A Page in the Life of a Surgeon

It is a routine Tuesday morning with my usual cup of tea in the solace of my room at work. This hour of tea is my time to kindle my thoughts: sit at the computer, check my mail, and meet some deadlines before the day begins. It’s Tuesday and I have a theatre case, a mastectomy on a breast cancer patient. It’s mundane, it’s routine but I know from all these years of practice that for the patient it is a life changing day, I know there is hope for cure for which she lays her life in my hands.

Let’s not dwell on these frills, it was a usual theatre morning where I go and the activities begin. Operation theatres have an exclusive atmosphere where there is the chitter chatter with residents and colleagues, pulling each other’s leg as hardcore work is done. The theatre is like a charm bracelet, you love it without really knowing why. It is the same ring you wear every day, but if you forget to wear it on a particular day you feel incomplete. For some hardcore coffee drinkers, it is a freshly brewed shot of hot coffee and for the book lover a novel you would love reading again and again: there is no argument about the intensity of the relationship of a surgeon and her theatre.

Where was I? Yes, in theatre and I have just finished my breast case and enjoyed my second cup of tea when I receive a call from my registrar reminding me that it’s my call day. There is a young woman with a gut perforation most likely due to typhoid. She is prepared for the standard emergency laparotomy and I have her shifted immediately to the theatre and the elective cases must go on waiting. Waiting, yet another classical experience in the OR – when will they shift the patient? Just as I decide to check, a female resident comes to the surgeons’ room and says the patient is refusing surgery. My male colleagues, with sarcastic humour, goad me to go and speak to the patient with compassion and empathy, which they believe are female traits, to convince the patient for the inevitable surgery.

I walk into the theatre and see a young woman who is supposed to be twenty-five years of age but looks no more than eighteen, beautiful in her simplicity, insisting that she will be fine. She does not want surgery. I begin to explain what is wrong in a language (Urdu) which I believe she understands. I explain that her life is of value and attempt to explore her fears but all I get is refusal and that she will become OK. I emotionally blackmail her: she has six children who need her and this is a routine surgery. I reinforce that she should trust us. There is no shift, instead she asks me if I believe in God and when I acknowledge this I am told, “For the love of God I don’t want surgery, it does not matter if I die.” I walk out of OR flustered and upset wondering how this mother of six can be so stubborn. I doubt her comprehension, and am willing to deceive her and have her anaesthetized with absolutely no moral discomfort. Controlling my frustration and anger I decide to call her husband who had consented for her surgery. My colleague, observing the drama, teases me that this paternalism goes against the ethics of care I am known to talk about.

My patient is in a state of emergency, in sepsis, kidneys going into failure with a pathetic nutritional status. Her husband, gowned, comes to the operating theater to speak to her. A cute couple, he patiently tries to explain to her that it is for her good, she argues with him and says you deceived me into coming to the big city, just take me back, I don’t want this surgery. Others in the room are viewers of the communication but the couple is oblivious to everyone. Some intervene and try to make her see the light. Her husband and a technician switch into their local dialect, and between her half “yes” and half “no” and the husband by her side with his arms around her, she is anaesthetized and the operation is underway.

Routine typhoid perforation, contamination that requires a thorough washout and a stoma (temporary opening made in the intestine) for she is nutritionally depleted and her parameters would not take anything else. Registrars do a good job and she is shifted to a step-down ICU and does well.

The next day her parameters improving, she is talking. Her stoma is a little slow to function but that is expected after such a surgery. She demands food which most of us believe is a good sign of recovery. However, her husband is told that only sips of water are allowed. I believe that within the next twenty-four hours she can take fluids and suck on sweets for taste; feel pleased at seeing her expression when she sips packaged mango juice, savoring the flavor she wants to gulp it down fast. Smiling, I ask her to take it slow and to drink more after a while. She changes her role and becomes a friend, complaining about her husband not giving her anything to eat or drink. I tell her, he is just carrying out doctors’ orders. Humorously, I tell the husband that your wife though delicate, is a headstrong woman, and I take my leave feeling happy. Tomorrow is another day, should one not feel happy or satisfied?

I see her once in the morning when all is well, her stoma functioning and labs normalizing, but as the minutes turn to hours the picture has changed. By the end of the day there is something not right, she is restless and drowsy all in one, her urine is concentrated. Am I missing something, what can it be? I tell my registrar to keep a watch and make sure he evaluates her again before he leaves at the end of the day. The next I hear of her being shifted to intensive care because of tachypnoea (fast breathing) and being electively ventilated with the expected need of ionotropic support. Why for the life of me I ask, her chest was clear, her parameters were near normal, why, just why? It becomes a downhill ride from there on, she starts to get acidotic, we stand by the bedside and look at her head to toe, we debate her re-exploration, has she perforated again, there is a septic focus somewhere. The resuscitation goes on, the labs get repeated to no avail and we discuss and explore in search of a reason for sepsis. We remove the double lumen placed, we check the chest, to find no answers anywhere. The much-needed CT scan cannot be done for her condition would not allow that kind of movement.

Then begins a feeling of impending doom that most surgeons have experienced. The conversation becomes another set of routine sentences: Ph is acidotic, urine output is only 12 ml in the last hour, she cannot be dialyzed because her pressures are not being maintained, dose of inotropes have been increased but BP still low. Nothing, just nothing gets better and finally the call that always makes you feel you failed comes and the saga ends. Aptly said in such circumstances: “man proposes and God disposes”; as mere humans we cannot fight fate.

Later in the day I ponder: where did I go wrong, what did I miss, I should not have forced the surgery. However, deep down I know if another such case came I would do the same thing, in the hope that this one would make it. I see her face and it is still painful, it is too soon to closet and move on. My eyes blur to say no more.