Monday, January 25, 2010

Futility, in its third year

Let's be honest. People don't, for the most part come to theatre for fun. We are doing a job here, and generally that means that patients are sick, and they are coming for surgery to cure their problem. With the possible exceptions of elective cosmetic surgery and a small number of what may be termed "unnecessary" procedures, the vast majority of patients leave theatre cured, or at least well on the way to being cured.

I'll be the first to admit that we as anaesthesiologists, for the most part, don't do much healing. Yes, we take sick patients, and steer them safely through the rough seas of major surgery and yes, we perform a very important role in the team. But we don't cure. Occasionally, our surgical colleagues are unable to cure either. I had occasion to reflect on this today.

A mitral valve replacement was scheduled in a grossly overweight 25yr old woman. We forgave her for being obese because her effort tolerance was so poor due to her very tight mitral stenosis. On a side note, I was trained by a consultant who would have described the tightness of the mitral valve as being "like the bottom of a duck, on a frozen lake in Moscow in winter."

"And," he would continue, "how do you know a duck's butt is tight? Because you NEVER see a duck sinking"

Anyhow, I digress. Suffice it to say that this was a tight mitral valve. The patient reported feeling dizzy and lightheaded every time she got up form a chair, and as for walking, lets say she couldn't do much. Despite the difficulty in placing invasive lines, my colleagues soon had her off to sleep and surgery proceeded. The course was uneventful and she was delivered to ICU in fairly good nick. Then, the wheels started to fall off.

The blood pressure fell precipitously, the ICU guys struggled to ventilate her (combination of obesity and fluid overload in the lungs) and despite increasing doses of Adrenaline, she was not doing well. At this point I was alerted to the fact that she may need to go back to theatre, a responsibility which would fall to me as the on-call consultant. So I went back to ICU to review her, to see why it was that she wasn't doing well.

As I walked into the ICU, I could see that things were taking a turn for the worse. She was surrounded by many surgeons, ICU docs and, most worrying, an ever increasing number of monitors and machines. We have a dogma that prognosis in ICU is inversely proportional to the number of machines around the bed. The heart-plumbers had opened her chest and the ICU registrar was standing with a big syringe full of neat Adrenaline, pumping it in by hand, 8ml at a time. To put this in perspective, if you had a severe allergic reaction, the recommended life saving dose of Adrenaline is 1mg i.e 1ml per dose. This lady was getting 8 times this. Despite these heroics, I could see that the BP was less than 60/30 most of the time.

I think the village policeman could have sensed the eventual outcome here. Unfortunately, we tend to get too close to our patients, not on a one-to-one emotional level, but we invest huge amounts of thought, planning and energy into their care. Often, this means that we lose objectivity. Anyone could see the patient was going to die, but we continued. Now she is lying in the ICU, on partial heart bypass to support her own heart, and still deteriorating. She will die, despite our best efforts. That much is certain. The question though, is when do we stop? The dramatic scenes on TV medical shows never play out like that in real life. There is more likely to be a slow dawning of the reality that someone will die even although we gave it our all.

Futility is the term used to describe what happened today. The problem comes when we try to say, at what point did treating this lady become futile? In hindsight, it is obvious. But we don't live in hindsight, so we find ourselves doing more and more heroic things in order to prolong life in the face of certain death. Why did this patient die? I'm not sure if we will ever know why her heart just gave up after coming through the surgery and immediate postop period so well. She had the right operation, perhaps the timing wasn't ideal. But it won't stop us from trying again, another day, on another patient, because we must continue.


Anonymous said...

I wonder if she had depression? 'Will to live' is one of those factors that sometimes sneak up on you.

Love your writing by the way.

- Nandipha

Doc-ZZZ said...

@Nandipha nice one. all the will to live in world won't help if you aren't getting enough blood to your brain. The only depressed thing about her was her left ventricular performance. /humour on/ Fortunately they don't make prozac as an IV drug. Then we may have had to consider giving it..... ;) /humour off/

Anonymous said...

What a beautifully written post. I love your blog and look forward to every new post.

Anonymous said...

As they once said in one of those TV medical dramas: We do it so that when we tell the deceased patient's family the bad news, we can sincerely tell them that we did everything we could for their loved one.

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