the author flashed back to a painful memory.

 

I could not let this patient die

Looking at the man's fear-stricken sons, the author flashed back to a painful memory.

By Moshe Schein, MD
General Surgeon/Brooklyn, NY

I watched them—three pale, freckle-faced boys—as their father was wheeled from the ICU to the operating room. The youngest was about 12, the oldest 18. The middle boy towered above his siblings. Something about the way the boys looked away, their eyes avoiding their father's distorted, swollen face, penetrated my chest.

They had come to bid him farewell. Only a few days ago, their handsome, powerful dad, a soft-spoken middle-aged man I'll call Bob Wilbur, had been cracking jokes at the Sunday dinner table. Now, facing a third reoperation for his severe abdominal infection, he was grossly ballooned by the numerous liters of saline that seeped across his leaky capillaries. With the bloating, and the endotracheal tube protruding from his dentureless mouth, he must have appeared to his sons like a figure from a ghastly nightmare. Was this why the boys kept their distance, eyes glued to the green wall of the ICU?

I tried to appear detached as I prepared to take him to the operating room. Families of dying patients make me nervous. "Leave that stupid wall!" I wanted to shout at them. "Hug your father while you can still feel his live, warm body. Kiss his disfigured face!"

Nothing happened. I remained mute as I marched toward the electronic door that leads to the OR. Turning for a last glance, I saw the boys cemented to the floor, fear in their eyes. They'll remember this moment all their lives, I thought. They'll forever regret not leaping onto their father's gurney, placing their lips on his cheeks, squeezing his immobilized hands.

As we approached the OR, I felt wetness building in the corners of my eyes. Now I was a boy, and my father was being taken away from me. I dried my eyes and started to scrub, preparing for the procedure I was about to do. But the image of the boys' tormented gaze kept interfering. Was that the way I had looked at my father 30 years ago?

On the morning of his operation, my father had painstakingly shaved himself, rinsed his face, and applied a fine after-shave lotion. A surgeon himself, he had kissed his own surgeon on both cheeks, wishing him luck.

A long procession of family members and friends each received a similar embrace. I was the last—the last to feel his soft, smooth, and perfumed cheeks—and I can sense that smell and touch even today.

The next day, I saw him in the ICU. His cheeks were gray, sunken, and stubbled with white whiskers, and a tube emerged from his toothless mouth. Horrified, I looked away.

Why didn't I touch him? I am still tormented by not having placed my lips against his unshaven face, bidding him a proper adieu. A day or so later, I saw him at the mortuary.

I threw away the scrub brush, rinsed my hands, and entered the room. Looking at the critically ill patient immersed in the spaghetti of lines, I thought: I have to save this guy!

Without the dressings, his fresh abdominal wound looked horrendous, pouring pus, intestinal contents, and necrotic matter. The scrub and circulating nurses looked at the scene with distaste. We know what a living corpse looks like, their attitude suggested, and this is all a waste of time.

We recleansed the abdominal cavity, removing stinking pus and necrotic tissue all the way from the diaphragm to the scrotum. "This guy is acidotic, pH 6.9," exclaimed the junior anesthetist from behind his screen. "I can't ventilate him properly; his CO2 is in the sky."

"Call your senior," I hissed. "Don't you know he has wet lungs? They're stiff. Increase the PEEP, for God's sake! Don't you know how to ventilate an ARDS patient?"

When we finished cleansing the filthy abdomen, we left the wound open and wheeled Bob Wilbur back to the ICU. It was late when I went to the families' lounge to talk to his wife. A stocky, plain-looking woman, she sat alone; her sons had left the hospital.

"How is he doing, Doctor?"

"Not too good, I'm sorry to say. The infection is spreading. As I told you yesterday, the perforation in the duodenum, which we had sutured before, broke down, and the necrosis at the retroperitoneum—that space behind [I pointed to my back]—has entered his scrotum. The infection destroyed his left testicle, so we had to remove it."

She looked at me calmly, fiddling with a large gold cross that dangled low over her white T-shirt.

"How many times are you going to reopen him?" she asked. "Look how swollen he is. Can he take all those surgeries?"

"You work for a dentist, right?"

"Right." There was a question in her eyes.

"When your dentist treats a root canal infection, doesn't he sometimes reopen and retreat the infected canal before closing it permanently?"

"Yes, he does."

"So think about your husband's infection as a root canal. I'm going to clean it out as many times as necessary. And we don't have to reopen him; his abdomen isn't closed, you know. It's open, as are his two loins."

"Doctor, is he going to survive?"

"I don't know. I'm not too optimistic. The infection is not yet under control, and his organs are failing—first his lungs, and now the kidneys. If he doesn't start to improve—or if he deteriorates within the next day or two—then the outlook is grim."

I looked at her, trying to assess the impact of my words. Her features remained calm; she seemed almost stoic. I stood up.

"Good night, then. I'll talk to you tomorrow."

"Just one more question," she said. "It's about his scrotum." She hesitated. "When he recovers, would he be able to function—you know . . . ?"

More than 30 days of reoperations followed, first in the OR, later at the bedside. In addition to the failing kidneys and lungs, Wilbur developed deep jaundice, and his circulation required inotropic support. In the intensivists' language, this was multi-organ failure, from which there would be no return.

But on one of those days, he stopped deteriorating. Then his organs gradually improved, the pus thinned, and the wounds pinked up. I realized he just might survive.

A few weeks later, I was called to the ICU. "Come down," the resident said. "Your guy's awake."

Rushing to the ICU, I found Wilbur in a bedside recliner, tethered to the ventilator by his tracheostomy tube. As I approached him, one of the nurses said, "Bob, look who's here. It's your doctor."

I didn't expect him to remember me after the many weeks of powerful sedating and paralyzing drugs. But lifting his head, he smiled, and gestured with his hands for me to come nearer.

When I approached, he placed his hands on my neck, pulling me toward him in a tight embrace. The tracheostomy tube prevented him from talking, but I could clearly understand his whispered words: "I love you." I had to swallow hard a few times, and—looking around—I saw the nurses doing the same.

A week later, we removed the tracheostomy tube, and the duodenal fistula sealed itself off. "What would you like to eat?" I asked.

He smiled and sighed. "I dream about a good diluted cold Scotch."

"Do you prefer blended or single malt?"

"I stopped drinking 18 years ago, Doc. I was a heavy drinker—haven't had a drop since. I still remember the taste. But I'll take a cup of Irish black tea with a lot of sugar."

Watching him slowly gulp the hot tea, each gulp followed by a deep, contented sigh, made my day.

One day before Wilbur went home, I sat on the edge of his bed.

"Doc, do you have children?"

"Yes. I have three sons—same ages as yours, more or less."

"How do you know?"

"I saw your sons around the ICU when you were 'out.' Nice kids."

"Is that why you worked so hard to save my life? Having three sons as I do, you felt what it would be like for them to lose their father?"

"I don't know."

But I suspected I did know why I couldn't give up on Bob Wilbur. Unlike that day 30 years ago, when I had failed to comfort my father, this rescue had succeeded. Bringing the Wilbur boys' father back to life had allowed me—at last—to repent.

"Doc, I'm going to pray for you every day."

"I would be grateful for that, Mr. Wilbur. I certainly need someone to pray for me. It may help."

 

Moshe Schein. I could not let this patient die. Medical Economics 2001;5:43.