The Blog by Ziyad Nazem

God of the Operating Room

It’s an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. “What the hell was that?” someone asks. “Why does that doctor get cuts?” “Oh, that wasn’t a doctor,” Pete says. “It was God. He just likes to play doctor once in a while.”

But it’s no joke. Whereas I don’t buy the “playing God” aphorism, I’ve had to make life-and-death decisions on occasion, and I don’t like it. I mean “life and death” literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance — looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable — is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?

Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it’s fatal. In operating, one may find — depending on the cause and the anatomy — a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.

And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it’s conceivable that two people might make different decisions; ergo, it’s subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you’re not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?

These people don’t come to see you in the office, don’t participate in a leisurely give-and-take about their illness. They show up in the ER in pain, sick as hell, in no position — much less able — to philosophize. Nor do they come to you because they like what they’ve heard about you. Luck of the draw: they show up when you’re the guy on call. Their lives are in your hands because of the most random of circumstances. But there’s no avoiding it.

It doesn’t take long to realize the power of influence you have. In fact, it’s my impression that often people — patients, their families — WANT to be relieved of the responsibility. Grandma has been in a nursing home for a couple of years. Ninety years old, not always recognizing everybody, she suddenly is complaining of abdominal pain and is now in the ER with signs of some sort of abdominal catastrophe. “We need to get her to surgery right away,” you can say. “Or she’ll die.” Clearly that stacks the deck toward going ahead, and, frankly, it’s the easiest way out — for the surgeon. I know many who always take that approach, and I think it’s neither that they love to cut above all, nor that they want the money (what little they’ll get from medicaid.) It’s just that it avoids all the moral wrestling; with the people, with yourself. But it is, of course, just as subjective.

“It’s obvious something serious is going on, something that would require an operation to fix. It may or may not be fixable; she may or may not be able recover from what we’ll have to put her through. This could be too much for her no matter what we do; so I want you to know that it’s possible to be sure she’s entirely comfortable, to be sure she doesn’t suffer in any way, and to let her go. You know her better than I; you know her life. I’m willing and comfortable with either approach. What do you think?” That’s another way to handle it, one which I’ve done many times. And sometimes, either when such an approach doesn’t lead to consensus, or when even before I’ve said such a thing I see a family in turmoil, I’ll ask, “Would you like to know what I think?” That’s where it gets hardest of all.

“We can take a look. I can see what’s going on, and make a judgement: if I think it’s a solvable problem with a reasonable chance of recovering, I’ll do what I can. Or I’ll come and talk to you before making that decision.” “I think whatever is going on in there, it’s too much for her, given her condition, and I think making her comfortable would be a kindness.” I’ve said each of those, more or less, on many occasions. Some people think that if there’s a one in a million chance of recovery, it should be taken: as a general rule; as a moral principle. I don’t share that idea, but I can’t say it’s objectively wrong. If a patient in a one-in-a-million situation got me as their surgeon, they’d be more likely to die without an operation. If another surgeon, they’d likely die with one. Should that be a matter of chance? From one point of view, always going for the one-in-a-million chance seems the purest, cleanest, most honorable (life-affirming?) approach. From another, it looks like the ultimate moral cop-out, an abdication of responsibility. Can anyone say for sure?

It doesn’t end, of course, with the decision for surgery. In the case of the dead bowel, you’ll likely be confronted with operative uncertainty. In the example of the old lady, if virtually all her gut is dead, it’s nearly automatic: take a look, and close up. (“Peek and shriek,” is an oft-used phrase.) But what about a twenty-year old? It could happen, as a result of blood clots. Most likely you’d remove the bowel and do everything you could to get the person through the crisis, knowing they’d be facing a very abnormal existence. Having the whole gut gone is pretty rare. Having most of it gone, though, is not; enough that you could hook a foot or two of small intestine to a foot or two of colon. Again, it’s not something I’d do with an elderly and sickly person; but I did it once with a young person. In both cases, it was entirely up to me, and I made the decisions — necessarily, far less than fully-assured. And if not ninety, but yes twenty, then where’s the line? Sixty-seven? Or what accompanying factors? Heart disease? How many vessels? More than that: what factors am I bringing to bear from within myself? Experience, knowledge of what I can (or can’t) do, what decision I’d like made if it were me? Am I allowed those colorations? Given that there are no clear answers, it’s not hard to understand how some surgeons would take the approach always to operate, and always to do what’s technically possible, no matter the consequences.