DAVID W. PAGE
BURR HOLES IN THE HEART
burr: a form of drill used for creating openings in skull bone to
relieve pressure from intracranial hemorrhage
In the subdued light of the ICU
isolation room, Lisa's thirty-one year old body hides beneath a single white
sheet. Obscene numbers rivet her racing pulse to the overhead monitor. QRS
complexes dart after each other across the screen like skittish fireflies.
Without warning her blood pressure sags to ninety over sixty. An alarm sounds.
A nurse peeks into Lisa's
cubicle. "Should I call a code?"
"Not yet," I say,
gambling.
Lisa's breathing deteriorated
moments before she was admitted to the ICU when an endotracheal tube was
inserted into her throat. She was attached to a ventilator and a surgical
consultation was requested for, "a question of sepsis." Was the young
woman infected? Other than a minor gynecologic procedure a few days earlier,
Lisa had no significant past medical history. On-call for our group, that was
pretty much the skeleton of her story I received.
So at two in the morning, three
days after what turned out to be an elective laparoscopy for pelvic pain, I
evaluate Lisa in her dimly lighted cubicle. I receive a tangle of mixed signals - electronic, visual, olfactory, and most important for a surgeon, the palpable
truth spoken by rigid abdominal wall muscles, stone-hard stiffness informing my
examining hand. In that brief moment at her bedside, I discover her illness is
chewing at a lifetime of health, her body shriveling up in the rabid fires of infection.
"They think she's in septic
shock," says the night shift nurse, hanging a bag of antibiotics.
"She's been like this for most of the day."
"What do they think caused
it?" I eye Lisa under the forgiving sheet. Her urine is the color of
Killian Red. When I touched her belly again to be certain, Lisa reacts as if
shot. Her eyes widen, wrists twist against the woven fabric of her restraints.
"Something in her belly they
think," the nurse said.
Why am I receiving this
information second-hand? Because the doctors who asked for the consult are at
home in bed and did not extend to me a personal phone call. I probe Lisa's
lower abdomen. "Right here?"
Her abdominal muscles tighten. I
release the pressure and Lisa's head jerks off the pillow. The breathing tube
and its corrugated tubing yank at the corner of her mouth and she falls back on
her damp pillow. Lisa's strawberry blond hair streaks her forehead, glued to
her sweaty skin in strings. It's called rebound tenderness - proof of
peritonitis. I turn away from her dilated gaze with a growing sense of dread.
On an overhead shelf the EKG monitor races. I decide quickly, intuitively,
faintly hearing a lawyer's voice asking what evidence I used to make the
diagnosis. Surgeons surely trip on the dread of the legally possible in moments
like this.
I turn back to Lisa and bend over
the bed. Her eyes flicker when I introduced myself as a surgeon over the noise
of her ventilator and beeping EKG monitor. Knife bites from her fingernails
leave marks in my palm, her strength out of proportion to her sickness. And in
that compressed moment, I see camouflaged beneath the sheets and bandages and
IV bags and the mucous-rattling endotracheal tube, a frightened young woman.
For the life of me, I don't remember the color of Lisa's eyes.
Her chart describes a diagnostic
laparoscopy days earlier after which she developed urinary retention. She
required catheterization. Lisa's fever had shot up a day later while she lay in
bed at home. Shortly thereafter she suffered the first in a series of
teeth-chipping rigors, a spree of shaking chills that terrified her mother and
brought Lisa to the Emergency Department gasping for breath. Within an hour of
arriving in the ER, Lisa had been transferred to the ICU. Antibiotics and a
quest for the source of her infection were begun. An abdominal CT scan
identified fluid in her belly. Was it pus? Ask a surgeon.
I meet with Lisa's parents in the
early hours of that first morning and explain that their daughter has a
life-threatening infection brewing in her abdomen. Lisa needs an emergency
operation. They don't seem surprised. Lisa's father looks familiar to me.
The ICU nurses move swiftly. They
prep Lisa for surgery. I don't share my reservations about coming to the case
late with her parents. They say we surgeons are often intuitive. Well, at that
point I already suspect my operation will be too late. And try as I may to
think otherwise on the trip to the operating room, I again imagine myself
explaining Lisa's death at our weekly Mortality and Morbidity Conference, and
quite possibly much later, when sadness ferments into the corn liquor of anger,
in court. It is almost impossible not to think these thoughts as dread of a
terrible outcome rides side-saddle on the facts.
Lisa clutches my fingers as we push
her ICU bed from the intensive care unit down a long hospital corridor to the
elevators. A nurse inflates her lungs with an Ambu bag; Lisa's eyes are huge,
darting from face to face. An orderly helps me propel the heavy hospital bed
across the gap left by the open elevator door. The jolt bounces Lisa's body.
She squeezes my fingers like a vice grip.
