Medical Catastrophe

by Ronald W Dworkin

  I’ve talked to, women talk more than men. I once had a patient blurt out

  under sedation the name of the man she was having an affair with. A

  second patient blurted out the name of the man her best friend was having an affair with. A third patient imagined aloud during a vaginal prep that she was having intercourse. A fourth patient mumbled during jaw surgery, “How long until I can have sex?” Her question confused the operat-

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  ing room staff, as her surgery wasn’t gynecological, until she complained that her husband demanded oral sex, which she hated performing. She

  asked if she could have her jaw wired shut for a year to absolve her of the duty. I have many such stories.

  Back to my narrative. I intubated the patient, turned on the anesthetic

  gas, and let the surgeon work. Now would have been the right time to

  wipe off the lipstick. Foolishly, I did not. On the contrary, I had been so careful not to smear it during the intubation that I was almost proud of

  myself. A few minutes later, the pulse oximeter (a probe placed on the

  finger to measure oxygen levels) malfunctioned—not surprisingly, since

  in those days pulse oximeters had difficulty seeing through nail polish. I fiddled with the device, trying it on different fingers, when I suddenly

  noticed that the pressure needed to push air into the patient’s lungs was higher than expected. With the pulse oximeter malfunctioning and the

  woman’s fingernails covered in polish, I instinctively glanced at her lips to inspect their color. They were bright red—from lipstick. I quickly

  wiped off the lipstick to reveal their true color, which was dusky because of a drop in oxygen levels.

  I figured the breathing tube must have drifted too far into to the pa-

  tient’s right lung, causing the left lung to go without oxygen. I listened to the patient’s chest with my stethoscope, confirmed the diagnosis, and

  pulled the tube back. With both lungs now oxygenating, the patient’s lips pinked up immediately. The rest of the case went uneventfully, although

  when wheeling the patient back to the recovery room, I noticed a red

  furrow on her wrist where her bracelet sat, caused by pressure from the

  armboard against the metal. I kicked myself for not having insisted that

  she remove her jewelry.

  This was not a catastrophe, but it might have been. It taught me some-

  thing about doctors and patients.

  Patients often do themselves a disservice, and even increase their risk

  of catastrophe, when they try to stand out. Doctors and nurses generally

  work best when allowed to follow their routines, and patients who em-

  phasize their VIP status just throw everyone off kilter. Exceptions are

  made. Deviations from protocol are permitted. Duties are overlooked

  because everyone is anxious. Such patients often get worse care, not

  better.

  From an anesthesiologist’s perspective, it is often safest for the patient to have no identity at all. This goes against the grain of contemporary

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  medical training, which tries to humanize doctors and strengthen their

  emotional connection with patients. Some doctors today even pride them-

  selves on making friends with their patients. 1 A few doctors call such behavior unprofessional. But more important, it’s dangerous. The more

  emotionally involved anesthesiologists are with their patients, the less

  they are able to think and reason during a crisis. The notion that someone dear to them, or to others, might die at their hands unsettles them. When disaster looms, they anticipate the tears on the faces of grieving family members, and fear spreads unreasoningly throughout the different com-partments of their mind, clogging their reason. It is why an anesthesiologist is never supposed to put a family member to sleep.

  Some of the finest anesthesiologists see patients as nothing more than

  bodies to be anesthetized. When waking up a patient from surgery, they

  scan the anesthesia record to relearn the patient’s name before calling it out, and then just as quickly forget it. Nameless patients stop being VIPs or even individuals. Even a patient asleep on the operating table remains an individual if he or she has a name; the anesthesiologist imagines asking the unconscious patient a question and thinks to himself, I know what he would say; if only he were awake, he would answer! Patients with names stand out. VIPs stand out even more. Nameless patients do not. A

  nameless patient is just human, just a concept. The anesthesiologist experiences less fear when taking care of such a patient.

  Callous, yes, but it lets the anesthesiologist’s mind work methodically

  and correctly during a crisis. Good medicine is a fine balance between

  worrying about a patient and not caring at all.

  The following week, I took care of a sixty-five-year-old man, Mr. D,

  scheduled for a trans-urethral prostatectomy (TURP). When he asked me

  about the anesthetic, I suggested spinal anesthesia. I told him there was no significant difference in mortality rates between general and spinal

  anesthesia, except when doing a TURP. It was the one operation where

  spinal anesthesia was recommended, as the anesthesiologist can more

  easily detect the unique complications of a TURP in an awake patient

  under spinal anesthesia. Mr. D didn’t care. He demanded general an-

  esthesia because he had heard that spinal anesthesia left people paralyzed.

  I told him how rare that was. Mr. D didn’t care. I told him how a cluster

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  of bad outcomes had occurred during the 1960s, in the United Kingdom,

  when glass spinal anesthetic ampules had been stored in formaldehyde to

  keep them sterile. Formaldehyde had entered through cracks in the am-

  pules, paralyzing patients when the mix was injected into their spines.

