Death is not always the same. Quantity, fixed: one per patient. Quality, variable.
Doctors see many deaths, of different kinds. This is true of any doctor, whether or not he or she is a surgeon, as I am.
It’s easier for the doctor when death is expected, following a long illness, a chronic disease. Harder when it’s unforeseen–the heart attack, the accident, the gun shot, the sudden death in a young man or woman who seemed a conqueror.
Sometimes, in a long-term patient-doctor relationship, the two types of death merge: Death becomes the harsh, abrupt end to a journey taken by two travelers.
M was a special patient–thirty-something, warm, charming, brave. At our first meeting, an office visit in the early Sixties, she gave me her special homemade pickles, just to my liking, medium sour with a dill flavor. Over the next decade, she and her family and I became close. She was generous, always patient. The operations I performed to treat her mitral valve disease, a manifestation of previous rheumatic fever, reflected cardiac surgery’s progress over that time.
In her first operation, I incised her chest between the ribs on the left side. I opened her calcified blocked mitral valve–the gateway to the left ventricle, which pumps blood to the body–by blindly inserting my finger through the left atrium, the heart’s upper chamber, breaking open the valve’s fused leaflets.
M was better for five years. I followed her closely at regular intervals until her increasing shortness of breath and fatigue signaled that the valve blockage had recurred. When her cardiologist and I suggested another operation, more complicated than the first, she did not hesitate. And when I explained the greater risk, she smiled and passed the pickle jar across the desk. Her trust, her belief was complete.
I replaced M’s diseased valve with a mechanical prosthesis of metal and plastic, this operation done through an incision in the midline dividing the breastbone. She again recovered swiftly, resuming her busy life as a wife and mother.
Another five years of follow-up, of friendship, during which M and I became even closer. We talked about more than just her medical care, kept up with what was happening with each other’s families and children.
Ten years after her first heart operation, five years after her second, M came to the office thin and weak, having suffered–and only partially recovered from–two small strokes. Despite her being on blood thinners, small clots were breaking off from the plastic and metal valve and traveling to her brain. She was more frightened than she had ever been, and seriously ill, so sick that she brought no pickles.
Serious consultations followed between patient, family, cardiologist and the surgical team. Reoperations carry greater risks because of the adhesions that join the heart, pericardium (the sac encasing the heart) and surrounding lungs in a mass of scar tissue. An operation to remove M’s mechanical prosthesis and replace it with a bioprosthesis–a pig valve, less prone to form clots–posed greater dangers than the first two. She, courageous, had expectations of full recovery.
As Susan Sontag has argued, caring for the very sick has consequences for the physician. Those consequences are magnified when patient and doctor are friends and enjoy a long relationship. I shared M’s suffering, her pain; I wanted to help.
The third surgery, through the right chest, was difficult. Extensive adhesions, plus the need to remove the previous valve embedded in the heart muscle, made for an epic procedure.
An epic procedure. And a technical error.
In excising the first prosthesis, I damaged the heart wall. Though I repaired the tear, I feared complications. M was taken to the intensive care unit in stable condition, but a few hours later a massive, sudden bleeding occurred.
My friend M died in the intensive care unit.
Any death in which a doctor participates has a powerful impact. Somehow, when the death is surgical and acute–a hands-on death resulting from a technical error–the onus and the guilt feel greater. Atul Gawande, MD, in his superb bookComplications: A Surgeon’s Notes on an Imperfect Science, reminds us that the best doctors in the best hospitals make mistakes, serious blunders that kill people.
I find no solace in knowing this.
Would I have felt less devastated, less depressed, better able to move on to the next patient if M and I had not been friends for ten years? I think yes.
But I would have missed the best part of medical practice–a long relationship, the sharing of an illness, the traveling of a road together.
That is my consolation.
About the author:
Following his residency and two years in the U.S. Army Surgical Research Unit, Larry Zaroff MD PhD has pursued five careers. He focused for twenty-nine years on cardiac surgery, including a stint as director of the cardiac surgical research laboratory at Harvard. There his work centered on the development of the demand pacemaker. He spent the next ten years concentrating on climbing and did a first ascent of Chulu West, a 22,000-foot peak on the Nepal-Tibet border. His third life has been at Stanford University, where he received a PhD in 2000 and where he teaches courses in medical humanities. His fourth career has been as a writer for the New York Times science section. He now works one day a week as a volunteer family doctor. He has received awards as the outstanding faculty advisor for the Human Biology program and in 2006 was honored as Stanford’s Teacher of the Year.