Week Ten
The newspaper
article would read something like this:
_____________________________________________________________
US Military Physicians Faced with Difficult Medical-Ethical Decisions
in
While on a humanitarian mission, US health care providers
discovered a 4 month old male infant that was afflicted with
Hydrocephalus. This disorder is the
result of an over-abundance of cerebral spinal fluid in the brain. Cerebral spinal fluid is manufactured by
structures in the brain, and provides nutrients to the brain tissue. Under normal circumstances, the amount of
fluid is regulated by a naturally occurring series of ducts and chambers within
the brain tissue. Excess fluid is
directed down the spinal cord and reabsorbed by the body.
In the case of Hydrocephalus, this normal drainage system is
obstructed. The result is an increased
accumulation of fluid and pressure within the brain. The pressure causes drastic enlargement of
the skull itself, as well as detrimental compaction of the brain tissue. This event causes severe brain damage and
eventually death if left untreated.
The standard treatment in the
Neurosurgeons, radiologists, and primary care providers
evaluated the child at the 86 CSH (hospital) in
If left untreated, the child would most certainly die within
the next year. Treatment would have
serious risks however. There would be
almost a 60% chance of mortality during the surgery itself. If the child even survived the surgery, there
would be an extreme risk of uncontrollable infection, which could also end in
fatality. And worst of all, the drain
(also known as the shunt) itself, normally fails within the first year and
requires replacement. There would be no
guaranties that shunt revision surgery would be available in the future.
Weather or not to even offer this risky a procedure to the
family raised difficult ethical considerations.
In the end, the deciding factor was based upon the patient’s own level
of pain. It was felt by all the
healthcare providers, that despite not altering the child’s time on this earth
significantly, a considerable amount of pain reduction could be brought about
with shunt placement. By removing the
extra fluid and thus excessive pressures exerted upon her brain tissue, a
drastic and possibly complete resolution of the patient’s pain may exist.
All of this was explained to the mother and family using
professional translators. The mother,
family and extended family members all acknowledged understanding of the risks
involved and limited change in overall mortality, yet opted for the chance to
reduce their beloved son’s suffering during her remaining months of life.
At the request of the family, the 86 CSH and TF 4-64 began the risky procedure on the child. The operation lasted one hour. Despite a few difficulties, the surgery was an overall success. The child remained in the ICU for 48 hours and then was discharged home. Reports from the family a week later indicated that the child was doing well.
That’s how the
article would read if it were actually published.
In truth, the
story was a little different.
To begin with,
there wasn’t even a good possibility that the boy’s pain would be
controlled. It was merely speculation.
I participated in
the surgery. When the boy arrived, we
performed a second…even more thorough evaluation of him. The existing brain damage was already
extensive. He had little control over is
upper extremity function (arms). Worse,
there was evidence of a meningiomyocele at the level
of L1, which means that the spinal cord was not intact from the pelvis
down. He would NEVER be able to use his
legs. The feet were already turned
skyward from disuse and the legs had atrophied.
He would be permanently paralyzed from the waist down.
He was also
extremely malnourished, this malnourishment would, in
itself, decrease his chances for survival, and complicated the surgery, as I will
explain later.
Despite our
begging her not too, the mother also fed the child prior to surgery. When the anesthesiologist found out, I almost
thought he wasn’t going to do the case.
The surgery was going to be risky enough, without the chance of aspiration
of stomach contents. (And yes, during
the surgery the child extubated and aspirated,
meaning that if it does get aspiration pneumonia, the mother signed its death
sentence herself)
The initial intubation went well (placing of the breathing tube while
under general anesthesia). The surgeons
made marks with a felt tip pen where they would cut, and the child was prepped
for surgery.
One neurosurgeon
was going to place the head portion of the tube while a second surgeon was
making the necessary cuts to place the drain end into the stomach. The upper part went smoothly, but when the
second surgeon tried to find the stomach and abdominal cavity, a very
unfortunate discovery was made.
The child’s
intestines were so badly malformed and scarred down, that we couldn’t find a
place to stick the drain. We couldn’t
identify the anatomy! It was a
mess. The whole procedure almost ended
there.
Another surgeon
was called in, and for about fifteen minutes the three surgeons peered into the
hole in the child’s abdomen and tried to find the area that they were looking
for.
Eventually it came
down to a guessing game. One surgeon
pulled up a piece of tissue that they thought was were
they wanted to be. They all looked at
it, but were still uneasy. You see, a cut
had to be made in it. If they were wrong
and cut into bowel, the child would be screwed and most certainly die of
infection.
It was sort of
like: “Do I cut the green wire or the red wire?” in bomb deactivations. Everyone held their breath and the cut was
made…
It worked. It was the correct wire, and the surgery
continued.
Then the breathing
tube slipped out. It’s not really
anyone’s fault. The intubation
had it’s own difficulties given the size of the
child’s head and the unusual anatomy.
Pediatric tubes also don’t have an anchoring cuff (balloon) at the end,
so they slip out easily.
Manual
(bag-valve-mask) respiration also was limited given the head size and position
needed for surgery.
At one point the
anesthesiologist looked at the oxygen saturation and heart rate and announced
that the child was dying.
We were actually
quit prepared for this event. None of us
really expected the child to survive the surgery. We just didn’t know specifically at what
point he would die.
Somehow though,
the doctor pulled the kid through and was able to re-intubate
him in time. I held my breath to see how
long the child had (an old anesthesiologist trick). I had to take a breath before the child did,
so I’m guessing a little more brain damage occurred. (But in this case it’s relative)
So…Now
the child’s shunt is in and he’s still alive. The
family thinks we performed a miracle.
In my opinion,
what we performed was an atrocity and a sin.
We had no business
doing any of this. The company commander
should not have asked us to do this, or at least backed off when we initially
declined.
We did not save
this child’s life. We merely prolonged
its chance to suffer, and increased the amount of time the mother and family
had to get emotionally attached to it before it died.
I also, don’t
think the family understood the real risks and likelihoods of a good
outcome. Now, when our “miracle” fails,
what will they do? Will they give up
peacefully, or will they expect continued miracles from US forces?
We should not have
done this.
My greatest
argument comes from the Hippocratic Oath itself. I am reasonably assured that only a handful
of you have ever read the oath, or have any real idea what it says. You, like most, probably assume it says
something about helping others and being there for people.
On the contrary,
it says, “Do no harm”.
Just because
science can accomplish something, doesn’t mean its execution is appropriate or
“good”.
We can build an
atom bomb. Does that mean it’s okay to drop it?
We can build
guns…Can we therefore shoot people?
There is a time
and place for intervention. Part of
being a good practitioner is knowing when to proceed
and when to refrain. Situations like
this case are hard enough medical-ethical dilemmas for physicians to face on
there own. In this event, we had the
added burden of numerous soldiers pressuring us to do something as well. The surgeon’s hands were tied, it became
almost impossible to say “No” and do what they felt was right. As the liaison between the
A number of times
during the surgery, we (the doctors) openly told each other that we were doing
this to help the soldiers. Perhaps we
were just rationalizing our actions; for we each knew in our own hearts, that
what we were really doing was breaking the Hippocratic Oath.
We will all die
with skeletons in our closets…One of mine will now be a small child with a big
head and many more months of suffering.
Be Good, Be Well
Daniel
