PERMISSION
Her eyes, wandered, questioning, as her eyelids began to droop. Tired. Exhausted. She could hear our muted conversation. As best she could, she faintly nodded and blinked once for yes. She understood and gave me permission. Permission to quit. It was time. It was hopeless. We’d tried everything. All the electrical shocks. All the drugs. We’d maintained circulation to her brain and vital organs with open cardiac massage at the operating table. But her heart just wouldn’t restart. She gave me permission to quit massaging her heart and let her go.
Forty years ago I was the chief surgical resident on a surgery unit in a prestigious university hospital. As first assistant, on a chest case that morning, I prepped, draped and positioned, on the OR table, a 42 year old woman patient for a major lung resection. She had a huge tumor in her left lung. The operation proposed by the attending clinical professor was a heroic attempt to remove the lung and the tumor before it took her life.
I had developed a rapport with this young woman when I did her admission history and physical exam. In the three day interval of preoperative evaluation and workup prior to operation, we had become close friends. This is unusual as residents don’t generally develop personal relationships with patients. But we connected for some unknown reason, and became good friends. I met her three teenaged children and her quietly apprehensive husband. The entire family and the patient herself put themselves in our hands in our desperate attempt to save her life.
The operation began without incident and things were going well. The senior surgeon began the lung dissection when she suddenly suffered a cardiac arrest. Her heart just stopped beating; for no apparent reason. It just stopped. We’d done only minimal dissection and disturbed little of her anatomy. Her heart just stopped beating. The result, of course, was that her blood pressure fell to zero and there was no blood flow to her vital organs. In itself, cardiac arrest during a chest operation is no reason to panic. During a lung operation, if cardiac arrest occurs, the heart is squeezed manually to maintain blood flow and blood pressure until the cause of the cardiac arrest is determined and corrected as the cardiac function resumes normally. As the first assistant standing directly across from the professor, I had immediate access to her now quietly flaccid heart right at my fingertips.
So I began rhythmically squeezing her heart with my right hand to maintain her vital signs and blood flow until we could right whatever was wrong. The anesthesiologist immediately switched off the anesthetic gases and administered pure oxygen via the tube in her trachea.
But, why had her heart stopped beating? We hadn’t a clue. It just stopped. We went through the standard checklist. Lab tests, blood gases, etc. All within normal limits. Still, we could find no apparent cause for this suddenly catastrophic cardiac arrest. We were mystified. Her heart remained lifeless and unresponsive to the cardiac stimulant drugs immediately administered intravenously by the anesthesiologist as I continued to massage the lifeless organ. We tried shocking her heart with defibrillator paddles placed directly on the heart. Once. Twice. No go. Her heart remained unresponsive to electrical shocks. I continued to massage and pump blood through the persistently ineffectual organ. We tried injecting cardio-tonic drugs directly into the heart itself; again, with no effect. Repeated shocks with the defibrillator paddles had no result. I continued to massage the flaccid organ during these machinations.
And then she opened her eyes. With no anesthesia and breathing pure oxygen, she awoke on the operating table. She looked directly into my eyes as my hand was massaging her heart. Our faces couldn’t have been more than two feet apart.
I lamely tried to explain.
“You have a tube in your wind pipe through your voice box. You can’t talk while the tube is in your throat. Everything is under control for right now. You’ve had a cardiac arrest. I’m massaging your heart to temporarily maintain pressure and flow till we can correct things and get your heart restarted. Do you understand me? Blink once if you understand.”
She blinked once.
“Are you having pain? Blink once for yes and twice for no.”
She blinked twice. Good. No pain.
“Close your eyes and try to rest. We have things under control.”
She blinked twice. She was apprehensive; justifiably so and continued to stare intensely into my eyes. I tried to look busy and break eye contact but my gaze returned repeatedly to lock onto her staring eyes.
We continued investigating the cause of the arrest. The professor used every means available and every drug known that might help get her heart started again. Nothing worked. We shocked and re-shocked the unresponsive heart. We repeated the cardiac stimulants both intravenously and directly into the cardiac chambers. Nearly two hours had gone by. I continued cardiac massage, switching from right hand to left hand periodically as impending cramps and muscle weaknesses dictated. Offers to spell me at my task were refused. I couldn’t break eye contact and I just couldn’t quit massaging her heart.
She continued to watch, staring intently at me as we desperately tried to restart her heart.
We called the medical cardiologist into the operating room for his consultation, suggestions and opinions. He could offer nothing. Another cardiothoracic surgeon was queried. He too, was of no help and offered only his commiseration. She continued to stare into my eyes as I continued to pump her inert, motionless heart, maintaining the circulation to her brain and heart. She could hear us talking and discussing the situation. She sensed our frustration and inability to rectify her cardiac arrest. She began to realize how hopeless the crisis had become. I’m sure she was completely aware of everything that was occurring.
We’d been at the operating table for more than three hours. My right hand and forearm had begun to cramp badly and I’d switched to the left hand and then again back to the right to maintain the rhythmic pumping action. Several others at the table insisted they spell me at the task but I still couldn’t break the eye contact with her. I wouldn’t quit. I couldn’t quit.
She too, was getting tired. She couldn’t speak and she was now less attentive to our frustration and the mounting futility of our efforts. Her eyes began to wander and her eyelids began to droop. I continued the cardiac massage. Leaning closer, I said,
“We’re doing everything we can. We’ve tried everything. Your heart refuses to start. We’re not giving up, though, but things do not look good.”
I sounded ineffectual. And I was. And we both knew it.
Still, I felt she should be aware of the desperate nature of her condition and be appraised of our efforts and our refusal to give up. But she could sense our anguish and the now pervasive hopelessness at the table.
The senior surgeon, who is the final arbiter, said, “It’s time to quit. We’ve done everything. We can do no more. Stop the massage.”
The anesthesiologist nodded in affirmation.
She understood. She looked deeply into my eyes, blinked once for yes, and then wearily closed her eyes. Peacefully. She gave me permission. Permission to quit as she closed her eyes for the last time.
“No. No. We can’t quit. We can’t. I won’t. No. NO!”
They had to forcefully pull me away from the operating table. Tears were streaming down my face. I turned and left the operating room, still in my bloody gown and gloves.
I remember little of the next hour or so. They found me in the chapel an hour later, still in my soiled gown and gloves. I could barely speak and was numb with grief. The tears had ceased.
Surgeons can’t let themselves get too close to their patients, emotionally. Good judgment calls for objective assessments of the patient’s problems and impartial decisions. Personal attachments only confuse and obscure what’s best for the individual patient. Emotions can only deleteriously influence surgical decisions and appropriate treatment. But sometimes….. Sometimes, emotional involvement is unavoidable.
She gave me permission. I’m think she did.
I‘m sure she did.
I must know she did. For me.
God help me, I hope she truly did.
God help me, she truly did.
Posted in Essays, Short Stories
Pushcart Prize Nominee Reilly Maginn's debut novel, BIO, a medical action thriller is a truly frightening tale of Jihadist bioterrorism. A story of weapons of mass destruction that could happen here in the US. Set in the south Pacific, a volunteer American physician/surgeon faces off against not only a deadly virus, but also the radical Muslim terrorists who developed it. There is a fittingly appropriate conclusion.
