A major understatement. The patient’s blood pressure went to zero on the screen and his heart rate, which had been 70 to 75 beats per minute, dropped within seconds from 40 to 20 to 0 beats per minute. No response was detectable from the EKG leads placed on the patient’s chest. This is a condition called asystole; indicating no measurable electrical activity or function in the heart. I immediately began chest compressions as part of cardiopulmonary resuscitation (CPR). The anesthesiologist “called a code,” initiating an inrush of nurses, support staff, and physicians into the operating room. The calm, measured, and pleasant environment from a few minutes earlier was replaced by barked orders for medications, harried placement of additional intravenous lines, and blood samples shuttled out of the room by sprinting orderlies to obtain laboratory results—STAT! I continued with chest compressions.
Fifteen minutes later, after alternating with other responders several times to apply CPR, I realized the patient’s family must be wondering where I was. I was overdue for my appearance in the waiting room. I shouted to a nurse to call and let them know we were having a serious problem, another gross understatement, and I would be out as soon as possible.
Imagine how chilling that terse message must have been for the patient’s family. It was miserable for the nurse to deliver it. I couldn’t believe I was asking her to convey the information. The previous communication that everything was “great” should have provided a measure of relief and reassurance.
We continued our attempts to revive my patient for an additional forty-five minutes, following every accepted and appropriate cardiac life-support protocol, with different individuals rotating in to provide chest compressions as people became tired. I even went through the abdominal incision and opened the pericardium, the lining around the heart, and massaged the heart directly. The patient never regained any electrical activity of his heart and never had a return of any blood pressure.
After an hour, one of my anesthesia colleagues walked up behind me, touched me gently on the shoulder, and said, “I think it’s time to stop. We’ve got no electrical activity.” I was performing chest compressions at the time. I stopped and stepped back. I saw the flat line on the monitor from the EKG leads and the blood pressure of zero. Benumbed and disbelieving, I looked at the clock on the wall and said, “I am calling it. Official time of death is now.”
The room went from loud, frenzied activity to silence and stillness. I walked past everyone who had come to help my patient, but nobody would look me in the eye. I took off my surgical gown, gloves, and mask and discarded them. I moved past the other operating rooms, gathered my white physician’s coat hanging from a hook near my locker, and made the slow, long walk to the surgical waiting room. An operating-room nurse had called ahead of me to have the patient’s family moved into a private consultation room. I walked in, closed the door, and said, “I am really sorry to tell you this, but he has died. Everything was going fine, but suddenly at the end of the operation his heart just stopped.”
Before I got out the final words the patient’s wife and daughters were sobbing loudly. All of the air seemed to leave the rapidly constricting, suddenly claustrophobic consultation room. I squatted down in front of the patient’s wife and daughters like a baseball catcher and held each of their hands alternately, vainly attempting to offer solace. After a few minutes of weeping and whispered remarks of disbelief, they calmed enough to begin asking questions.
What happened? How did it happen? What went wrong? We thought everything was going fine, what changed? Why did this happen? I was peppered with a series of how, why, and what questions. I was shaken and stunned, too, but I maintained my composure and a professional demeanor. In retrospect, I think my voice was likely dull and monotonic. I gave an accurate and complete account of what had transpired and admitted I did not know or understand why his blood pressure had dropped precipitously at the end of the operation. Things had gone from smooth and stable to no heart activity in less than forty-five seconds.
For more than an hour I sat with them, sometimes quietly with no words spoken, sometimes responding to the next set of questions, which tended to be repetitive. But they had a right to all the time they needed from me. I eventually steered the conversation to a difficult topic when I asked their permission to perform an autopsy. I explained rotely that this was an opportunity for us to discern what had gone wrong and why an operation that had proceeded in a flawless, choreographed sequence, with no problems and minimal blood loss had ended disastrously, tragically. The family exchanged glances, and the patient’s wife nodded and gave her assent. I handed each of them a copy of my business card with my office and cell number and asked them to call me at any time if they had questions or other concerns.
I was severely distressed by the experience; I had never had a patient die during an operation before. It has never happened since, but once was enough to burn a lasting impression on my mind. I didn’t sleep that night. I lay awake for several hours mentally replaying the events time and time again trying to visualize anything that would explain the occurrence. I finally got out of bed and went to the kitchen table and reimagined every step, self-flagellating because I was not able to identify any unusual intraoperative variances or technical mistakes. I thought about every conversation I had had with the patient. What had I missed or failed to ask? I had gone through the standard “Review of Systems” questions about chest pain, heart disease, palpitations, breathing difficulties, reduction in exercise tolerance, and on and on, and all his replies had been negative. I specifically recalled a poignantly glib comment the patient had made during our first consultation visit: “If it wasn’t for this damned cancer, I’d be perfectly healthy.”
Late the next afternoon I received a call from the pathologist who performed the autopsy. The cause of the unexpected death had been identified. While the patient had no symptoms or signs of heart disease, including a normal preoperative EKG, the pathologist found an ulcerated atheromatous plaque at the origin of his left anterior descending coronary artery. This artery supplies blood to the beating muscle wall of the front side of the heart, including the left ventricle, which pumps blood through the aorta into all areas of the body. The vessel was severely narrowed and an acute clot had formed at the site causing complete blockage of this important artery. He had died of a major intraoperative myocardial infarction, a heart attack.