  The tragedy hit the newspapers, I explained, causing spinal anesthesia to be unfairly maligned. Mr. D didn’t care. He demanded general anesthesia

  and said it was his right as a patient to choose.

  I understood his fears. He feared being paralyzed. He also feared

  surgery on his penis. Most men do. The very idea sickens them. Never-

  theless, Mr. D’s challenge signified a greater trespass on my authority as a physician and a greater risk of catastrophe than had my patient the week before. The doctor’s wife had demanded an exception that interfered with

  my ability to monitor her under anesthesia. Mr. D wanted to decide the

  entire anesthetic.

  Mr. D’s demand didn’t come out of the blue, especially his use of the

  word “right.” Cultural change lay behind it. The patients’ rights move-

  ment grew out of a larger bioethics movement that started in in the late

  1960s, bringing the discourse of moral philosophy into the world of pro-

  fessional medicine. Words such as “rights” and “autonomy” spread from

  the university to the patient’s bedside. The bioethics movement, in turn, arose from other rights-based movements, each with its own medical

  connection. The civil rights movement invoked the infamous Tuskegee

  experiment, where black men with syphilis were purposely denied treat-

  ment for decades. The women’s rights movement rebelled against restric-

  tions on abortion. The gay rights movement condemned psychiatry for

  calling homosexuality abnormal. Each of these movements had their

  counterparts in Europe, and each, in turn, drew from an even larger set of ideas, including the belief that medicine had become an op
pressive arm of the modern industrial state.

  But the pedigree of Mr. D’s demand also included something uniquely

  American, as the patients’ rights movement in the United States was also

  part of a larger consumer choice movement. By the 1970s, Americans no

  longer wanted to choose from among four kinds of breakfast cereal; they

  wanted to choose from among fifty. It was the same with cars, television

  shows, and every other kind of consumer product. Americans wanted the

  right to customize their consumer experience. This demand penetrated

  medicine in subtle ways. For example, drug companies, which had con-

  fined their advertisements to medical journals for much of the twentieth

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  century, began marketing their products directly to patients—now viewed

  as consumers—starting in the early 1990s. This was unique to the United

  States, as drug companies are still banned from advertising directly to the public in Europe. This shouldn’t surprise, as state-dominated health

  care—indeed, state-dominated anything—is often antithetical to consu-

  mer choice.

  I hesitated to pick a fight with Mr. D. After all, some patients do have

  TURPs under general anesthesia without problems. Just because an anes-

  thetic is suboptimal doesn’t mean it’s illegal. I also took the words

  “rights” and “autonomy” very seriously. I believed in the ideology. The

  problem was that Mr. D’s urologist was mediocre. His urologist cut into

  prostates in ways that opened up channels for the glycine-filled solution used during the procedure to flood into the bloodstream. In addition, the surgeon was technically slow, made worse by his tendency to talk sports

  and politics. He would operate for thirty seconds, then raise his head to argue something about Democrats or Republicans, during which time

  more fluid would pass into the patient’s system. That is why I wanted to

  use spinal anesthesia. Unlike a general anesthetic, which can theoretically last for days, a spinal anesthetic lasts only a couple of hours, which forces a urologist to quit cutting at a certain point, regardless of whether he or she wants to. In addition, I could detect fluid overload in Mr. D more

  quickly if he were awake.

  But I couldn’t tell Mr. D that his surgeon was lousy. Physicians have a

  code. When a layperson asks a physician to recommend a good doctor,

  the physician won’t recommend someone terrible. But if a layperson is

  already under that terrible doctor’s care, physicians usually avoid bad-

  mouthing that doctor to his or her patient, unless the patient is a friend or family member, in which case they tell the patient immediately. Mr. D

  was a stranger. I couldn’t tell him that I needed to do a spinal because his urologist was slow, sloppy, and a chatterbox. So I let it go.

  We brought Mr. D into the operating room. I induced general an-

  esthesia and the urologist started working. Sure enough, every few min-

  utes he launched into a tirade about Congress and, later, the National

  Football League. To prod him to return to work, I told him he had to

  finish quickly to lessen the time for fluid to enter Mr. D’s bloodstream.

  “Oh, yeah. Sure,” the urologist replied in agreement, but then a short time later he moved his head away from the cystoscope and started talking

  again. He was in the mood to talk.