In the operating room, I place
surgical drapes over Lisa's prepped abdominal skin for sterility, and, of
course, to keep her humanity out of sight. It is time to shift gears. I must
transition hastily from compassionate care-giver, thinking of my own daughter
asleep at home, to resolute surgeon. A Himalayan ice crevasse is smaller than
the emotional distance surgeons must leap in a heartbeat between empathy and
focused indifference. The risks are deadly if you miss your footing.
Lisa's abdomen lies exposed
between fat-pouting lips of a midline abdominal incision. My entry is quick,
efficient. The surgical resident assisting me is a junior, untested, but observant.
The first whiff of putrid air hits us from the open wound. Lisa's blood
pressure slithers, unobtainable for a moment. The anesthesiologist mutters
something vile.
"Problem?" I ask over
the ether screen.
"Pressure's going
south," says the anesthesiologist. "I'll bolus her with fluid. Keep
going."
I slip a gloved hand into Lisa's
belly. "We've got lots of pus down here."
"CT scan was right,"
says my assistant.
"Apparently."
Youth attuned to the prognostic
shadow dance of technology, I find his remark audacious, his infatuation with
images distracting him from the vile reality stinking up the room.
Not only did she have putrid
fluid inside her abdominal cavity, Lisa's abdominal wall also bulged with
foul-smelling pus trapped in sinewy pockets, killing her by inches. I cut into
Lisa's belly wall muscles. Creamy infected fluid spurts onto our sterile
drapes. The operating room floods with the stench of rotting tissue.
We run two suctions. Ugly sucking
noises turn the disciplined dialogue of the anesthesiologist into an
incomprehensible mumble. The middle of three laparoscopic incisions - the
central stab wound over her bladder - looks inflamed. It takes less than an
hour to explore and irrigate Lisa's abdomen, clean her abdominal wall, close,
and transfer her to the post-anesthesia recovery room.
I wash up and change into fresh
scrubs. I head toward the waiting room where Lisa's parents await me in
morning's ambivalent lull.
*
What I did not know I had missed
at surgery (would not learn for another three or four days when my associate
re-explored Lisa), was a tiny hole in her urinary bladder. Later, we surmised
the Veress needle (used to inflate the belly cavity during the original
laparoscopy) had punctured Lisa's bladder. When a cystogram, an x-ray of her bladder,
showed contrast material spilling into her belly, and when cultures of her
urine and the abdominal pus grew the same nefarious organism, we knew the
origin of Lisa's problem: she'd developed a ravenous bladder infection after
her diagnostic laparoscopy.
Tragically, the innocent urinary
tract infection had been left to rage out of control. As pressure in Lisa's
bladder grew, pus escaped through the bladder wall hole, overflowed into her
belly and abdominal wall, and caused a picture of generalized sepsis. The
raging infection had swiftly marched forward. It caused an unforgiving
condition known as systemic inflammatory response syndrome, or SIRS, which
quickly transformed into the deadly early stages of multiple organ failure. It
was the condition in which I had found Lisa in the ICU when I first examined
her - ventilator-dependent, feverish, and with a high white blood count - that
had made me suspicious of the inflammatory killer. I was now convinced the
process had accelerated out of control like an Australian brush fire before I
operated on Lisa.
When I performed Lisa's surgery,
her inflamed bladder tissues had squeezed the putative puncture hole shut.
That's why I had not seen it. The good news: there was no on-going
contamination. No more leak. If I had been called sooner, Lisa might have
survived.
The family's lawyer didn't see it
that way.
When my associate operated on
Lisa a week later, he found no further infection, no urine leak, no pus pocket,
but he did see the tiny hole in the bladder. Sad days of what seemed like
futile treatment crept into Lisa's ICU course. Outlaw bodily responses, buckets
of destructive enzymes flooded Lisa's tissues and led to a downward spiral of
multiple organ failure that ended her life two weeks after my consultation. In
the end, I knew Lisa only by her infected body and the frantic communication we
had momentarily shared beside her stretcher on the way to the operating room. I
will always remember the terror Lisa's eyes deeded to me when she pleaded for
mercy, squeezing my hand that long night.
*
I sit with Lisa's parents. We are
in the ICU waiting room. We stumble cautiously through the first hour of
anguish after Lisa's death, thinking out loud about what had happened, waiting
to go back into the ICU to say goodbye. We discuss her illness and my
conviction that Lisa's immune system had unraveled before my knife found its
mark. The process is well-described in the scientific literature, I explain. A
point in time is reached with raging sepsis when the body's physiology cannot
be repaired, the terrible bugs swarm and win, and some molecular critical
distance is surpassed. We surgeons say this with conviction, knowing it to be
true, almost certainly sounding defensive.
