The longest day I have ever worked
As you walked into the preoperative holding room, you could tell from the doorway that something was wrong with this man. Before me sat a hispanic male named Juan, his abdomen was so large he looked pregnant. He didn’t speak english, so I had to call the interpreter to help obtain consent for his surgery. He was about to go to the operating room in an effort to further investigate his abdominal tumor, and if able, the plans were to remove it. Well, the plans seemed simple, but the surgery did not go well – as soon as we opened his abdomen, he began bleeding so profusely that after the half an hour it took to just control the bleeding from the surface, we had to abort the case. He was transported to the post-operative recovery area with his still pregnant-appearing-belly. The plan was to begin treatment using chemotherapy the following week with the intentions of trying to shrink the tumor. I again called the interpreter to help explain this to the family (none of whom spoke English). Juan remained in the recovery unit over night.
The very next day was a Saturday and I was to take overnight call – by myself. I met with the other surgery intern early in the morning to cover all of the events that had occurred the previous night. The first thing he said was, “your pregnant guy is tanking. They called me nonstop about him all night long.” I completed the morning checkout, and then rounded with the chief resident. We saw all of the patients, including our specific guy (whom at least for the time being appeared relatively stable). Surgery services frequently round very early in the morning – this helps limit interruptions, expedite the Q&A from sleeping family members, and more importantly, allows for starting in the operating rooms on time. The main problem is that most of the lab tests and or daily scans are not back in time for rounds. About 2 hours later I received the first of many calls that day from the PACU, informing me that my patient had a very low blood pressure and a weak pulse. I went to see him immediately, and his blood pressures and heart rate were steadily falling and he was going into shock (meaning his body was shutting down). This is not normal. People go into shock frequently because of severe infections, significant blood loss, and although he lost some blood yesterday, that seemed under control. Juan was quickly becoming unresponsive. He had already received plenty of IV fluids, but he was not urinating. I checked his catheter, and even repositioned it – nothing. His abdomen looked much larger to me, and was so tight it looked like it was going to pop. I checked his labs which were now back – his creatinine level, which tells you how well the kidneys are functioning was sky high – meaning, they were not working. He was about to crash. Within minutes he stopped breathing and became unresponsive, I coded him for about 2-3 minutes successfully, put him on the ventilator, and started him on iv medications to keep his heart beating.
I called the chief resident to inform him of what transpired, who was now home. Now as a surgery resident, there is a lot of things that simply do not surprise you anymore, but that day I was definitely surprised at what I heard from my chief, “Cut his f@*king belly open, now, he’s got a compartment syndrome. I’m on my way.” I was not in an operating room, and this was not a regular happening in the PACU. I looked at the nurse, whose name was Ralph, and told him to get a scalpel. He nodded his head in disbelief, but retrieved a scalpel looking like a little kid excited for what comes next, yet terrified at the same time. I cut the sutures from the day before, and opened up his abdomen. There was an immediate burst of blood and clots coming out. Unable to find the source (or much less do anything about it), I placed a large ioband sheet that would contain the bleeding for now.
Within a few minutes my chief resident arrived. He was a tall, large Irish guy, who spoke with a thick accent. “Nice work Feddock” he told me as he walked in and saw that Juan was still alive. We immediately re-evaluated him, and his blood pressures and heart rate were definitely improving. I then went to meet with the family again with the interpreter to explain to them what had happened. This was not a particularly difficult interaction as it largely consisted of reporting the facts pertaining to what had transpired. His family was understandably having a hard time with this, but he was young and otherwise healthy so the plans at that point were to do everything we could, and they were thankful.
Unfortunately, he was not out of the woods yet as he still had an open abdomen. We were trying to coordinate a return trip to the operating room when his new set of labs returned. His kidneys were getting worse, and the electrolyte abnormalities resulting were so significant that he was going to require dialysis to improve the situation. I consulted the nephrology service who agreed while scratching their heads, so thus began the next invasive step – placing central line catheters to begin dialysis. I called the interpreter back, we had a family meeting again where I again objectively provided the details of the situation and explained the need for dialysis. This talk too was relatively straight-forward as I was presenting both the problem and the solution.