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  I should have been more adamant in telling him to shut up and work,

  but politics intervened. In those days, surgeons often behaved like kings, expecting not only to be obeyed but also to be entertained. Some of them

  saw the anesthesiologist as a kind of court jester, to speak to them when they desired conversation, to shut up when they didn’t, and to grovel

  before them when they wanted to feel important. Anesthesiologists were

  once happy to perform in this role, since surgeons brought the patients,

  and without patients there would be no work. “Yes, it’s embarrassing

  what we’re doing, trying to humor the surgeons,” anesthesiologists would

  admit to themselves. “So long as we remain fully conscious, it’s for the

  good of the practice, it’s okay. Just don’t make a circus of the job.”

  Rather than protest when the urologist talked, I was soon giving my own

  opinions on the national debt and the likely winner of the next Super

  Bowl.

  About ninety minutes into the procedure Mr. D’s blood pressure

  climbed higher. No change in anesthetic state or surgical stimulus ex-

  plained the increase. I assumed it was from too much fluid entering the

  patient’s bloodstream through the open prostate, so I told the urologist to move things along. He refocused, only to lose his way again.

  “Who do you think will win the next election?” he asked.

  The patient’s blood pressure rose higher. Had Mr. D been awake, I

  might have been able to glean important data from his complaints. Short-

  ness of breath would have suggested fluid overload. Restlessness, confu-

  sion, and nausea would have suggested water intoxication. Gradually, the

  inflation pressure needed to push air into Mr. D’s lungs increased, most

  likely from fluid overload. The urologist had to stop.

  “That’s enough. You’re done,” I said sternly.

  “Just a little more. Really. Maybe another twenty minutes,” pleaded

  the urologist.

  “You said that twenty minutes ago. No, you’re done. If you have more

  prostate tissue to shave off, you can bring him back another day. He’s

  showing signs of fluid overload,” I insisted.

  The urologist glared at me but quickly wrapped things up. I turned off

  the anesthetic gas. Twenty minutes later Mr. D was still unconscious. We

  brought him to the recovery room. I ordered a blood test for a sodium

  level, which came back 119 (the normal is 140). It explained Mr. D’s

  sleepiness. Too much sodium-poor fluid had entered his bloodstream

  through the open prostate sinuses. Indeed, the sodium level was so low as

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  to risk seizures. Yet I couldn’t treat Mr. D aggressively with sodium

  because that would have expanded his blood volume when he was al-

  ready fluid overloaded and risk pushing him into heart failure.

  After five hours, the sodium returned to acceptable levels. Mr. D woke

  up—blind. It was a known, albeit rare, complication of TURPs. Glycine

  in the cystoscopy solution had entered the patient’s bloodstream in large amounts, interrupting neural transmission in his retinas.

  “I can’t see!” screamed Mr. D.

  I tried to evaluate Mr. D’s vision, but he kept shaking his head in

  panic. “I can’t see!” he screamed.

  His eye exam was consistent with glycine toxicity. I stared at his

  sightless head, feeling helpless. I tried to explain to him that his blindness was likely temporary, but my words of reassurance were drowned out by

  other sounds in the recovery room, all bombarding his consciousness.

  I sedated him with Versed, hoping his vision would return by the time

  the drug wore off. He woke up an hour later. His face was as blank and

  lifeless as the faces of the blind. Then he cried. I gave him another dose of Versed. When he woke up an hour later, he saw light but no forms. I tried again to reassure him, but other
sounds from the recovery room kept

  coming, flying, falling over one another. A clamorous darkness. They

  tortured him. He started to cry again. I gave him more Versed.

  Two hours later, he woke up and said he could see vague forms. He

  was calmer now, in part from the Versed but also because he sensed

  things were improving. He still had that far-out gaze. Over the next hour, more images filtered their way to the dark recesses of his brain. He

  looked around to test his vision, reaching out to the recovery room’s

  brightly lit parts. Increasingly, he enjoyed the conviction that he had seen.

  Two hours later, he did see.

  I swore I would never let myself get into such difficulty again. In the

  future, if a patient refused my advice, I would refuse to do the case.

  Simple as that. After all, some doctors don’t even give their patients a

  choice. “You’re going to get a spinal. No discussion,” is how one senior

  doctor said he would have approached Mr. D. I wasn’t ready to go that

  far, but I was ready to shut things down if a patient demanded an unsafe

  anesthetic. Brave I would be to shut things down, I thought.

  Then again, how brave would I be to shut things down simply because

  I feared telling my patient that his or her surgeon was mediocre? Not very brave. Something was missing from the oath I had sworn.

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  The courage to say “no” is a part of being a doctor. But it is only a

  part. A doctor also has to be flexible. He has to know what is possible.

  The sense of what is possible includes the ability to recognize that certain things are impossible—in other words, unsafe—but also to know that

  things that appear to be very difficult are in fact possible. A stubborn

  patient can sometimes be charmed, coaxed, nudged, or inspired to follow

  the wiser path. A good doctor does more than just draw red lines and say,

  “No.” He or she also persuades.

  It is the difference between commanding and governing. To command