This past week I did an operation which resulted in the untimely death of a patient. The man had come to the hospital with his daughter, hoping that I could do an operation on her. She had been born with an anorectal malformation and shortly after birth she underwent a diverting colostomy. The girl was now seven years old. The father had heard there was a surgeon at the hospital and he came in the great hope that I could do an operation to repair the defect and reverse the colostomy. This is a pretty specialized operation and not one I have experience in doing. I had to tell him that, sadly, I could not undertake the operation. I thought we were done, but he kept talking. The interpreter informed me that the father also needed surgery. He had been operated several years ago for a bowel obstruction and he had what is called an enterocutaneous fistula. This means that the intestines have a hole which communicates with the abdominal wall. The result is that intestinal contents drain continuously. It is a miserable condition. Disappointed to not be able to help the daughter, I thought I might be able to help him. There is nothing quite so dangerous as wanting to help someone.
In an ideal world, a detailed record of prior operations would be available. Imaging studies would help delineate the location of the fistula, determine the amount of scarring, suitability to recover from a major operation, etc. In the context of this hospital, my pre operative work-up consisted of looking him over and figuring that I could probably help him. Would it be a difficult and risky operation? Yes, it most certainly would. The intestines were going to be stuck together and it would be difficult to free them up and repair the holes. He was malnourished, as these patients always are. This is a combination of malabsorption from a shortened working intestinal tract, and the tendency to not eat or drink. These patients learn that the more they take by mouth, the more drains out the hole. I’ve had a lot of experience dealing with these operations, and without seeming vain, I knew I was his best shot at fixing the problem.
As I began operating, I quickly realized that the intestines were very stuck together. I changed tactics and tried operating through the upper abdomen, to find a window. There were no accessible planes. In a difficult operation, you look for that critical juncture, where you either go forward or you stop, limit the damage, and do whatever you need to do to finish the operation. Unfortunately, by the time I had reached that point, I had already burned my bridges and I had torn the intestines in several places. I had no option but to keep going on. I eventually ended up removing a huge knot of intestines, and sewing the ends together. I also tore a large hole in the urinary bladder. It was so thin that I thought it was a membrane. I eventually was able to close the abdomen and send the patient to the ward. I knew that he would not be able to survive, and in fact he died two days later.
Here’s the thing about a high risk operation; it is risky. Maybe 9 times out of 10, things will go OK, but not always. The stakes are very high. Now I am left with the terrible knowledge that I saw a person who was walking, talking, living his life and providing for his family, and I performed an operation that ended in his death. I made the decision and my hands did the damage. He traveled a long distance to see me, trusted me to open him up, and ended up dead. It’s hard to write about this. I feel guilt, sadness, responsibility. I didn’t even want to talk about it for a couple of days, because there’s nothing much to say. I am not looking for someone to say, “It wasn’t your fault.” It was. In my heart I wanted to help him, I did the very best I could, but I made things much worse. This is the terrible reality that a surgeon must deal with and be honest about, especially in this context where resources are limited. I cannot explain to anyone how hard it is to go through this, and to go on working. But go on working you must…there are other patients to see, other things to do, other people who want you to help them. Somehow you learn to say to yourself, “This happened and it was terrible…but maybe in some mysterious way it was part of God’s plan.” Maybe it will make me a better doctor by giving me a better sense of judgment.
I think I’m going to see a lot of death here in Aru. Things are very basic and patients come late. Most of the patients I’m dealing with have been operated on at other health centers. I won’t go into all the disasters I’ve seen. The problem seems to be not a lack, but a dangerous surfeit of operations. I’m working with practitioners who don’t exactly know when to consult a surgeon. This morning I saw a coffin being carried out of the hospital and asked what happened to the patient. It turns out that she had a dental abscess and died because it was obstructing her airway. I asked why no one called me, and they told me that I was busy operating. Maybe I couldn’t have done anything to save her life, but it would have been nice to have been asked to see her. This is a hard place for me to work, but I’m trying to figure out how to fit in.
We like happy endings. If not a happy ending, at least let there be a moral to the story. In this case I don’t have either. This man died in the night and in the morning the bed was empty. His wife left a widow and his girl (the age of my own child) an orphan. She left till suffering from the same affliction that brought them to the hospital in the first place.
Why share such a story? Can people handle it? Maybe it is a way of sharing how hard it is to do this job, how much we need prayer. Maybe, in the end, our tears and our witness of suffering in this world is part of our offering to God, an acceptance of the cross that we each get to carry. I asked a friend of mine to read a preliminary version of this account and he told me this. “I hope you print your story on the blog, and that it will be a summons to all who read it to live life with courage, and surrender the good and the harm we do in our lives to the Lord.”
Those who sow in tears will reap with songs of joy. He who goes out weeping, carrying seed to sow, will return with songs of joy, carrying sheaves with him.
Psalm 126:5,6
Warren
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