Maria was one of my luckier patients, someone with a solid support system and safe home. She came into the hospital for a relatively small surgery. Her concerned family drilled me with questions.
“How is her wound?”
“It’s looking pink and clean, just like it should.”
“Is abuelita in pain?”
“I think the morphine is helping. Her face is peaceful.”
“Can she hear us?”
“Maybe. Talk to her. Hold her hand. Let her know you are here.”
Unfortunately, Maria suffered a major operative complication. And, even though she woke up after a second emergent surgery, she soon went into multi-organ failure.
I was heartbroken, struggling with how to explain what happened to the family and myself. Despite my best efforts and the tools of modern medicine, Maria’s life was slipping away. I stayed up nights replaying what happened before, during, and after the surgeries. I went into work early to do thorough physical exams; I stayed late to scrutinize lab results and imaging studies. I consulted subspecialty teams to patch up every failing organ. I relentlessly called the nurses and residents for updates, and bombarded my attendings with details about Maria’s medications, oxygen supplementation, and fluids. Her family members weren’t the only ones praying for a miracle.
“She’ll be ok, right, doc? Please do everything you can. She was bossing us around before she came in. She’s a fighter.” The family said this every day, as if repeating it could make it true.
I nodded. “We’ve been taking care of her a long time, and will keep doing so. She’s in critical condition, but we will do everything we can. She won’t suffer.”
Partly out of guilt and partly to prove my commitment, I took extra care to tend to Maria’s open wound every day. While I removed the drenched dressings, gently scrubbed the edges clean, and placed new gauze, I talked to her family members. I explained the numbers on the vitals monitor and went through each intravenous drip. I described for them what was happening to her heart, lungs, and kidneys. Sometimes, she was better for awhile, and then declined, and then held steady. I didn’t want to take away Maria’s family’s hope, but I also didn’t want them to be surprised if she died sooner rather than later.
“Her hands are so swollen it looks like they’re going to pop. Last night, she started gurgling. What do we do now?” For the first time since I met him, the grandnephew looked defeated. He had organized a family schedule to make sure Maria was never alone, and took the late shifts himself.
“Can you get the family together? I think we need to talk again.”
“Ok doc. We’ll be here. An hour? Will you still be here?”
“Yes, of course.”
Maria passed away a week after her second surgery.
Perioperative mortality is a known occupational hazard for all gynecologic oncologists. No matter how meticulous we try to be, we all know that patients may die from surgery. Sometimes, we re-operate only to find that the problem is beyond repair. Occasionally, we can identify the mistakes. Most often, we are grappling with messy uncertainties, trying to make sense of the perpetually moving targets of clinical data. Like patients and families, we too bounce between the extremes of optimism and objectivity.
When Maria was dying, it might have been practical to step away. More experienced physicians advised that I shouldn’t try to do everything. I had other patients to tend to, and I needed to pace myself to avoid burn-out. They said it would be prudent to call a palliative care consult and let “the professionals” take over the end-of-life discussions. In a fragmented county system where the patients and families see a different face every shift, the family would not have expected more from a surgeon.
Yet, though I could no longer fix Maria’s broken body, I felt responsible for her family’s experience of grief. Staying to the end felt like the right thing to do under the traumatic circumstances. As I physically tended to Maria’s open wound, I was preparing her family for their impending loss. I wanted to communicate that my team would be present in the most vulnerable and difficult moments. We would see them through, even if there was little left to do medically.
The night before Maria took her last breath, I shook each family member’s hand and they thanked my team for “having a heart, and not just doing our jobs.” We all had tears in our eyes. Despite the deep sadness, there was an air of peace. The wound healing had begun -- the one without a roadmap.