Permission
Her eyes, wandered, questioning, as her eyelids began to droop. Tired. Exhausted. She could hear our muted conversation. Staring into her questioning eyes, I wordlessly asked her for permission. As best she could, she faintly nodded and blinked once for yes. She understood and she 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 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 operating table, a forty-two year old female 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 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 surgical intervention, we had become close friends, and this is unusual, as resident doctors don’t generally develop personal relationships with patients. Nevertheless, we connected for some unknown reason, and became good friends. I met her three teen-aged children and her quietly apprehensive husband. The entire family and the patient put themselves in our hands in our desperate attempt to save her life.
The operation began without incident and things were going well and after entering the chest cavity, 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 had done only minimal dissection and disturbed little of her cardiac anatomy. Her heart just stopped beating. Immediately her blood pressure fell to zero and blood flow to her vital organs ceased as her heart stopped pumping on its own.
In itself, cardiac arrest during a chest operation does not cause panic, for 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. Blood flow to the vital organs, the brain, the kidneys and the heart itself is maintained by the manual open cardiac massage performed at the table. Usually normal cardiac function resumes when the cause of the arrest is corrected. As the first assistant standing directly across from the professor, I had immediate access to her now quietly lifeless heart, right at my fingertips.
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. We could find no apparent cause for this suddenly catastrophic cardiac arrest. Her heart remained lifeless and unresponsive to the cardiac stimulant drugs the anesthesiologist immediately administered intravenously, as I continued to massage the lifeless organ, maintaining blood flow to her vital kidneys, heart and brain. We tried shocking her heart with the sterile defibrillator paddles placed directly on the heart. Once. Twice. No go. No response.
Her heart remained unresponsive to the electrical shocks. I continued to massage and pump blood through the persistently lifeless heart. We tried injecting cardio-tonic drugs directly into the heart itself; again, with no result. Repeated shocks with the defibrillator paddles had no effect. I continued to massage the flaccid heart during these machinations.
She suddenly opened her eyes. With no anesthesia and breathing pure oxygen, she awoke on the operating table, her chest wide open and a tube in her windpipe. She looked directly into my eyes as I continued to massage her heart with my right hand. Our faces could not have been more than two feet apart.
I lamely tried to explain. “You have a breathing tube in your windpipe through your larynx; your voice box, and this is why you can’t talk while the tube is in your throat and we’re breathing for you. Everything is under control for right now. You have had a cardiac arrest. I am massaging your heart to temporarily maintain blood pressure and flow until we can correct things and get your heart restarted. Do you understand me? Blink once for yes 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 intently, directly into my eyes, terror stricken. I tried to look busy and break eye contact but my gaze returned repeatedly to lock onto her frightened, widely staring, frightened eyes.
We continued investigating the cause of the arrest. The professor used every means available and every drug he knew 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 the impending cramped and muscle weaknesses of my arm and hand dictated. I refused multiple offers to spell me at the table as I massaged her heart. I could not break eye contact. I could not quit massaging her heart. She continued to watch me, apprehensively staring intently at my every move as we desperately tried to restart her heart.
We called the internal medicine cardiologist into the operating room for his consultation, suggestions and opinions. He could offer nothing more than we had done. 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, temporarily maintaining her 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 now completely aware of everything that was occurring and the potential consequence.
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 a rhythmic pumping action. Several others at the table insisted they spell me, but I 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 our mounting sense of futility. Her eyes began to wander and her eyelids began to droop. I continued the cardiac massage. Leaning closer, I whispered, “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 have sent word to your family about the problem and they are aware.”
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 operating table and in the entire operating theater. The senior surgeon, who is always the final arbiter, finally 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, closing her eyes for the last time.
“No. No. We can’t quit. We can’t. I won’t. No. NO!” I was adamant.
They had to forcefully pull me away from the operating table. Tears were streaming down my face. I turned and stumbled from 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 blood stained 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 is best for the individual patient. Emotional attachments to a patient may deleteriously influence surgical decisions and appropriate treatment. But sometimes… Sometimes, emotional involvement is unavoidable. She gave me permission. I think she did. I‘m sure she did. God help me, I hope she did.
Posted in Short Stories
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. The novel is a real page turner and soon will appear on the big screen.
Linda Anderson March 9th, 2010 at 5:37 pm
Reilly, you just get better all the time. This story had such a natural flow and was so riveting. Loved the last sentence.