Angel of Death

Yesterday was a day of tears on the neurosurgery service. It started out a day like any other, rounds, a list of tasks and chores to complete, fielding phone calls from patients and outside hospitals. But then in the late afternoon the service became a field of tears as I made my first stop to pull the life sustaining ventriculostomy on one of our patients. He had been in the hospital since the beginning of my R2 year, his neurologic function crumbling away with each week of cognitive and physical immobility. His wife, ever optimistic and never faltering, had an hour long conversation with the attending surgeon who while drying off her own eyes asked me to pull the catheter. When I did I saw a tear rolling down the side of the patient's face.

A newly diagnosed brain tumor in someone who had only weeks before been completely healthy. We discussed what we had found on the MRI and what steps would need to be taken to find out exactly what it is and how to treat it. The funny thing with brain masses is that you can never be 100% sure what you're looking at on a radiographic study until you have a tissue diagnosis. Most times the scans are pretty predictive, but in our field we do not treat until the microscopic pathology confirms the disease process we suspect. This one was clearly GBM, or glioblastoma multiforme the most malignant of all brain tumors. The wife pressed me for prognosis, I parried and tried to divert her question stating that we couldn't tell until we found out what it was. She persisted and asked me to give a realistic estimate based one what we knew. Worst case scenario, 6 months, but some live 5, 10, 15 years with what we think this is (less than 1% of patients). The creed of physician is "primum non nocere" or "first do no harm." Leaving the young couple embracing while the wife succumbed to a flood of tears seemed to violate the spirit of that motto somehow. The nurse said that I was such a great doctor because of my compassionate bedside manner. It didn't seem like they would remember me that way. They would remember me as the young asian guy who told them that their lives together would be cut short, that she would need to bury him, that they would actually fulfill their marriage vows of staying faithful till death do them part rather than being separated by the mundane trifles of life.

An elderly gentleman who had just celebrated another year on earth the day prior came in with a massive stroke, and would with 100% certainty end up a vegetable unable to eat, speak, or understand anything. To tell a family that their father/uncle/grandfather who had only hours before blown out candles while laughing with them would now be a shell of his former self, that his memories and cognitive abilities would never return, and that surgery was not only NOT an option, but would hasten his death... more crying.

Then I saw Mr. K. After a 2 month stay we had finally gotten him healthy enough to go to a rehabilitation facility. He left us engaging, still smiling, making jokes despite his tracheostomy. I had spent literally hours speaking to his wife over the past months telling her there was hope, that he would make it through this. But he returned to us blind from an episode of hypotension (low blood pressure), back on the ventilator, unresponsive and unaware. When I went in to examine him I didn't know what to say. It wasn't good to see him again, I wish he had made it out and lived a long life away from the hell of the ICU. But still, "it's good to see you again... sorry it couldn't have been on different terms." It seemed trite. He couldn't hear me.

And then a transfer from an outside hospital. A lady who had an aneurysm rupture in her head, now in a persistent vegetative state with little chance of recovery. The family asked me how long it would be before she woke up since it had already been 2 months. The doctors must have never told them her prognosis. You cowards. I just made 4 different families I met for the first time cry today because they deserved the truth and you couldn't man up to one that you had taken care of for 2 months? Granted you must always give hope when describing prognosis (unless it's pretty devastating like the stroke patient above), but unrealistic expectations just set up families for a greater let down when they realize the reality of the situation. We would talk later, and our team would be responsible for cleaning up the mess of hopes the outside physicians had scattered before them.

Yea, yesterday kinda sucked.