"Hope I don't sound as if
I'm making excuses," I tell Lisa's parents. "We call it the 'systemic
inflammatory response syndrome', a snowball effect we can't stop once it
starts. It's impossible to know when the line of irreversibility was crossed
with your daughter."
Lisa's father seems vaguely
convinced, but confused. Her mother shows no reaction to my explanation, her
dark eyes wet, uncertain, locked on me, her radar seeking clues. I reword my
explanation. This time Lisa's mother asks me if I thought the laparoscopy had
anything to do with the infection.
"My associate found a hole
in Lisa's bladder," I say. "It played a role."
It is impossible to end a death
talk. You sneak around and around on a frightening path, and you see it
narrowing up ahead, closing in on the truth with ever smaller explanatory strides
until you discover you're staring into your own soul. In the early hours of the
morning Lisa died, we sully our conversation around the unspoken atrocity: a
thirty-one year old healthy woman is dead.
The hardware of my surgical
intervention, tubes, drains, bandages, even the ventilator, seem like
archeological artifacts in Lisa's brief hospital history, the debris of failure
her parents see when we stand mute and they say their final farewell in Lisa's
curtained room. Nothing I had done had helped Lisa. I had simply been called
too late, a slippery reality absent from the medical record.
*
When her brother appeared in my
office, I was stunned. Lisa's parents had never mentioned him. Where was he
during the throes of his sister's demise? Where was he when his parents
suffered the most profound tragedy of their enjoined lives? What family
connections lay hidden from me?
Although I could not answer these
queries, I did understand why he sat before me now. It wasn't the threat of
litigation that saddened me. The absentee stakeholder, this invisible brother,
had the right to keep and bear grudges. And so as he bluntly rehashed his
understanding of the facts of Lisa's death, his parents sat next to him and
suffered through his queries in silence.
Her brother's insistence that
something had gone wrong, that something must have been done incorrectly,
negligence in a word, brought back my own sister's death in Canada in 1971. I
snapped back to her head-on car collision on a remote Canadian road and a small
Ontario hospital's failure to provide the most basic emergency care. Sandy had
been transferred to Ottawa General Hospital. She died within an hour of
neglected minor injuries and the simple need for IV fluid resuscitation
withheld in the northern community hospital. The autopsy report - an impersonal
recitation of my adopted sister's organs and tissues - had resided in my bottom
desk drawer for years, the residual of a lost family relationship, ammunition
for a legal battle I lost the heart to fight, and hidden in a memory-proof
container until Lisa's brother pried off the lid.
I experienced shame and anger
when Lisa's brother brought me to tears in my own office, remembering Sandy's
case, real medical malfeasance. But that wasn't the source of my wet eyes,
averted behind tissues before reasserting my game face against his indignity.
It was my failed relationship with Sandy that burst my heart that day.
*
It's called a deposition.
It should be properly referred to
as prolonged emotional torture, psychological water-boarding. It was how, a few
months later, Lisa's brother extracted his measure of revenge. A clever Boston
lawyer worked me over for two hours, drilling random burr holes into my heart,
expecting guilt to pour out of my ventricles, seeking an admission of guilt I
didn't feel and refused to own. He drilled into my conscience without relieving
the pressure and only reluctantly accepting my SIRS explanation of Lisa's
demise after hours of interrogation.
The inexorable consequence of
neglected sepsis finally became a matter of record. Having failed to indict me
with that line of inquiry, the Boston lawyer then attempted to coerce me into
incriminating the gynecologist who had performed the laparoscopy. His inquiries
felt like electric shocks from alligator clips leading from a car battery and
clamped to my conscience.
Eventually, I was released from
Lisa's brother's lawsuit without prejudice, but with a lifetime of regret,
Lisa's memory evermore glued to my sister Sandy's - two young women who should
not have died.
Eventually, I remembered where
I'd seen Lisa's father. And so for years we encountered each other at our local
professional hockey team's games. He was a goal judge; me, an occasional team
doctor. We always shook hands and talked of hockey and other things. I sensed
no hostility in his presence. His grasp was forgiving. It reminded me of Lisa's
hand clutched in mine that night of failure.
In those greetings, Lisa's father
granted me a measure of reprieve from the guilt I still own for having lost his
daughter's life, SIRS or not. And I would like to think he understands that in
my mind at least the tragedy of Lisa's and my sister's deaths are inseparably
linked. Both could have been avoided.
I've seen both sides of loss in
my surgeon's years. The burden saddens me. Of course, there are elements of the
care we gave Lisa to question, the delay in getting her treated, the poor
communication between the gynecologist and me. The healing art often stumbles
in the dark when the science underfoot leaves an incompletely cleared path.
The answer is seldom litigation.
Punishment leaves scars. And scar tissue retracts into itself. To
compassionately manage a treatment catastrophe, one must care for the wounded
survivors. Doctors too.
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