Central line catheters were placed, but before anything could be done Ralph paged me again to inform me the blood pressures were declining and was again becoming unstable. What transpired over the course of the next 4 hours essentially included constant supervision at the bedside changing iv medications called pressors. As a surgery intern, my knowledge of intensive care unit medicine is not very adept, so I was also called the nephrology fellow and the icu fellow constantly, getting their ideas and suggestions. The bottom-line was that there was nothing that was going to turn Juan around. He was bleeding from his abdomen, we needed to get to the operating room in order to fix it, but he was too sick for the time being to transport. Then, the bigger picture is that he was a man with a likely incurable cancer. I continued to communicate with my chief resident, made several visits to the operating room where he was busy, and then I got my orders to “get the family to make him a DNR.”
This is not as easy as I simply write an order in the chart. I had to call the interpreter again, and visit the family and get them to request that Juan not be resuscitated should he stop breathing or his heart stop beating again. After providing my previous objective explanations and plans, always returning to the idea that we are going to do everything possible to save him, the tone quickly changes when hours later you try to explain to the family that the treatments and interventions we are doing are not fixing the situation. His wife yelled at me, then cried, then pleaded, asking me to do everything possible, but did admit he probably wouldn’t want to have CPR, the yelling resumed, and then she stormed out of the consultation room. I caved and actually did not get the do not resuscitate order. Deep down I hoped that the situation might fix itself, and just let it slide. As I started to walk back, Ralph looked at me, with a clearly sad look on his face and just said, “You’ve got to do this, you’re the Doc. He’s not going to survive this and you know it.” I turned back, went through the motions again, and got the do not resuscitate order. My chief again told me, “Nice work Feddock.”
I wish I could say that was the end of it. Unfortunately, a do not resuscitate order just means that once things stop, we will not try to bring them back, and it doesn’t mean we will not continue trying. The day progressed on. My chief resident returned to check on the situation which was still about the same – slowly getting worse. It was now after 10:00 at night. I was exhausted, and the angst from carrying the code pager alone after hours was beginning to set in. I ran all over the hospital putting out fires as surgery interns do, and at 11:15 I got my final page from the PACU team. Juan had another set of labs return – not only are the kidneys getting worse, he is now having a heart attack. His vital signs are in the toilet, and the pressors aren’t doing anything.
I go down to see him. He is on 3 different medications which are keeping his blood pressure and heart rate barely within the acceptable range. He is on a ventilator, his pregnant looking belly is still open with a giant yellow sheet stretched across it, and he doesn’t respond to any stimuli. Its time to call it. The reality is that Juan was not going to get better, and there comes a point where continuing on is simply inhumane. I call my chief who tells me he is on his way to help, I then call the interpreter, and we hold our final family meeting. This is the 6th time I have approached the family today alone. Yesterday, I reassured them surgery would go smoothly. Today, I first met with them to discuss the treatment plan for the following week, then I had to code him, open his belly, and start pressers, then escalate care, then answer questions, obtain the DNR and answer more questions, and now it was to explain to them that it was time to withdraw care – Juan is dying and he is not coming back. I cannot now and I surely could not then imagine being in his wife’s situation. He walked into the hospital yesterday, and now within 36 hours, he has gone from sitting upright to being past the point of no return. There was a lot of crying. His wife couldn’t make the decision, but his father was there who instructed us to allow him to go with the lord. Within 5 minutes of stopping the medications, Juan passed away. It was December 23rd.
I learned a lot from myself over those 2 days. I definitely learned that there are distinct limits in terms of what we as physicians can and cannot do. I also learned the unfortunate kickbacks of being overly optimistic. Most importantly, that sometimes no matter how emotionally tied up into a situation or a patient that I become, there’s a difference between what you want to do and what you should do. That day I wanted to avoid the PACU, I didn’t want to have to approach the family and deliver progressively terrible news, and I honestly just wanted to go home. I have never seen his family again, but I hope that they know I really tried everything that I could that day and I didn’t want to give up, but as my nurse Ralph told me, “I’m the Doc, so this is what I have to do.”