I didn’t sleep that second night either. I ran the entire scenario in an endless repeating loop. During the day, I was distracted and withdrawn. Fortunately, I had no other operations scheduled for the next several days. I was able to push myself through a full day of the outpatient clinic and several research and administrative meetings, trying to maintain a veneer of normalcy. I reviewed the patient’s medical record several times, wondering what I could or should have done differently. He had completely asymptomatic but critically dangerous coronary-artery disease. Were there signs I missed or should have detected?
I called his wife and family and explained the autopsy findings. I reported that I was surprised because he had had no symptoms or clinically evident findings of an impending heart attack. Acute blockage of the left anterior descending coronary artery is a common cause of sudden death; cardiologists call it the widow maker. The patient’s wife was incredibly gracious and thanked me for the information and for my attempt to help her husband by performing an operation to rid him of the cancer.
The next week my patient’s case was presented at our weekly Morbidity and Mortality, also known as M&M, conference, in which we discuss any complication or death that occurred during or after an operation. Customarily, a surgical resident or fellow involved in the procedure presents the patient’s information, describes the complication, and reviews surgical literature on the specific condition and operation, including any reported earlier complications and their subsequent management. The M&M conference is a surgical tradition. These days the meetings are much calmer and kinder than the ones I attended as a surgery resident more
than twenty-five years ago, but M&M is and should be an open and honest disclosure to our surgical peers, trainees, and students of any complication or death that occurred during or after an operation. After the primary surgeon and the resident or fellow lay out the facts and findings, we await an unflinchingly direct review from our colleagues with comments, suggestions, and discernment of what could and should have been done differently. In order to understand the genesis of a complication and to avoid a recurrence of the situation in the future, we often categorize problems as: technical mistakes, errors in judgment, misdiagnosis, or delayed diagnosis. It is an important educational episode with an opportunity for all present to learn from earnest and forthright discussions on improving our patient care and surgical outcomes. The fellow involved in the operation with me gave a succinct but thorough presentation, including projected slides of the patient’s CT scans showing his liver tumors, his normal preoperative blood tests, and his normal preoperative EKG. The fellow also provided a verbal description of the operation and terminal events.
After the fellow finished speaking the room was silent. There were no pearls of wisdom to be gained from my peers or colleagues. One of the senior surgeons sitting in the middle of the room turned to me, sitting sullenly in the back row of the small auditorium, and stated plainly, “I know this is tormenting you, but things sometimes happen you can’t predict or alter. This man had no symptoms warning you about critical coronary-artery disease, and there is no obvious reason why it occluded at the end of your operation.”
M&M conference can be somewhat humiliating and humbling, or it can be cathartic. This conference was neither for me. My senior colleague’s comments were sympathetic, but I was not comforted. None of us could detect a technical error, an equipment malfunction, a preoperative-assessment omission, or a mistake in judgment. It was what it was. Reports in surgical scientific literature regarding techniques and outcomes for a variety of procedures inevitably include a list or table with rates of complications and mortality. That is why, for some surgeons, complications and deaths are reduced to a statistical event, an austere and unfeeling probability, and they sometimes adopt a perspective that may be too dispassionate. This is not, and should not be an accepted reality because a surgical complication affects the patient, the family and caregivers, the surgeon, and the entire surgical team. Ultimately, after several days of excessive and unhealthy self-torment, I realized I had to grieve, accept, exercise (run) to blow off some angst, and allow myself to heal over time.
For high-acuity (meaning difficult, technically demanding, unusual, or dangerous) operations, reports in surgical journals repeatedly indicate that the results are better when the procedure is undertaken by surgeons who perform the operation routinely. The results are better regarding complication, mortality, and survival rates of patients. An additional important factor in the improved-outcome equation is that the operations are performed in hospitals that provide care for large numbers of patients undergoing the operation. This is certainly true for many advanced surgical oncology procedures. But no surgeon and no medical center is perfect. Every time I meet with a patient and his or her family and review the list of potential complications and problems that may arise after an operation, I quietly hope and pray the patient will recover well and uneventfully. I have learned in harsh lessons to remain vigilant because problems can arise to blindside us just when we think all is well.
One of the complications we fear after surgery is deep venous thrombosis, or DVT, which is blood clots forming in veins. Cancer patients may have a higher risk of developing this complication than other surgery patients do. In a worst-case scenario, the blood clot can break free from a vein in the leg or pelvis and travel through the heart to the pulmonary arteries and cause a blockage called a pulmonary embolus, or PE. This can trigger shortness of breath, low oxygen levels in the blood, or sudden death. A few years ago, I operated on a sixtysomething-year-old businessman from an Eastern coastal state. He had a solitary right-lobe intrahepatic cholangiocarcinoma. He was an avid sportsman who enjoyed hiking, camping, and fishing. He ran two to three miles daily. He was in excellent physical condition and had no other medical problems when I performed a routine right-liver resection on him. Pre- and postoperatively we treated him prophylactically with subcutaneous injection of an anticoagulant medication to reduce the risk of blood clots. The operation went well with a blood loss less than 150 milliliters. He was up walking laps around the nursing unit the night of the surgery. On postoperative day four he was discharged from the hospital. When I saw him a week later in my clinic he expressed his sincere appreciation, he reported he was feeling well and was ready to return home. We set an appointment for him to see me six weeks later with blood tests and a CT scan to assess his liver regeneration and overall progress before beginning chemotherapy.
