Breaking Point

During my third year of OB/GYN residency, I became determined to subspecialize in gynecologic oncology. I realized that I enjoyed taking care of cancer patients the most. Despite being overworked and perpetually exhausted, I always had the energy for the long surgeries and involved patient-family conversations. I reveled in the challenges and the teamwork. I knew I wanted to do this for the rest of my life.

The first surgical case of the day was Margaret, an adorable, delightful lady with advanced cancer. Her husband of 60 years, Charlie, stuck close to her side. They hobbled down the hallway, arms around each other, free hands holding matching canes. Charlie asked us to take good care of her; she was all he had. I assured them that her attending surgeon was someone I would trust to operate on my own family members. Charlie and Margaret shared an extraordinary, palpable connection. Their hearts and souls were so clearly intertwined I knew they couldn’t survive without each other.

The surgery went smoothly. The day after, Charlie was there first thing in the morning, wearing a full-body, neon jogging suit. “You gotta get out of bed and walk. That’s what the doctors said,” he nudged Margaret. When I looked in, they were giggling and whispering to each other.

Margaret was only in the hospital for 4 days. She didn’t want to go to a nursing home, but Charlie needed minor knee surgery and wouldn’t be able to watch over her. We worked out a temporary stay at a nearby facility. After his surgery, they would go home together.

A week later, the nursing home sent Margaret back to the hospital with a fever. Margaret and Charlie were excited to see us and wanted her to remain under our care. We kept her over the weekend for observation.

On Monday, Margaret felt much better, but her stool looked abnormal, as if she was bleeding in her colon. We checked her blood level and found that it was unexpectedly low. We started a blood transfusion while we investigated possible causes. As a matter of protocol, I sat down with Margaret and Charlie to discuss the course of action for the worst-case scenario. “Of course, she wants everything done, right, honey? We still have to see the pyramids!” Charlie answered. Margaret nodded, petting his cheek. I was confident Margaret would pull through, and told Charlie, “She’ll be fine in the morning when you get here.”

I stayed late that night because Margaret’s 88-year-old veins were thin and spidery, and rejected our best efforts at getting consistent IV access. I tried. The charge nurse tried. We asked the anesthesia and ICU teams to try. I suggested to the ICU fellow that he place a central line, basically a large IV direct to the heart. He felt that Margaret looked well, and didn’t require such an invasive procedure. I finally went home at 10 pm after we secured one small IV line.

From home, I checked Margaret’s repeat lab work and noticed that she was missing a lot of the usual blood clotting factors, which means she could have a fatal bleed at any moment. I called into the hospital to see how her blood transfusion was going, and found out that her IV had stopped functioning. We nagged the ICU team again to help and they were able to place another small IV. We redoubled efforts to get the blood products in.

Margaret looked exhausted in the morning from the overnight commotion, but still gave us a cheerful smile. My team was getting breakfast, when we heard an emergency overhead announcement for the rapid response team to Margaret’s room. We dropped our food and ran.

When we got there, the nurse was already doing CPR. I took over the chest compressions, attempting to pump Margaret’s heart through her rib cage. I could feel ribs cracking under my palms. I pushed myself to keep going more than one compression per second. I watched blood pouring out of her mouth for 40 minutes. It had been obvious that Margaret could not be revived, but I couldn’t stop. I wasn’t thinking about her welfare anymore. I was wondering how I was going to tell Charlie. I think people might have tried to get my attention, but the necessarily detached ‘doctor’ in me was gone. I was acting out of pure emotion. I promised Charlie he would see Margaret this morning, and I couldn’t fail him. I talked myself into believing in miracles and resurrection. When we called time of death, Charlie had not yet arrived.

My team sat in the nursing station to piece together what had happened. A fax had just come through with Margaret’s medication list at the nursing home. It turns out she had been started on a blood-thinning pill that was very high-risk for a cancer patient after surgery. I assumed any doctor would have asked her surgeons before starting her on such a drug, but clearly, this slipped through the cracks. Now, it was obvious why Margaret had bled to death so quickly and tragically.

“You killed her with your carelessness,” an attending spat out in anger. “How many times do I have to tell you to get outside records immediately?” Paralyzed with fear that she might be right, I walked away. The weight was too much to bear. This was my breaking point.

Watching Charlie walk down the hallway by himself literally broke my heart. I told him Margaret’s heart had stopped, and we couldn’t get it back. He cried into her neck, and then on my shoulder, and said this is worse than being in the war. We shared a box of tissues. Charlie mumbled about cemetery plots and their new apartment being too big for him alone. I couldn’t stop apologizing for not getting the records earlier, for figuring out the diagnosis too late, for not being able to resuscitate Margaret, for leaving her bedside to eat breakfast, for not running up the stairs faster, for not making sure she had better intravenous access, for underestimating her body’s reserve….

Clearly shaken, I marched into the division chair’s office and asked to reassign my surgical cases for the day. I wanted and needed to help Charlie get things in order. Charlie and I sat quietly in the waiting area with our separate thoughts, mourning together. He looked lost and frightened, and I worried about him. I called him every day, until he told me he was moving into an assisted living facility where an old war buddy also lived. He thanked me for taking care of the two of them, and made me cry again. He didn’t blame me, but I couldn’t forgive myself. I tried calling him once more, but his phone number no longer worked.

Margaret’s case was presented at the monthly ‘Morbidity and Mortality’ conference which reviewed unexpected deaths in detail. As I recounted minute-by-minute what transpired over those days, my colleagues argued about fragmentation of care and poor inter-doctor communication. When they asked me what I could have done differently, I said I wished I could put in a central line myself. After the meeting, people came up to console me. They said the usual things. You are not God. It would have happened anyway. Death is an occupational hazard when you have elderly cancer patients. You treated her correctly even without knowing the cause, which is all that can be expected.

For many nights, I second-guessed if I was qualified to be a surgeon, playing cat-and-mouse with questions I was too afraid to ask myself. Did I have what it takes to hold someone’s life in my hands? Maybe I should have stayed overnight and not left Margaret’s bedside. How much of yourself do you sacrifice? What’s reasonable? Would the world be a safer place if I got a desk job? Am I being selfish and arrogant to think I can care for cancer patients? Maybe oncology isn’t for me. It’s all fine and good to be human, but what if my imperfections costs someone her life?

It took me a while to make decisions confidently again. Being a doctor is all about sorting through a multitude of complex, nuanced choices and then bearing the inevitable weight of responsibility. I went to my chief resident for wisdom beyond the facts that I’m not God and the system is flawed. She said, “Not everyone is cut out for this. But, I know you will be one of the good ones, because I have seen you work and you dare to ask yourself this question 8 years into the game.”

So, I’ve stayed, and I’ve kept reaching for a deeper understanding of humility and forgiveness. I strive to balance the beauty of connecting with patients with the burden of potentially losing them. I have found that I am willing to carry the load.

Every holiday season, I still think about Charlie.