I have been practicing neurosurgery for over twenty years and two weeks ago something happened to me that I have never experienced before…
Tracy Schlachter was a 67-year-old gentleman who had undergone two craniotomies in the early 90’s for presumably a benign meningioma. As a result he was left with some right-sided weakness and over time he had to resort to using a walker to help him get around.
In fact within the past few years he had several falls requiring hospitalization. Each time it was thought he may have had either a stroke or a seizure. Each time, tests failed to reveal the reason for his falls. Nonetheless he was placed on an anti-seizure medicine just in case.
Though these ‘falls’ were often accompanied by periods of confusion, in general he was ‘alert, pleasant and fully oriented’. That was of course, until he fell, for the last time, that Sunday night.
I received a call from Chad, my PA, telling me that Tracy was in the ER at Morton Plant Hospital. He had been told he had an epidural hematoma which, of course, was a neurosurgical emergency.
I logged in to the hospital computer system from home and reviewed Tracy’s CT. There was a hematoma but it was a subdural; still it was causing a great deal of pressure as well as a shift of the brain structures from right to left. I called Matt at the transfer center who then set up a conference call with Dr. Davis in the emergency room.
Apparently Tracy had fallen several hours earlier and when he began to have a seizure at home his wife had called 911. Initially when he was brought to the ER he was conscious but shortly thereafter he had begun to have another seizure and he quickly became comatose. Dr. Davis had spoken to his wife who agreed that Tracy should be placed on the ventilator because of his condition.
As I spoke to both Matt and Dr. Davis I ascertained that Tracy still had brain function and though the appearance of the CT scan indicated to me that his prognosis was poor I decided that emergency surgery should be performed in the hope that Tracy would survive and recover. I directed Matt to arrange emergency transfer and that EMS should bring Tracy directly to the operating room at Mease Dunedin Hospital, where I would be waiting. Dr. Davis then spoke with Tracy’s wife who consented to the emergency transfer.
Now, I must clarify my position regarding treatment of gravely ill patients. In circumstances where the patient has an injury that has caused (likely) irreparable damage from which the patient cannot recover, or if he or she does recover it would result in vegetative state I cannot argue with a family’s decision to withhold extraordinary measures.
However in most cases, the outcome is usually in doubt and so I usually advocate doing what we can. If there is no improvement and the family wants to withdraw ventilator support I honor their wishes.
Of course if the patient is in their 90’s and/or was severely incapacitated either physically or mentally beforehand, I can hardly disagree with providing comfort measures only and allowing the patient to die peacefully and with dignity, if that is what is to happen. However, as far as I could tell Tracy did not fit into any of these categories so I believed we should do what we could.
A soon as Tracy arrived at Mease approximately 1 hour later he was taken immediately back to OR room #2. After the anesthesiologist connected Tracy to the anesthesia machine, I positioned him on the operating room table. I then shaved his head and marked my incision and directed Bill to start prepping his scalp.
It was at this point I received a phone unlike any other I have ever received at this point in a surgical procedure. The ICU nurse told me that he was bringing Tracy’s wife to the surgical department. She wanted to speak with me immediately… and she meant, ‘right now!’
As I walked through the automatic doors of the operating room out into the hall, there was a woman standing there staring at me as if she had expected me at any moment and yet she was distracted. I said, ‘Mrs. Schlachter?’ She shook her head ‘no’ and with a strange, almost fearful look on her face peered around the corner and motioned toward the other woman whose footsteps I could hear walking quickly and determined in my direction.
She was eating a health food snack and she talked and ate at the same time. ‘What do you think you are doing?’ she demanded. Immediately I was taken aback (and what rarely happens to me), I was put on the defensive! I said, ‘Well I had planned to remove the blood clot that is pressing on your husband’s brain and threatening his life.’
‘Why would you want to do that?’ she stammered.
I felt as though I was a resident again being interrogated by one of my attending surgeons. Before I could answer she began listing the reasons why surgery was not only a bad idea it was the dumbest one she ever heard of!
‘He’s already had two brain surgeries for brain tumor… he has a seizure disorder… and despite all the tests he has had, the doctors still can’t figure out why he falls all the time.’
I was confused by her reasoning. First of all the brain tumors were benign and the surgeries were 20 years ago; his seizures were controlled by medication and most of the time he walked just fine, albeit with a walker. It wasn’t as if he had terminal cancer or had been confined to a nursing home with Alzheimer’s disease for the last five years.
It seemed to me she was talking about mere inconveniences, not life threatening illnesses. ‘Well, I thought I would perform the surgery to give him the best chance of recovery’ I said.
‘Why, so he can wind up in a nursing home? No, you are not doing anything!’ she said as she stared directly into my eyes with pinpoint accuracy.
To say the least, I found her behavior a bit odd because usually when something sudden and unexpected happens, most family members want everything done. If not just to see if recovery is possible but also partly because they don’t want to feel guilty that they didn’t do everything that they could.
But it was clear that this woman was not going to change her mind so I said, ‘Fine… we will transport your husband to the ICU and when you are ready he can be taken off the ventilator and allowed to pass’. She nodded emphatically and gestured towards me, as if to dismiss a servant, took another bite of her snack and turned to go to the ICU and wait for her ventilated husband to arrive.
As I arrived at Tracy’s ICU room there was an older woman in a wheel chair, to whom Tracy’s wife was almost reprimanding. ‘Do you want him to be in a nursing home for the rest of his life?’
A taller woman with dark hair approached me and asked, ’Doctor, what do you think his chances would have been?’ The answer to this question really didn’t matter, but before I could say anything, Tracy’s wife practically pushed her to the side and said, “I don’t care what his chances would have been.’ To which I replied, ‘Yes mam, you made the perfectly clear’, and I turned to sit and write my progress note.
Tracy’s wife went to his bedside and the other women remained outside his room, the taller one mumbling that this decision would never sit right with her.
I didn’t really know what to think about what had just happened. In reality, Tracy was likely terminal anyway since as soon as the ventilator was removed he died shortly thereafter. But his wife didn’t know that and I couldn’t be 100% certain he wouldn’t have survived either.
In the end I have to respect the family’s wishes even if I don’t agree with them… although most of the time I do.
