Time of Death I

I'm not sure whether this is the type of post I should write. Intraoperative deaths are awful occurrences, a terrifying thought for patients and physicians alike. And though they are extraordinarily rare, they still do happen and to ignore that is to paint a rosier picture of medicine, anesthesia, and surgery than is the truth. This blog, as well as providing me a place of reflection for understanding those tough emotions of residency, is also openly available to the public, forcing me to balance the wish to write things honestly with the desire to censor anything that might be misinterpreted. This post is not meant to say anything about the patient, physicians, hospital, or circumstances in which a death happened. It is instead a sincere wish to help me make sense of my own feelings, hesitations, sorrows, and ruminations. As such, details about what happened have been changed to de-identify the situation.

I was assigned to provide anesthesia for an inpatient undergoing a complex cardiac surgery the following day. As is my habit, I saw the patient in the hospital the evening before surgery. In looking at the chart, laboratory values, and echocardiogram, I knew this was going to be a risky operation. Using a validated model, I calculated the mortality of the surgery to be over 30%.

The patient was a vibrant young man who, unfortunately, had endocarditis - infection of the heart valves. He had several bouts of endocarditis in the past, one of which landed him with a prosthetic valve, and now the bacteria were eating through this artificial valve as well as one of his native ones. Antibiotics could not clear this infection, and he was getting sicker and sicker with progressive heart failure. His kidneys were infected and failing; his liver was congested and injured; he had already thrown a septic embolus to his brain. The only way to clear this infection was to go in and replace the infected valves. If we did not, he would die.

He shook my hand. I sat down. We reviewed his history and when I examined him, I saw spots on his fingers and toes, evidence of a systemic infection stemming from his heart. I could hear the whoosh of his incompetent valves, no longer one-way. He had crackles up and down his lungs. He had so much trouble breathing, he could not lay flat. I talked to him and his brother quietly about what to expect with the anesthesia. I told him the risks of the surgery, including the fact that he may not make it through - something I don't usually say, but I felt obligated given the mortality risk calculation I had made. He told me clearly, "I cannot live like this, I want the surgery." He shook my hand again, and I said, "I will take good care of you."

What did I mean by that? I say that often, to almost any patient apprehensive of surgery, to reassure them that they are not alone in this experience, that my job as the anesthesiologist is to take care of the patient, to weather them through the surgery, to protect the body from the injury the surgeon would inflict, to understand how the anesthetic and surgical stress intercalate with the patient's other medical issues, to support the cardiopulmonary systems, to protect the brain, kidneys, liver, and even the eyes and limbs, to ward away pain, discomfort, nausea, suffering, and to be that person who holds the hand as the patient takes a nap and whose voice rouses them from slumber. "I will take good care of you," I said, to this patient who was putting his trust in me for a surgery I knew to be extremely risky.