Two weeks prior to his scheduled visit, his wife left a message at my office. I saw the note on my desk when I returned from the clinic. I called her and cheerfully said, “Hi, how’s everything going?” My ebullience immediately disappeared when she said, “I’m sorry to tell you, but I have bad news.” She told me her husband had gone that morning to sit in a lawn chair overlooking a lake on the back of their property in the foothills of the mountains. This was his long-standing ritual and he would relax with his Labrador retriever and a cup of coffee enjoying the view as the sun and mist rose over the water. When he failed to come in for his routine shave and shower before going to work, she walked out to check on him. The dog was sitting beside him, his chin resting on my patient’s arm. She spoke to her husband as she walked up behind him, and when he didn’t reply, she noticed he was slumped sideways in his chair. She came around in front of him, and realized he was dead.
I was staggered, but then asked what I could do for her. I discerned from her voice that she was in the peculiar disbelief phase that often follows an unanticipated event. She told me that all she wanted was an answer to what had happened. She informed me she had agreed to an autopsy because she didn’t understand why he had died suddenly when he was recovering well and had returned to work and normal activities. A few days later, the referring medical oncologist called to inform me that my patient had suffered a major pulmonary embolus.
I was dumbfounded—but also angry. The entire medical team and I had followed all of the current and recommended guidelines and protocols. We treated him with anticoagulation medicine before and after the operation, and he was still on this medication at the time he developed the blood clot that traveled to his lungs and killed him. How the hell had this happened despite our adhering to the correct DVT-prevention treatment protocols? Maddening! This patient’s untimely death reminded me of a harsh reality of surgical practice. Numerous publications and studies note that the incidence of DVT and PE after major surgical operations is reduced by proper use of anticoagulation medications, but it’s not eliminated. We are like Las Vegas bookmakers: we calculate and assess odds and intervene in an attempt to lower risks and influence fate, but there are no guarantees. Complications may arise despite thorough assessment, a well-performed operation, and adherence to all preventative measures.
Patients are willing to accept significant risks to undergo an operation to remove their malignant disease. Nonetheless, when those potential risks materialize as problems affecting the length of hospitalization, quality of life, or even survival, it is a disturbing, painful, and frustrating occurrence for all involved. Surgeons continue to search for ways to reduce risk profiles, but complications are the ghosts in the machine, lurking and appearing to disrupt a patient’s course and treatment plans.
I obsess and worry about any patient I treat who develops a complication. When I was a surgical resident, the vice chairman of surgery, a man I deeply respected and who was very important in my surgical training, pulled me aside, and said, “You need to be careful. You get too involved, and you care too much.” While I understood the remark, I admit I stared at him with some incredulity and responded, “I don’t
know how else to take care of our patients. If I stop feeling, it will be time for me to stop doing this.”
I’m not planning to stop any time soon.
25
The Golfer
“Everyone should be respected as an individual, but no one idolized.”
Albert Einstein
Respect: A feeling of deep admiration for someone or something elicited by the person’s abilities, qualities, or achievements
Golf is a peculiar game. I occasionally watch the standup-comedy routine by the late comedian Robin Williams describing, with a heavy Scottish brogue, of course, the origins of the game in Scotland. Not only is it funny, but it rings true. His explanation that each swing of the club is called a stroke because frequent frustration and errant shots make the average golfer feel like he or she is having an actual stroke is an inspired etymology. I always find it odd but entertaining to watch grown men and women thoughtfully choosing a long metal or graphite stick attached to a variably angled piece of metal to hack away, some much more gracefully than others, at a small white ball, hoping to control its destination. Even the most skilled golfers, those who earn a living playing the game, hit a fair number of shots that end up in all the wrong places. Like the beach, also known as a sand trap; or the rough, devilishly long grass that seemingly engulfs and grasps the ball. Or the woods, an interesting and potentially dangerous opportunity for self-injury caroming the ball off trees like a ball in a pinball machine; or the water, where the ball splashes down like the capsule at the end of an Apollo space flight.
I am not a good golfer. I play six or seven times yearly. It is unusual for me to find four or five hours of time on a pleasant day to go out and chase a little white ball through the high grass, trees, and back yards of the people unfortunate enough to live on a course where I happen to play. However, I am guaranteed four rounds of golf annually. Every spring I partake in a hallowed tradition. I go to Las Vegas with three friends and fellow surgeons from Chicago suffering from severe cabin fever related to the long cold winter in their Lake Michigan–side city. The sum total of our sins in Sin City is to play four consecutive days of bad golf, eat more red meat in four days than we eat in the four months before the trip, and talk so much trash and laugh so hard that we return to work the next week hoarse.