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.
