Wednesday, 9 April 2008
I’m back, at long last, my broadband is up and (semi)functional again. A lot’s happened in the three weeks or so that I’ve been offline but one situation a found myself in when I was on call that particularly sticks in my mind.
A lot is written about doctors “playing God” and being arrogant enough to believe that they can decide who should live or who should die. As always, the real truth is somewhat more complicated so let me tell you the story of me and Mr Johnstone.
It’s about 10am on a Sunday and I’m on call for anaesthetics in NewTown Hospital. I’m doing a little studying on one of the computers in the staff room when my pager goes off. It’s one of the surgical registrars who tells me that they want to operate on a Mr Johnstone on Ward 4B who has bowel obstruction. I ask her a couple of questions about the patient and it’s immediately apparent that this isn’t going to be a straight-forward situation.
I logoff and go to the ward where I bump into Mr De Luca, the consultant surgeon on-call, who tells me that he thinks the obstruction in Mr Johnstone’s bowel is most likely to be cancerous but that he is too frail to perform major surgery on. Mr De Luca’s plan is to perform a small operation to create a colostomy for Mr Johnstone which would prevent his bowel from bursting, which would be fatal for him. Mr De Luca asks if we could do the operation under spinal anaesthetic i.e. an injection in the back to numb the nerves so the operation can be done with Mr Johnstone awake.
I tell Mr De Luca that I’ll go and speak to Mr Johnstone and then we’ll discuss things more, he says “Fine, go ahead.”
I pick up Mr Johnstone’s hefty medical notes and walk into the bay where he is lying. He’s all skin and bones and has the emaciated look of a man that has obviously been unwell for a very long time. Mr Johnstone’s belly is grossly swollen (a sign of his underlying intestinal obstruction) and thin, blue veins meander across his belly. His paper-thin skin gives it the look of a balloon filled with water. There is a drip attached to his arm that is trickling fluids into his bloodstream and out of his nose emerges a naso-gastric tube connected to a bag by his bed that is filled with green, bilious vomit. There is a smell of stale sweat and puke around his bedside and you don’t need to be medically qualified to tell that Mr Johnstone is a very unwell man indeed.
“Good Morning Mr Johnstone,” I say as I approach his bed.
His eyes flicker open as he regards me approaching him. I give him a small smile.
“My name is Dr Anderson,” I continue. “I’m the anaesthetic doctor and the surgeons have asked me to come and see you because you need an operation on your belly. How are you feeling?” It’s a stupid question, I know. “You’ve had better days, yeah?”
Mr Johnstone gives me a wan smile and replies, “You can say that again, I feel awful doctor.”
Mr Johnstone and I speak for about twenty minutes or so about his current illness and about his general health.
I won’t go into too many details but from speaking to Mr Johnstone and reading his medical notes, I found out that he has severe heart, lung and kidney problems. The last six months of his life have been studded with hospital admissions for chest infections and heart attacks. When he is at his very best, he can only manage to walk a dozen steps after being helped up from the chair, but Mr Johnstone hasn’t been at his best since October. He’s been getting steadily worse and has been bed-bound for the last two months.
It was obvious to me that Mr Johnstone was so frail that if I gave him any sort of anaesthetic, he wouldn’t survive. The question now was whether a more experienced anaesthetist would feel that he would be able to safely guide Mr Johnsotone through the surgery.
I call Dr Adams, the consultant anaesthetist on-call and explain the situation to him and ask him to come and help with this patient. One of the great things about working in anaesthetics as opposed to other medical specialties is that if you feel you need help from your consultants, they come in and help you. They don’t have a go at you and tell you to “get on with it, just make sure you don’t fuck up.”
Half an hour later, Dr Adams and spoken to and examined Mr Johnstone and poring over his medical notes, scratching his beard (literally) as he tussles with the question that I’ve asked him to answer. “Can I give Mr Johnstone an anaesthetic, and if so how?”
Dr Adam’s brow is furrowed and you can almost see his mind working. After about ten minutes of deliberation, he comes to a decision…
“No.” He says to me. “We can’t do it. I’ve been weighing up all the different options and scenarios in my head. I’ve been thinking of all the things that are likely to happen to him if he has an operation and I can’t see a situation where he will have a decent outcome.
“I agree with you Michael, that he’s far too frail to have a general anaesthetic and he’ll die on us if we try to give him one. That leaves us with the option of giving him a spinal (the injection into the back) and I’ve been going through what the best-case scenario is likely to be.
“Best-case: We get him down to theatres, and we actually manage to get the spinal needle in. For a colostomy, he’s going to need quite a high block – up to about T7-8. He had a heart attack a couple of months ago, and his echocardiogram shows his heart has been knackered since 2002, so the chances are his heart won’t cope with the drop in blood pressure that you get with a spinal anaesthetic. Even if we manage to achieve that and the block works well, and even if we manage to lie him flat enough to have the operation and even if the surgeons are quick and slick and aren’t digging around for ages, what’s going to happen next?
He’s going to come back to the ward and in six hours time, the spinal will wear off and then he’ll be in pain. He won’t breathe properly because he’s in pain and then, with his lungs, he’ll get a chest infection and die. Or someone will come along and give him some morphine which will stop him breathing properly and then he’ll get a chest infection and die.
So, in the very best case scenario, he has his operation, is semi-conscious for 12 hours post-op before dying here a week later, and you’ve got to ask ‘have we done him any favours?’”
We go and explain our decision to Mr Johnstone and then to the surgeons. Mr Johnstone understood that he needed the operation to save his life and was very upset when we told him he couldn’t have it. Later in the afternoon I return to the ward to explain the decision to Mr Johnstone’s daughters and other relatives who are understandably very upset by the whole situation.
Later on, I had a quiet moment and thought about the events of the morning. Unless a miracle happens, Mr Johnstone’s bowels will burst and then he’ll die. Over the preceding day or so, he was told that there was an operation that could prevent this and he was given hope. Then we snatched away any hope he had by telling him he was told that he couldn’t have the operation. This was cruel, horribly, horribly cruel.
I can’t put myself in the shoes of Mr Johnstone or his family, his final days will probably be difficult, painful and horrible. But death is often difficult, painful and horrible and unfortunately for Mr Johnstone, this time we can’t stop him dying.
I don’t really think that this is “playing God,” I think it’s accepting the fact that death is an inevitability that we all have to face and that doctors can’t save everyone from dying, no matter how much we’d like to.
What do you readers think about what happened with Mr Johnstone?
n.b. Interestingly, when I talked about this is the doctor’s mess later on, two surgical SHOs, the surgical SpR and the Medical SpR initially all said that they thought that Mr Johnstone should have had the operation. Personally, I think this just shows a lack of understanding about how anaesthesia works and all apart from the Medical SpR reversed their opinions when I explained the effects of spinal anaesthesia on the cardiovascular system.