I am on call today, and I got a call from a surgeon about a possible case. The patient is a 65 year old male with esophageal cancer, who was admitted last night with abdominal distension and discomfort. He had undergone his first round of chemotherapy this past Tuesday, and his white count is 1.6 (although many of the facts in this story have been altered to protect the identities of those involved, his white count is in fact real. And for those of you who are not familiar with white counts, this is really, REALLY,
REALLY low). He has not urinated in days. His
creatinine is 3, and his potassium is high (again, true facts, and VERY abnormal). A CT scan reveals obstruction at the esophageal-gastric junction (between the esophagus and the stomach). The oncologist is suggesting that the patient undergo surgery. The surgeon is hesitant, so he calls me, and asks me what I think. I tell him that the patient is at high risk for complications from surgery and anesthesia. With his very low white count, he is poorly capable of fighting off infections, which may be introduced during anesthesia (via a breathing tube) and surgery (via the wound). He may need many, many more invasive tubes in various places (IVs, bladder, etc) which may increase his risk for infection. In addition, he is starting to look
septic; anesthesia medications may drop his blood pressure so low, that he may die on the OR table. And even if he survives the surgery, he most likely may need to remain on the ventilator after surgery. This also
places at him at risk for infection, particularly from pneumonia.
Together, the surgeon and I talk to the wife about all of the above. She is an intelligent, well-read woman, and understands what we are saying. She nods, without expression. Her voice is even, but still very conversational. She brushes away a lock of her chestnut brown hair that obscured her view of one side. She adjusts the jingle bells sewn to her red, festive, holiday sweater. She clears her throat, and tells us she is going call other family members.
She returns later and tells us just to keep him comfortable for now. No surgery. Once the decision has been
communicated, her voice begins to quiver, her hands start to shake, and tears well up, then stream down her face. "Just three months ago we were golfing, without a care in the world. Our house is three stories with hills and lots of stairs -
certainly not an old person's house. What am I going to tell the children?"
At this, the surgeon places his arm around her, and I stand beside her, supporting her. The nurse offers her a seat and a cup of cold water. And I fight so hard to keep my composure, as my heart wrenches for this strong woman, who married the love of her life 37 years ago; whose constant companion since then has been this dying man; who has enjoyed skiing and golfing and vacationing with him; who now has to say good bye to him.
"I take you, to be my husband; To have and to hold, from this day forward, for better, for worse, for richer, for poorer, in sickness and in health, to love and to cherish, 'till death do us part."
