The patient was older, but not that old. I mean, I hear that someone is 85 or more, give or take, and I immediately start thinking of ways to hide the scalpels and clamps. Chronologically speaking, he wasn't too bad but he carried a lot of miles on those years. Advanced stage cancer, severe pulmonary co-morbidities, multiple hospitalizations over past few months. I asked the nurse, is the family there? Yes, a son and a daughter. The son went downstairs for coffee. Ok, I said. I'll be in.
The guy was already intubated and they had just started levophed to maintain a pressure. First thing I notice are areas of mottling on his shins and flanks. Nothing more ominous in my experience. His abdomen was distended tight like he'd swallowed a beach ball. He seemed to wince when I percussed him. He opened his eyes and I saw fear.
-Your dad is in a bit of trouble, I said.
-What are his chances? Can you save him?
-I can operate. I can fix the hole. I can wash out the contamination. But hard to say how well he could tolerate it. He may be too far gone. He could die on the table. He could die tomorrow. Or three weeks from now. He could make it, as far as that goes. But he might end up on a ventilator for weeks. He might never breathe on his own again. Tracheostomy, feeding tubes.
-I don't know if he would want that,.
-Did he have a living will, an advanced directive?
-No, he said. He stared past me at his dad. He looked tired.
-Doc, can you give me a number? His chances?
-Can't give you anything accurate.
-Just give me something
-I don't know. Maybe 5-10% chance he ultimately achieves anything resembling a life as he had. If he makes it, this will take a lot out of him. He'll never be the same.
-He'll die if we don't do surgery?
-By morning, I imagine.
-Let me talk to my sisters.
-Of course. I'll be here. If you decide, let me know. I need to call in the OR team from home.
So I waited. Loneliest place in the world, a hospital at night. And then my phone rings. The nurse tells me they "want to try surgery". I walk back to the ICU. More family is there. A woman is weeping. Everyone looks gut-punched and broken down. The man has three daughters and four sons. We want you to try, the older son tells me. We know it's a longshot but my dad was a fighter. It's what he would have wanted. I review the situation again. We discuss arbitrarily defined odds. They know all this. They want me to try. They are all looking at me.
In the OR we find a perforation of the cecum. The whole side wall of the bowel is gangrenous and stool is seeping out into the right lower peritoneal cavity. The stool is thick, fetid, mud-like. It takes several minutes to find the source and control the spillage. We do a quick hemi-colectomy, stomas are created, the abdomen is washed out with 15 liters of saline. His pressure was labile and he didn't bleed much from cut edges. We finish and he makes it back to the ICU alive. The family is thankful and relieved. I put some orders in. I tell the nurses, it could get a little rocky the next few hours. By the time I get home, it's nearly 5AM. I put on some coffee and walk the dog. I take a shower. I pick out a tie and shirt. It's time to start another day.
By the time I finished my scheduled cases at the other hospital the next day, it was close to three. I had been checking on my guy via computer all along. Acidotic. I tinkered with his fluids. I gave an order for blood transfusion. But on paper, things didn't look so hot. I didn't have the greatest feeling as I mounted the stairs on the way to his room in the ICU. Turning the corner, I knew. The palliative care nurse was there. The room was full of people. As I got closer, I could hear muffled sobs. I stood on the edge of the room. The atmosphere in the small room was one of cramped anguish. The son and daughter from the previous night turned to see me. Oh Dr. Parks. You're here. Come in. We all thank you for all you have done. This is Dr. Parks. He did daddy's surgery last night. I tentatively entered, not wanting to intrude on their final moments of intimacy. There were 7-8 adults in the room. I eased through them. I just wanted to see him, I almost whispered. And there he is, bloated and swollen, eyes closed, tubes and wires exiting his massive form in all directions like a radio taken apart. His bluish toes extend past the edges of the blankets. I'm sorry I couldn't make him better. I'm sorry this has happened to your father and grandpa. Bless you all.
And that's how it ends. A daughter steps out to thank me again. I put a quick note in the medical record. There are other patients to be seen that day. I'm tired and I have to finish my rounds.
I contrast this tale with another episode from just two weeks ago. I had been called on a Saturday afternoon about a 88 year old man bleeding to death from a duodenal ulcer. He coded during the unsuccessful endoscopic procedure to identify the bleeder and then 4 more times in the ICU. This is when I was called. I got the quick back story from the medical resident. Heart failure patient, admitted initially for COPD exacerbation. Had received high dose steroids. Blood was going in wide open and then out again via his NG. He was on three pressors. I asked if family was there. I asked the resident to put the son on the phone. I told the son that the situation was grim. I told him that surgery had a less than 1% chance of saving his father. That he was more likely to suffer more pain than derive any benefit from invasive surgery. He told me he had to run it by his brothers. Five minutes later he called me back; no surgery. They made him DNR-CC and he passed an hour or two later, while sedated on the ventilator.
What drove the decision making in these two cases? Age? The time of day? Do we see things differently when we are tired and worn down? Did the fact I quoted a 10-15% chance in one case and less than 1% in the other impact the family decision process? In the one case I spoke over the phone; in the other it was a face to face encounter. Does this matter? Would these questions all be rendered irrelevant if we mandated that all Americans create legal documents to guide end of life care and take it out of the hands of emotionally distraught, overwhelmed adult children?
I don't know man. I don't know. I feel rested today. Already those patients are starting to blur into the mosaic of "past surgical cases" that rattles around in the hinterlands of my brain. The only questions I have now are self-doubts. Should I have just called in the OR team on the bleeding ulcer and paternalistically instructed the son that "I needed to do surgery to save his life". Should I have cancelled my elective cases after the perforated cecum case? Maybe if I had sat with him bedside I could have changed the outcome. I could have talked the family through the rocky phases with more precision than a medical intensivist . Maybe I could have done more. Did I do enough? It is the familiar inner refrain of a surgeon who is worth anything. That whisper from the edge of darkness.