When a patient arrives at the Emergency Room and I am called, my initial response is to rapidly evaluate the seriousness of the injury and determine whether the patient’s life could be in danger. Often times I can do this by looking at a CT scan. If that appears to be the case, I am trained is to correct the problem at hand in an effort to save the patient’s life.
In some cases after an initial discussion, the patient’s family will say upfront they do not wish anything ‘extreme’ to be done, like surgery. And when the patient is elderly and infirm, of course, this makes sense. In other cases the patient’s condition is so far-gone that functional recovery is not only unlikely, it is impossible.
With other patients, the decision is clear – surgery should be performed immediately. However, if I were to sit down and have a discussion with the family of another patient I might discover that while they may have been ‘relatively independent’ before their injury, in reality their existence was not a happy one. In fact, even if they were to recover from the surgery fully, I might not be doing them any favors.
And in general, at 80 years of age, it is highly unlikely their recovery following a head injury and brain surgery will be complete.
The problem that I am often faced with is being presented with an emergency while I may be performing another surgery, and I have to make the determination what to do, based on limited social information.
As it turned out recently, I wished I had known more about Gertrude Anthony, before I operated on her.
The night before she was admitted, Gertrude had fallen. Because she became very confused and was vomiting uncontrollably, her niece became concerned and called 911. A CT scan on arrival to Mease Countryside Hospital revealed she had a large subdural hematoma pressing on the right side of her brain.
Because I was told Gertrude was ‘functional’ prior to her fall and that the family consented to surgery, I instructed the nurse at the Transfer Center to arrange transport of the patient to Mease Dunedin for surgery.
Prior to taking Gertrude back to the operating room I spoke to Gloria, her niece about the nature of the procedure, its risks and the likelihood of successfully removing the hematoma. I did not, however, have a discussion about the potential outcome, and how it might affect Gertrude’s capacity to take care of herself post-operatively and her ability to enjoy the life she had left.
Unfortunately, the reality of the situation is that time is of the essence. Gertrude had fallen quite some time ago and it took an additional amount of time to transfer her to Mease Dunedin to have the surgery. All the while the hematoma was causing undo pressure on the brain and the more time that passed, the more likely it was to cause permanent damage.
So it is not always possible to have an in-depth discussion of whether surgery should be performed at all.
Surgery went well. It took only a little over an hour and there was not a lot of blood loss. All in all, I fully expected Gertrude to return to her previous level of functionality.
As it turned out prior to this last fall she really wasn’t all that ‘functional’.
Gertrude had hypertension, heart disease, a history of heart failure and she had a pacemaker. She also had the neurologic disorder, myasthenia gravis, which caused her to have daily weakness and fatigability. She lived in an assisted care facility and required frequent help with her walker and when she was too weak to walk, her wheelchair.
In fact, she fell frequently; and as a result sustained several spine fractures and recently had been hospitalized for rib fractures caused by another fall.
Immediately post-operatively I was primarily concerned with whether or not Gertrude was alert, that there was no paralysis and that her CT scan revealed that I had completely removed the hematoma. On all counts, everything checked out perfectly.
However, when I walked into her room on Hospital 3, one of the medical wards of Mease Dunedin Hospital, I quickly realized how limited she was. Every time I visited her she was in bed, unable to get up by herself. And every time she tried to pick up a cup to get a drink of water she would spill it all over the floor or her bed sheets.
When she tried to speak, because of the myasthenia gravis, not only was her voice almost a whisper, her pronunciation was garbled as well. Consequently, it was as much of a chore for her to speak as it was for me or anyone else listening to understand what she was saying.
As I stood there speaking with her and her niece I thought to myself, ‘so, what good have I accomplished for this woman?’ The only thing I did was to put her back in a wheelchair or bed, and back into a nursing home.
Partly because of the guilt I felt, I would visit with Gertrude every day I was in the hospital. Not to check on her medically, because she had recovered from the surgery, but to spend time with her and just talk. I almost came to feel like I was visiting my own grandmother.
She actually had a good sense of humor and would often make me laugh. But in the end the words that rang in my ears was what she said the last time I saw her. She said, ‘I pray to God that He either cures me or takes me’. I don’t think she said that to make me feel bad but I definitely didn’t feel like I had been a good steward of the gifts God had given me.
In reality, even if I didn’t operate, Gertrude may have survived and had been the same or more likely worse off.
So in searching for something to say to her as I was about to say good-bye for the last time, I said, ‘I will pray for you’. She smiled and replied, ‘Thank you for your prayers and for everything you had done for me’.
In that moment I was reminded that the patients I take care of, are people whose lives are made up of so much more than a CT scan that needs to be made to look better.
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